Recommended Medications for Insomnia in the Acute Inpatient Setting
For managing insomnia in the acute inpatient setting, dexmedetomidine is the first-line pharmacological agent as it improves sleep architecture without suppressing REM sleep, while non-benzodiazepine options like zolpidem, zaleplon, and low-dose doxepin are preferred for specific sleep onset or maintenance issues. 1
First-Line Pharmacological Options
For General Use in Acute Care
- IV dexmedetomidine: Improves sleep architecture without REM sleep suppression 1
- Low-dose doxepin (3-6mg): Non-habit forming option for sleep maintenance insomnia with minimal next-day sedation 1
For Sleep Onset Insomnia
- Zolpidem: 10mg for adults, 5mg for elderly 1
- Zaleplon: 10mg (shorter half-life, useful for middle-of-night awakenings) 1
- Ramelteon: 8mg (FDA-approved melatonin receptor agonist with fewer adverse effects than many alternatives) 1, 2
For Sleep Maintenance Insomnia
- Eszopiclone: 2-3mg (1mg for elderly) - shown to improve sleep maintenance in clinical trials 1, 3
- Temazepam: 15mg (intermediate-acting benzodiazepine) 1, 4
- Suvorexant: 10-20mg (5mg for elderly) 1
Special Considerations for Inpatient Setting
Preferred Agents Based on Comorbidities
- With depression/anxiety: Trazodone (50-100mg) or mirtazapine (7.5-15mg) 1
- With PTSD/nightmares: Prazosin (first-line for trauma-related sleep disturbances) 1
- With neuropathic pain: IV gabapentin (improves both pain and sleep scores) 1
- With chronic benzodiazepine use: Parenteral benzodiazepines to prevent withdrawal while using non-benzodiazepine approaches for sleep 1
Medications to Avoid
- Propofol: Should not be used solely for sleep improvement due to REM suppression, hemodynamic side effects, and respiratory depression 1
- Diphenhydramine: Not recommended for sleep onset insomnia, particularly in elderly due to anticholinergic effects and delirium risk 1
- Melatonin: Insufficient evidence for use in critically ill adults 5, 1
Non-Pharmacological Interventions
Environmental Modifications (Critical in Inpatient Setting)
- Minimize noise (offer earplugs) and light disruptions 5, 1
- Maintain comfortable room temperature 1
- Reduce unnecessary nighttime interventions 1
For Mechanically Ventilated Patients
- Use assist-control ventilation at night rather than pressure support ventilation to improve sleep efficiency 1
Implementation Algorithm
- First attempt: Environmental modifications (earplugs, reduced noise/light, comfortable temperature)
- If ineffective, select agent based on insomnia type:
- Sleep onset: Zolpidem, zaleplon, or ramelteon
- Sleep maintenance: Eszopiclone, low-dose doxepin, or suvorexant
- For patients with specific comorbidities:
- Depression/anxiety: Trazodone or mirtazapine
- PTSD/nightmares: Prazosin
- Pain: Add gabapentin
- Respiratory conditions: Avoid benzodiazepines
- For elderly patients: Use lower doses (zolpidem 5mg, eszopiclone 1mg, suvorexant 5mg)
Monitoring and Safety
- Monitor for side effects, particularly daytime sedation, falls, and cognitive changes 1
- Assess for paradoxical reactions to benzodiazepines, especially in elderly patients 1
- For patients with respiratory conditions, avoid benzodiazepines due to risk of respiratory depression 1
- Be cautious with hypnotics due to potential cognitive and behavioral changes, driving impairment, and risk of motor vehicle accidents 1
Pitfalls to Avoid
- Using propofol solely for sleep improvement 1
- Prolonged use of benzodiazepines (increased risk of dependence) 1, 4
- Overlooking environmental factors that may be contributing to insomnia 5, 6
- Using antihistamines like hydroxyzine, which can cause daytime sedation and delirium, especially in older patients 1
- Relying on melatonin in critically ill patients due to insufficient evidence and concerns about product quality and consistency 5
By following this evidence-based approach, clinicians can effectively manage insomnia in the acute inpatient setting while minimizing adverse effects and optimizing patient outcomes.