What is the first line pharmacologic treatment for insomnia?

First-Line Pharmacologic Treatment for Insomnia

For patients requiring pharmacologic treatment for insomnia, short/intermediate-acting benzodiazepine receptor agonists (BzRAs) or the orexin receptor antagonist suvorexant are recommended as first-line options, with cognitive behavioral therapy for insomnia (CBT-I) remaining the gold standard first-line treatment overall. 1

Treatment Algorithm for Insomnia

1. First-Line Non-Pharmacologic Treatment:

   • CBT-I should be the initial treatment approach for all patients with insomnia
   • If CBT-I is not immediately accessible, consider digital CBT-I applications or self-help materials

2. First-Line Pharmacologic Options (when medication is needed):

   • For sleep onset insomnia:

     • Zolpidem 10mg (5mg for elderly) 2, 1, 3
     • Zaleplon 10mg 2, 1
     • Ramelteon 8mg (especially for patients with substance use history) 2, 1

   • For sleep maintenance insomnia:

     • Suvorexant 10-20mg 2, 1
     • Doxepin 3-6mg 2, 1
     • Eszopiclone 2-3mg (for both onset and maintenance) 2, 1, 4

Medication Selection Considerations

• Patient Age: Elderly patients require lower doses of all medications 1
• Type of Insomnia: Match medication to specific sleep complaint (onset vs. maintenance) 2, 1
• Comorbidities: Consider respiratory conditions when selecting medication 1
• Substance Use History: Non-scheduled options like ramelteon preferred for patients with history of substance use 1

Important Medication Details

• Zolpidem: Effective for reducing sleep latency but can cause residual sedation 1, 3
• Eszopiclone: Improves both objective and subjective sleep measures and can be used for both onset and maintenance insomnia 4
• Suvorexant: Dual orexin receptor antagonist effective for sleep maintenance 1, 5
• Doxepin: Low-dose option with minimal side effects, effective for maintenance 1

Medications to Avoid

The American Academy of Sleep Medicine specifically recommends against using:

• Trazodone 2, 1
• Diphenhydramine and other antihistamines 2, 1
• Melatonin 2, 1
• Valerian and other herbal supplements 2, 1
• Tiagabine 2
• Tryptophan 2

Cautions and Monitoring

• BzRAs can cause residual sedation, memory impairment, falls, and sleep behaviors (sleepwalking, sleep-eating) 1
• Administer medications on an empty stomach for maximum effectiveness 1
• Avoid long-term use of sleep medications when possible 2
• Use the lowest effective dose for the shortest period possible 2
• Monitor for tolerance, dependence, and rebound insomnia 6, 5

Treatment Duration

• Short-term use (<4 weeks) is generally recommended for most hypnotics 2
• For chronic insomnia, reassess treatment efficacy after 4-6 weeks 1
• Non-benzodiazepines like zolpidem and zopiclone may be better options for longer-term treatment when necessary, as they develop tolerance less rapidly 6

Remember that while pharmacologic treatment can be effective for insomnia, CBT-I produces sustained benefits without risk of tolerance or adverse effects and should be incorporated into treatment whenever possible 1, 7.