From the Guidelines
Insomnia can be effectively treated with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, and pharmacological treatments such as eszopiclone, zolpidem, and suvorexant may be considered for short-term use in adults with chronic insomnia disorder. The most recent and highest quality study 1 suggests that suvorexant, eszopiclone, zaleplon, zolpidem, triazolam, temazepam, ramelteon, and doxepin may be used as treatments for sleep onset and sleep maintenance insomnia in adults. However, the study also notes that the evidence for these treatments is generally weak, and the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not well established. Key points to consider when treating insomnia include:
- CBT-I is a non-invasive treatment that can be performed in the primary care setting and has been shown to be effective in treating chronic insomnia disorder in adults, including older adults 1.
- Pharmacologic treatments for insomnia are intended for short-term use and can be associated with serious adverse events, such as cognitive and behavioral changes, and increased risk for dementia, fractures, and major injury 1.
- Patients should be discouraged from using pharmacologic treatments for extended periods, and the long-term adverse effects of these treatments are unknown 1.
- Before starting any sleep medication, patients should discuss their complete medical history and other medications with their doctor, as these drugs can cause side effects including dizziness, confusion, and next-day impairment. Some of the key pharmacological treatments for insomnia include:
- Non-benzodiazepine hypnotics like zolpidem (Ambien) 5-10mg, eszopiclone (Lunesta) 1-3mg, or zaleplon (Sonata) 5-10mg taken at bedtime.
- Melatonin supplements (1-5mg) may help regulate sleep cycles with fewer side effects.
- For chronic insomnia, medications like trazodone 25-100mg or mirtazapine 7.5-15mg might be prescribed.
From the FDA Drug Label
Zolpidem is a GABA A receptor positive modulator presumed to exert its therapeutic effects in the short-term treatment of insomnia through binding to the benzodiazepine site of α1 subunit containing GABA A receptors... The mechanism of action of suvorexant in the treatment of insomnia is presumed to be through antagonism of orexin receptors. Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.
The pharmacological treatments for insomnia include:
- GABA A receptor positive modulators such as zolpidem 2
- Orexin receptor antagonists such as suvorexant 3
- Melatonin receptor agonists such as ramelteon 4
From the Research
Pharmacological Treatments for Insomnia
The following pharmacological treatments are recommended for insomnia:
- Positive GABAergic modulators such as short and medium acting benzodiazepines and "Z-drugs" (eszopiclone, zaleplon, zolpidem, zopiclone) 5
- Dual orexin receptor antagonists (DORAs; daridorexant) 5, 6
- Melatonin receptor agonists (melatonin 2 mg prolonged release - PR) 5, 7
- Nonbenzodiazepine benzodiazepine receptor agonists (zolpidem, zopiclone, zaleplon) 7, 8, 9
- Antidepressants, antipsychotics, and anticonvulsants (although not approved by the U.S. Food and Drug Administration for this indication and may have severe side effects) 7
- Opiates (valuable in pain-associated insomnia) 8
Considerations for Treatment
When treating insomnia, the following considerations should be taken into account:
- Non-pharmacological interventions (cognitive behavioural therapy) are recommended as first-line treatment 5, 6, 7, 8
- Pharmacotherapy should be used if behavioural interventions are not effective or available 6
- Hypnotics should generally be prescribed for short periods only, with the frequency and duration of use customized to each patient's circumstances 8
- The choice of hypnotic should be based on the patient's primary sleep complaint, health history, adverse effects, and cost 9
- Clear guidance regarding safe and effective protocols for switching medications is necessary, especially for patients with chronic insomnia 5