What is a good medication for steroid-induced insomnia when steroids cannot be discontinued?

Management of Steroid-Induced Insomnia

Short-intermediate acting benzodiazepine receptor agonists (BzRAs) such as eszopiclone are the first-line pharmacologic treatment for steroid-induced insomnia when steroids cannot be discontinued. 1

First-Line Pharmacologic Options

When steroids cannot be discontinued and are causing insomnia, the following medications should be considered in order of preference:

1. Short-intermediate acting BzRAs:
   • Eszopiclone (2-3 mg): Particularly effective for both sleep onset and maintenance insomnia 1, 2
   • Zolpidem (10 mg): Effective for both sleep onset and maintenance 1
   • Zaleplon (10 mg): Better for sleep onset difficulties 1
   • Temazepam (15 mg): Effective for both sleep onset and maintenance 1

Why Eszopiclone is Particularly Suitable:

• Demonstrated efficacy for both sleep onset and maintenance problems 1, 3
• FDA-approved for longer-term use without restrictions, unlike most hypnotics 4
• Effective in improving daytime functioning in addition to sleep parameters 5
• No evidence of tolerance development with continued use 4
• No significant rebound insomnia upon discontinuation 4

Second-Line Options

If BzRAs are ineffective or contraindicated:

1. Ramelteon (8 mg): A melatonin receptor agonist effective for sleep onset difficulties 1

   • Non-scheduled medication (not a controlled substance)
   • Particularly suitable for patients with history of substance use disorders

2. Doxepin (3-6 mg): A sedating antidepressant effective for sleep maintenance 1

   • Low doses specifically approved for insomnia
   • May be particularly useful if patient has comorbid depression/anxiety

Medications to Avoid

The following medications are not recommended for steroid-induced insomnia:

• Trazodone 1
• Tiagabine 1
• Diphenhydramine and other OTC antihistamines 1
• Melatonin supplements 1
• L-tryptophan 1
• Valerian 1
• Barbiturates and older hypnotics 1

Important Considerations

Dosing Considerations

• Start with the lowest effective dose, especially in elderly patients 1
• Take medication immediately before bedtime 1
• Consider intermittent dosing (e.g., 3-4 nights per week) to minimize tolerance 1

Monitoring and Follow-up

• Follow patients every few weeks initially to assess efficacy and side effects 1
• Monitor for common side effects:
  • Unpleasant taste (most common with eszopiclone) 2, 3
  • Dry mouth 2
  • Dizziness 2
  • Somnolence 2

Common Pitfalls to Avoid

1. Not addressing both components of insomnia: Steroid-induced insomnia often affects both sleep onset and maintenance - choose an agent that addresses both when possible 1

2. Overlooking behavioral interventions: While medication is often necessary, combining with cognitive behavioral therapy for insomnia (CBT-I) improves outcomes 1

3. Inappropriate timing of medication: Taking hypnotics too early in the evening can lead to evening sedation without improving nighttime sleep 1

4. Failure to adjust steroid timing: When possible, administer steroids in the morning to minimize sleep disruption (though this doesn't replace the need for hypnotic therapy when insomnia persists) 1

5. Prolonged use without reassessment: Regular follow-up is essential to assess ongoing need and effectiveness 1

Adjunctive Non-Pharmacologic Approaches

While pharmacologic therapy is typically necessary for steroid-induced insomnia, the following should be implemented concurrently:

• Sleep hygiene education
• Stimulus control therapy
• Relaxation techniques
• Sleep restriction therapy

These behavioral interventions should be used in combination with medication rather than as standalone treatments for steroid-induced insomnia 1.