What medications are recommended for the treatment of insomnia?

Medication Recommendations for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be recommended as first-line treatment for insomnia, with pharmacological options reserved for when non-pharmacological approaches are insufficient or while CBT-I is being initiated. 1

Treatment Algorithm

First-Line Approach

1. Non-Pharmacological Interventions
   • CBT-I is the gold standard first-line treatment 1
   • Sleep hygiene practices:
     • Consistent sleep/wake schedule
     • Comfortable sleep environment
     • Limited evening light exposure
     • Avoiding stimulating activities before bedtime
   • Other effective approaches:
     • Stimulus control therapy
     • Regular physical exercise
     • Morning bright light exposure

Pharmacological Options (When Needed)

For Sleep Onset Insomnia

• First choice medications:
  • Zolpidem 10mg for adults, 5mg for elderly 1, 2
  • Zaleplon 10mg 1
  • Ramelteon 8mg 1, 3

For Sleep Maintenance Insomnia

• First choice medications:
  • Eszopiclone 2-3mg 1, 4
  • Doxepin 3-6mg 1
  • Suvorexant 10-20mg 1

Special Considerations

Elderly Patients

• Avoid benzodiazepines due to increased risk of cognitive impairment, falls, and motor vehicle accidents 1
• Limit Z-drugs to short-term use (<90 days) at lowest effective dose 1
• Doxepin at low doses (3-6mg) is particularly well-tolerated 1

Patients with Respiratory Conditions

• Avoid benzodiazepines due to risk of respiratory depression 1
• Non-benzodiazepine options are safer 5

PTSD-Related Insomnia

• Prazosin is first-line for insomnia with trauma-related nightmares 1

Medication Selection Nuances

• Z-drugs (zolpidem, zaleplon, eszopiclone) have better safety profiles than benzodiazepines with similar efficacy 6, 5

  • Zolpidem is FDA-approved for short-term treatment of sleep initiation difficulties 2
  • Eszopiclone is approved for both sleep onset and maintenance insomnia 4
  • These medications generally cause less disruption of normal sleep architecture than benzodiazepines 7

• Avoid quetiapine for insomnia due to significant safety concerns 1

  • Alternative medications like trazodone (50-100mg), low-dose doxepin, and mirtazapine have better evidence and fewer metabolic risks 1

Monitoring and Follow-Up

• Assess treatment response within 2-4 weeks 1
• Monitor for side effects:
  • Daytime sedation
  • Orthostatic hypotension
  • Cognitive changes
  • Falls

Important Caveats

• Hypnotics should generally be prescribed for short periods only 5
• Routine use of over-the-counter antihistamines for sleep should be discouraged 5
• Alcohol should not be used as a sleep aid 5
• For long-term management of chronic insomnia, non-benzodiazepines like zolpidem and eszopiclone are preferred over benzodiazepines due to lower tolerance development and abuse potential 7, 8
• "Start low, go slow" approach is recommended, especially in patients with cardiovascular conditions 1