What is an as-needed treatment for insomnia?

From the Guidelines

As-needed treatment for insomnia is typically pharmacologic therapy, such as benzodiazepines or nonbenzodiazepine hypnotics, used in conjunction with cognitive behavioral therapy for insomnia (CBT-I) or as a supplement when CBT-I is unsuccessful.

Key Points

• The goal of treatment for insomnia is to improve sleep and alleviate distress or dysfunction caused by the disorder 1.
• Pharmacologic therapy options include benzodiazepines (e.g., triazolam, estazolam, temazepam), nonbenzodiazepine hypnotics (e.g., zaleplon, zolpidem, eszopiclone), orexin receptor antagonists (e.g., suvorexant), melatonin receptor agonists (e.g., ramelteon), and antidepressants (e.g., doxepin) 1.
• Cognitive behavioral therapy for insomnia (CBT-I) is a recommended first-line treatment for chronic insomnia disorder, with moderate-quality evidence showing improved global outcomes and sleep outcomes in the general population and older adults 1.
• A shared decision-making approach is recommended when considering the addition of pharmacologic therapy to CBT-I, taking into account the benefits, harms, and costs of short-term medication use 1.

Treatment Considerations

• The American College of Physicians recommends CBT-I as the initial treatment for chronic insomnia disorder, with pharmacologic therapy considered as a supplement when CBT-I is unsuccessful 1.
• The choice of pharmacologic therapy should be based on the individual patient's needs and medical history, with consideration of the potential benefits and harms of each medication option 1.
• As-needed treatment with pharmacologic therapy may be necessary for some patients, particularly those who have not responded to CBT-I or who require occasional supplementation to manage insomnia symptoms 1.

From the Research

As-Needed Treatment for Insomnia

• Zolpidem can be prescribed on an 'as-needed' basis for the treatment of insomnia in routine general practice, with patients adapting the treatment to their needs and to the evolution of their insomnia 2.
• The consumption of zolpidem decreases steadily during the treatment period, from 5.1 +/- 1.9 doses/week during week 1 to 3.7 +/- 2.5 doses/week during week 3 2.
• Factors predictive of stable or increased zolpidem consumption include a prior sleep-disorder episode, high initial zolpidem consumption, or insomnia having started >3 weeks before the inclusion 2.
• Low-dose zolpidem sublingual tablets can be used to alleviate middle-of-the-night awakenings 3.
• Other medications that can be used as-needed for insomnia include eszopiclone, zaleplon, and ramelteon, although the choice of medication should be based on patient-specific factors such as age, proposed length of treatment, and primary sleep complaint 3, 4, 5.

Patient-Specific Factors

• Age: consideration should be given to the potential risks and benefits of different medications in older adults 3, 4.
• Proposed length of treatment: medications with a shorter duration of action may be preferred for short-term use, while medications with a longer duration of action may be preferred for longer-term use 3, 4.
• Primary sleep complaint: medications that target specific sleep complaints, such as sleep onset or sleep maintenance, may be preferred 3, 4.
• History of drug or alcohol abuse: consideration should be given to the potential risks of medication abuse or dependence 3, 4.
• Cost: consideration should be given to the cost of different medications and their potential impact on patient adherence 3, 4.