What are the best medications for treating chronic insomnia?

From the Guidelines

The most effective medications for treating chronic insomnia are nonbenzodiazepine BZRA, such as zolpidem (Ambien, 5-10mg) and eszopiclone (Lunesta, 1-3mg), which should be administered at the lowest effective dose and for the shortest possible duration. These medications are effective for sleep initiation and maintenance, typically used for 2-4 weeks to avoid dependence 1. For longer-term management, low-dose doxepin (3-6mg) may be a safer option, as it has been suggested as a treatment for sleep maintenance insomnia in adults 1.

Some key points to consider when treating chronic insomnia include:

• Avoiding the use of benzodiazepines, such as triazolam and temazepam, due to their potential for dependency and adverse effects 1
• Not using trazodone, antihistamines, and antipsychotics for treatment of chronic insomnia disorder, as their benefits are outweighed by their adverse effect profiles 1
• Considering cognitive behavioral therapy for insomnia (CBT-I) as an effective therapy for chronic insomnia disorder, which can be performed and prescribed in the primary care setting 1
• Combining medication with good sleep hygiene practices, including consistent sleep schedules, limiting screen time before bed, avoiding caffeine and alcohol, and creating a comfortable sleep environment

It's essential to consult a healthcare provider to determine the best course of treatment for individual patients, as these medications can cause side effects like daytime drowsiness, dizziness, and in some cases, dependence or complex sleep behaviors 1.

From the FDA Drug Label

The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™) Ramelteon Tablets reduced the average latency to persistent sleep at each of the time points when compared to placebo.

The best medications for treating chronic insomnia include:

• Eszopiclone: significantly decreased sleep latency and improved measures of sleep maintenance at the recommended adult dose (2 to 3 mg) and elderly dose (1 to 2 mg) 2
• Zolpidem: was superior to placebo on objective (polysomnographic) measures of sleep latency and sleep efficiency at a dose of 10 mg 3
• Ramelteon: reduced the average latency to persistent sleep at each of the time points when compared to placebo at a dose of 8 mg 4

Key considerations:

• The choice of medication should be based on individual patient needs and medical history.
• It is essential to follow the recommended dosage and administration instructions for each medication.
• Patients should be monitored for potential side effects, such as next-day residual effects, rebound insomnia, and memory impairment.

From the Research

Medications for Chronic Insomnia

The following medications are used to treat chronic insomnia:

• Benzodiazepines: however, their use is often discouraged due to the risk of dependence and other side effects 5, 6
• Nonbenzodiazepine hypnotic medications: such as zolpidem, zaleplon, and eszopiclone, which have shorter durations of action and may be associated with less risk of tolerance and abuse 7
• Melatonin receptor agonists: such as ramelteon, which are safer and well-tolerated but have limited effectiveness 7, 5, 6
• Dual orexin receptor antagonists: which are effective in patients with sleep maintenance insomnia or difficulty with sleep onset 5, 6
• Antihistamines: such as doxylamine, which is effective for up to four weeks, but evidence for their use is generally lacking 5
• Low-dose doxepin: which has been demonstrated to have efficacy for sleep maintenance insomnia, particularly in the latter third of the night 7, 6
• Suvorexant: which can improve sleep maintenance 6

Considerations for Medication Use

When choosing a medication for chronic insomnia, the following factors should be considered:

• Efficacy: the ability of the medication to improve sleep parameters
• Safety: the risk of side effects, dependence, and other adverse events
• Tolerance: the potential for the medication to lose effectiveness over time
• Abuse potential: the risk of the medication being misused or abused
• Comorbidities: the presence of other medical or psychiatric conditions that may affect the choice of medication 7, 5, 8, 6

Non-Pharmacologic Treatments

Non-pharmacologic treatments, such as cognitive-behavioral therapy, stimulus-control therapy, relaxation, and sleep restriction, are often recommended as the first line of treatment for chronic insomnia 9, 5, 8