What medications are recommended for treating insomnia?

Medication Recommendations for Insomnia

Low-dose eszopiclone (1 mg) is the most appropriate first-line medication for insomnia, particularly in elderly patients with fall risk, due to its demonstrated efficacy for sleep maintenance and better safety profile compared to benzodiazepines or trazodone. 1

First-Line Pharmacological Options

The FDA has approved several medications for insomnia treatment, with specific indications based on the type of sleep disturbance:

Sleep Onset Insomnia

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

Sleep Maintenance Insomnia

• Eszopiclone: 2-3mg (1mg for elderly) 1, 4
• Doxepin: 3-6mg 1
• Suvorexant: 10-20mg 1
• Temazepam: 15mg 1

Efficacy Comparison

Different medications show varying efficacy for different aspects of insomnia:

Medication	Sleep Onset	Sleep Maintenance	Sleep Quality
Eszopiclone	Moderate improvement	10-14 min improvement	Moderate-to-Large improvement
Zolpidem	Moderate improvement	25 min improvement	Moderate improvement
Ramelteon	Significant improvement	Limited effect	Not well-reported
Doxepin (3-6mg)	Modest improvement	Effective	Improved
Suvorexant	Limited improvement	16-28 min improvement	Not well-reported

Medication Selection Algorithm

1. Identify the type of insomnia:

   • Sleep onset difficulties → Consider zolpidem, zaleplon, or ramelteon
   • Sleep maintenance issues → Consider eszopiclone, doxepin, or suvorexant
   • Both onset and maintenance → Consider eszopiclone or zolpidem

2. Consider patient factors:

   • Elderly patients or those with fall risk → Start with low-dose eszopiclone (1mg) 1
   • History of substance abuse → Avoid benzodiazepines; consider ramelteon
   • Respiratory disorders → Non-benzodiazepines preferred due to minimal respiratory depression 5

3. Evaluate contraindications:

   • Avoid benzodiazepines in patients with cognitive impairment risk or Huntington's disease 1
   • Avoid first-generation antihistamines in older adults due to anticholinergic effects 1

Important Prescribing Principles

• Start with lowest effective dose for the shortest duration necessary 1
• Schedule follow-up within 7-10 days to evaluate treatment response 1
• Monitor for side effects including falls, confusion, memory impairment, and drug interactions 1
• Consider gradual tapering when discontinuing medications to prevent withdrawal symptoms 1

Common Pitfalls and Caveats

• Avoid long-term use of hypnotic medications due to limited evidence for safety and efficacy 1
• Benzodiazepines carry higher risks of altered sleep architecture, psychomotor impairment, tolerance, dependence, and respiratory depression compared to non-benzodiazepines 5
• Rebound insomnia may occur after discontinuation, particularly with zolpidem (increased sleep onset latency by 13 minutes) 6
• Women may have higher plasma concentrations of zolpidem than men after 8 hours, increasing risk of next-day impairment 6
• Complex behaviors including sleepwalking, hallucinations, and sleep-driving have been reported with zolpidem use 6

Non-Pharmacological Approaches

Before or alongside medication:

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered first-line treatment 1
• Sleep hygiene education and regular exercise are recommended 1
• Image Rehearsal Therapy, Progressive Deep Muscle Relaxation, and Mindfulness-Based Techniques can be effective for anxiety-related sleep disturbances 1

The non-benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon) generally have better safety profiles than benzodiazepines, with less disruption of normal sleep architecture and lower risk of dependence 7, making them preferred options for both short-term and long-term management of insomnia when pharmacotherapy is indicated.