What medications are recommended to help patients stay asleep?

Medications for Sleep Maintenance Insomnia

For sleep maintenance insomnia, eszopiclone (2-3mg), doxepin (3-6mg), temazepam (15mg), and suvorexant (10-20mg) are the recommended medications based on their efficacy in helping patients stay asleep. 1

First-Line Approach

Before considering medications, it's important to note that Cognitive Behavioral Therapy for Insomnia (CBT-I) is recommended as the first-line treatment for sleep maintenance issues. However, when pharmacological intervention is necessary, several options are available specifically for maintaining sleep throughout the night.

Medications Specifically for Sleep Maintenance

1. Eszopiclone (2-3mg)

   • Specifically indicated for sleep maintenance insomnia 1
   • Demonstrated efficacy in improving sleep maintenance without significantly altering slow wave sleep or REM sleep 2
   • Effective for both short-term and long-term use (up to 12 months) 3
   • Common side effects include unpleasant taste, headache, and dry mouth 4

2. Doxepin (3-6mg)

   • Recommended specifically for sleep maintenance issues 1
   • Lower doses (3mg) recommended for elderly patients due to increased sensitivity 1

3. Temazepam (15mg)

   • Effective for sleep maintenance 1
   • Caution: Benzodiazepines should be avoided in elderly patients or those with cognitive impairment due to increased risk of falls, confusion, and dependence 1

4. Suvorexant (10-20mg)

   • Orexin receptor antagonist specifically indicated for sleep maintenance 1

Medication Selection Considerations

Age Considerations

• Elderly patients (65+ years):
  • Use lower doses: doxepin 3mg or eszopiclone 2mg 1
  • Avoid benzodiazepines due to increased risk of falls and confusion 1
  • Strongly avoid sleep medications in elderly patients with dementia 1

Special Populations

• Patients with substance use history:

  • Prefer non-scheduled options like doxepin 1
  • Consider periodic medication-free intervals to assess continued need 1

• Patients with respiratory conditions:

  • Use caution with sedating medications 1
  • Lower doses may be appropriate 1

Medications Less Effective for Sleep Maintenance

1. Zolpidem

   • More effective for sleep onset than maintenance 1, 5
   • Risk of complex sleep behaviors including "sleep-driving" 5

2. Zaleplon (Sonata)

   • Short half-life makes it less effective for sleep maintenance 1
   • Better suited for sleep onset issues 1

3. Ramelteon

   • Primarily indicated for sleep onset insomnia 1, 6
   • Limited efficacy for maintaining sleep throughout the night 6

Monitoring and Follow-up

• Reassess patients within 2-4 weeks after initiating treatment 1
• Monitor for side effects, particularly daytime sedation, falls, and cognitive changes 1
• Use the lowest effective dose for the shortest duration necessary 1
• Consider periodic medication-free intervals to assess continued need 1

Common Pitfalls to Avoid

• Long-term use of any sleep medication is generally not recommended without periodic reassessment 1
• Avoid antihistamines (e.g., diphenhydramine) for long-term use due to limited efficacy data and risk of anticholinergic side effects 1
• Be aware that tolerance develops to the sedating effects of many sleep medications 1
• Avoid combining sleep medications with alcohol 5

By selecting medications specifically designed to address sleep maintenance issues and carefully considering patient factors, clinicians can effectively help patients who struggle with staying asleep throughout the night.