From the Guidelines
Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment for adults with chronic insomnia disorder, as it has been shown to improve global outcomes and sleep quality with minimal harms 1. When it comes to pharmacological treatments, the evidence suggests that eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known 1. Some key points to consider when prescribing pharmacological treatments for insomnia include:
- Using the lowest effective dose for the shortest duration possible to minimize the risk of dependence, tolerance, or morning grogginess
- Considering the potential benefits and harms of short-term use of medications, including improved sleep outcomes and increased risk of cognitive and behavioral changes
- Discussing the benefits, harms, and costs of pharmacological therapy with patients using a shared decision-making approach 1
- Being aware of the limitations of the evidence, including the lack of data on the long-term efficacy and comparative effectiveness of pharmacotherapies for insomnia 1 In terms of specific medications, some options that may be considered include:
- Eszopiclone (Lunesta, 1-3mg) or zolpidem (Ambien, 5-10mg) for short-term use
- Melatonin supplements (1-5mg) for circadian rhythm disorders
- Low-dose trazodone (25-100mg) or mirtazapine (7.5-15mg) for depression-related insomnia However, it's essential to consult with a healthcare provider before starting any sleep medication to determine the most appropriate option based on individual sleep issues, medical history, and potential drug interactions.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Ramelteon reduced the average latency to persistent sleep at each of the time points when compared to placebo. A randomized, doubleblind, parallel group study was conducted in outpatients aged 65 years and older with chronic insomnia and employed subjective measures of efficacy (sleep diaries). Subjects received ramelteon (4 mg or 8 mg) or placebo for 35 nights ramelteon reduced patient-reported sleep latency compared to placebo. Zolpidem is a GABA A receptor positive modulator presumed to exert its therapeutic effects in the short-term treatment of insomnia through binding to the benzodiazepine site of α1 subunit containing GABA A receptors, increasing the frequency of chloride channel opening resulting in the inhibition of neuronal excitation.
The most effective pharmacological treatments for insomnia include:
- Ramelteon: effective in reducing sleep latency in patients with chronic insomnia, with a recommended dose of 8 mg for adults and 4 mg or 8 mg for older adults 2
- Zolpidem: a GABA A receptor positive modulator that exerts its therapeutic effects in the short-term treatment of insomnia, with a recommended dose of 5 mg for elderly patients and 5-10 mg for non-elderly patients 3
From the Research
Pharmacological Treatments for Insomnia
The most effective pharmacological treatments for insomnia include:
- Benzodiazepines 4, 5, 6
- Benzodiazepine receptor agonists 4, 5, 6
- Melatonin receptor agonists 5, 6, 7, 8
- Orexin receptor antagonists 4, 8
- Low-dose sedating antidepressants 4, 5, 8
- Daridorexant 4
- Prolonged-release melatonin 4, 8
Treatment Duration and Patient Factors
When considering pharmacological treatment for insomnia, the following factors should be taken into account:
- Treatment duration: short-term (≤ 4 weeks) or longer-term treatment 4, 5
- Patient age: prolonged-release melatonin can be used for up to 3 months in patients ≥ 55 years 4
- Primary sleep complaint: choice of agent should be based on patient-specific factors, including primary sleep complaint 5, 8
- History of drug or alcohol abuse: choice of agent should be based on patient-specific factors, including history of drug or alcohol abuse 5
- Cost: choice of agent should be based on patient-specific factors, including cost 5
Non-Recommended Treatments
The following treatments are not recommended for insomnia: