What are the recommended medications for insomnia?

Recommended Medications for Insomnia

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for insomnia, with medications considered only when CBT-I is unsuccessful or as a temporary adjunct. 1

Treatment Algorithm

1. First-line approach:

   • Start with CBT-I (8-12 sessions)
   • Components include sleep restriction therapy, stimulus control, cognitive therapy, relaxation techniques, and sleep hygiene education

2. When pharmacotherapy is needed:

   • First-line medications:
     • Short/intermediate-acting benzodiazepine receptor agonists (BzRAs):
       • Zolpidem (10mg for adults, 5mg for elderly) - effective for sleep onset 1, 2
       • Eszopiclone (2-3mg) - effective for both sleep onset and maintenance 1
       • Zaleplon (10mg) - specifically targets sleep onset with very short half-life 1
     • Orexin receptor antagonist:
       • Suvorexant (10-20mg) - recommended for sleep maintenance insomnia 1
     • Other options:
       • Doxepin (3-6mg) - effective for sleep maintenance with minimal side effects 1
       • Ramelteon (8mg) - non-scheduled melatonin receptor agonist, reduces sleep latency by approximately 9.6 minutes 1, 3

3. Reassess in 4-6 weeks:

   • If inadequate response, try alternative first-line agent or move to second-line options
   • Continue CBT-I throughout treatment as it provides long-term benefits

Evidence for Recommended Medications

Zolpidem

• Reduces sleep latency and improves sleep efficiency 2
• Available in immediate-release (IR) and extended-release (ER) formulations 4
• Peak plasma concentration occurs in 45-60 minutes with terminal half-life of 2.4 hours 5
• Efficacy comparable to benzodiazepines and other non-benzodiazepine hypnotics 6, 7
• Caution: Associated with increased risk of falls (OR 4.28), hip fractures (RR 1.92), and CNS-related adverse effects 4

Ramelteon

• FDA-approved for sleep initiation
• Reduces latency to persistent sleep compared to placebo 3
• Good option for patients with history of substance use disorders (non-scheduled) 1, 3
• No evidence of abuse potential at doses up to 20 times the recommended therapeutic dose 3

Medications to Avoid

• The American Academy of Sleep Medicine specifically recommends against:
  • Trazodone
  • Diphenhydramine and other antihistamines
  • Melatonin
  • Valerian and other herbal supplements 1

Special Considerations

• Elderly patients:

  • Require lower doses (e.g., zolpidem 5mg instead of 10mg) 1, 2
  • Higher risk of adverse effects including falls and cognitive impairment

• History of substance use:

  • Consider non-scheduled options like ramelteon 1, 3

• Respiratory conditions:

  • Screen for obstructive sleep apnea before prescribing sedatives 1

• Pregnancy:

  • Zolpidem is FDA category C; associated with increased risk of low birth weight, preterm delivery, and SGA babies 4

Importance of CBT-I

CBT-I produces results equivalent to sleep medication with several advantages:

• No side effects
• Fewer episodes of relapse
• Continued sleep improvement after treatment ends 8
• Long-term benefits without risk of tolerance or adverse effects 1

If access to traditional face-to-face CBT-I is limited, alternatives include:

• Digital CBT-I applications
• Brief Behavioral Treatment for Insomnia (BBT-I)
• Self-help CBT-I materials (books, online resources) 1

Common Pitfalls to Avoid

• Using medications as sole treatment without addressing behavioral factors
• Prescribing medications for too long (recommended duration ≤4 weeks for most hypnotics)
• Not screening for other sleep disorders that may mimic insomnia
• Failing to adjust dosages for elderly patients
• Rapid discontinuation of benzodiazepines (can cause withdrawal symptoms)
• Not considering drug interactions and comorbidities when selecting medications