What are the medications, including brand (e.g. Lunesta) (eszopiclone) and generic names, used to treat insomnia?

DORA Medications for Insomnia: Brand and Generic Names

The FDA-approved medications for insomnia (DORA - Dual Orexin Receptor Antagonists and other classes) include zolpidem, zaleplon, eszopiclone, ramelteon, doxepin, and suvorexant, with cognitive behavioral therapy for insomnia (CBT-I) recommended as first-line treatment before pharmacological options. 1

First-Line Treatment

• CBT-I is strongly recommended as first-line treatment for chronic insomnia by the American Academy of Sleep Medicine and American College of Physicians due to superior long-term outcomes and fewer adverse effects 1
• Only consider medications when CBT-I is insufficient, unavailable, or patient is unwilling/unable to participate

FDA-Approved Medications for Insomnia

Benzodiazepine Receptor Agonist Modulators (Non-benzodiazepines)

• Eszopiclone (Lunesta)

  • Dosage: 2-3 mg at bedtime (1 mg in elderly or those with hepatic impairment)
  • Indication: Sleep onset and maintenance insomnia
  • Intermediate-acting with no short-term usage restriction 2, 3

• Zolpidem (Ambien)

  • Dosage: 10 mg at bedtime (5 mg in elderly)
  • Indication: Primarily for sleep onset insomnia
  • Short-to-intermediate acting 2, 1

• Zolpidem CR (Ambien CR)

  • Dosage: 12.5 mg at bedtime (6.25 mg in elderly)
  • Controlled-release formulation for sleep maintenance 2

• Zaleplon (Sonata)

  • Dosage: 10 mg at bedtime (5 mg in elderly)
  • Indication: Sleep onset insomnia
  • Very short-acting 2, 1

Benzodiazepines

• Estazolam

  • Dosage: 1-2 mg at bedtime (0.5 mg in elderly)
  • Short-to-intermediate acting 2

• Temazepam (Restoril)

  • Dosage: 15-30 mg at bedtime (7.5 mg in elderly)
  • Short-to-intermediate acting 2, 1

• Triazolam (Halcion)

  • Dosage: 0.25 mg at bedtime (0.125 mg in elderly)
  • Short-acting 2

• Flurazepam

  • Dosage: 15-30 mg at bedtime (15 mg in elderly)
  • Long-acting with risk of daytime drowsiness 2

Melatonin Receptor Agonists

• Ramelteon (Rozerem)
  • Dosage: 8 mg at bedtime
  • Indication: Sleep onset insomnia
  • Non-scheduled medication 2, 1

Dual Orexin Receptor Antagonists (DORAs)

• Suvorexant (Belsomra)
  • Dosage: 10-20 mg at bedtime
  • Indication: Sleep maintenance insomnia 1

Sedating Antidepressants

• Doxepin (Silenor)

  • Dosage: 3-6 mg at bedtime
  • Indication: Sleep maintenance insomnia 1

• Trazodone

  • Off-label use for insomnia
  • Low doses (25-100 mg) 1

• Mirtazapine

  • Off-label use for insomnia
  • Low doses (7.5-15 mg) 1

Important Considerations and Cautions

Safety Concerns

• Benzodiazepines and non-benzodiazepine hypnotics are associated with:
  • Memory loss, confusion, and disorientation (5-fold increase in older adults)
  • Dizziness, loss of balance, and falls (3-fold increase)
  • Residual morning sedation (4-fold increase) 2
  • Reports of complex sleep behaviors including sleepwalking, sleep-eating, sleep-driving, and sleep-sex 3

Special Populations

• Elderly patients:

  • Use lower doses of all medications
  • Avoid benzodiazepines due to increased risk of falls, cognitive impairment 1
  • Consider ramelteon or low-dose doxepin as safer alternatives 1

• Patients with substance use history:

  • Prefer non-scheduled options like ramelteon or doxepin 1

Duration of Treatment

• Short-term use (4-5 weeks) is recommended for most sleep medications 1
• Eszopiclone is unique in not being limited to short-term use 4, 5
• Periodic medication-free intervals should be considered to assess continued need 1

Medication Selection Algorithm

1. For sleep onset insomnia:

   • First choice: Zaleplon (shortest half-life)
   • Second choice: Zolpidem or Ramelteon
   • Third choice: Eszopiclone

2. For sleep maintenance insomnia:

   • First choice: Eszopiclone or Suvorexant
   • Second choice: Low-dose Doxepin
   • Third choice: Temazepam (use with caution)

3. For both onset and maintenance insomnia:

   • First choice: Eszopiclone
   • Second choice: Zolpidem CR
   • Third choice: Temazepam (use with caution)

4. For patients with risk of substance abuse:

   • First choice: Ramelteon
   • Second choice: Low-dose Doxepin

Remember to monitor patients for improvement in sleep parameters within 2-4 weeks of starting treatment and for potential side effects, particularly daytime sedation, falls, and cognitive changes 1.