Best Medications for Insomnia
For adults with insomnia, eszopiclone is suggested as the first-line pharmacological treatment for both sleep onset and sleep maintenance insomnia due to its proven efficacy and favorable safety profile. 1
Medication Selection Algorithm Based on Insomnia Type
Sleep Onset Insomnia (Difficulty Falling Asleep)
First-line options:
Alternative options:
Sleep Maintenance Insomnia (Difficulty Staying Asleep)
First-line options:
Alternative options:
Evidence-Based Advantages of Eszopiclone
- Demonstrated efficacy for both sleep onset and maintenance insomnia 1, 2
- Approved for long-term use without evidence of tolerance development during 12 months of treatment 4
- Improves daytime functioning and health-related quality of life with 6 months of therapy 4
- No rebound insomnia or serious withdrawal effects upon discontinuation 4
- Effective in both adult and elderly populations 2
Medications NOT Recommended for Insomnia
The American Academy of Sleep Medicine specifically recommends against using:
- Trazodone 1
- Tiagabine 1
- Diphenhydramine (and other antihistamines) 1, 5
- Melatonin 1
- L-tryptophan 1
- Valerian 1
Important Clinical Considerations
Safety Concerns
- Next-day impairment: Eszopiclone 3mg has been associated with next-morning psychomotor and memory impairment that may persist up to 11.5 hours after dosing 2
- Memory effects: Memory impairment reported in 1-1.3% of patients taking eszopiclone 3mg 2
- Elderly patients: Use lower doses (eszopiclone 1-2mg, zolpidem 5mg) to minimize adverse effects 2, 3
Pharmacologic Profiles
- Newer non-benzodiazepines (eszopiclone, zolpidem, zaleplon) have better safety profiles than traditional benzodiazepines, making them preferred first-line choices for chronic insomnia 5, 6
- Benzodiazepines are most useful for short-term treatment only, as long-term use may lead to adverse effects and withdrawal phenomena 5
Duration of Treatment
- Eszopiclone is uniquely positioned as the only non-benzodiazepine hypnotic that has been evaluated and approved for long-term treatment of chronic insomnia 7
- Most other hypnotics should be prescribed for short periods only 5
Special Populations
Elderly Patients
- Use lower doses: eszopiclone 1-2mg, zolpidem 5mg 2, 3
- Eszopiclone 2mg has been shown to improve next-day functioning and daytime alertness in elderly patients 7
Patients with Co-morbid Conditions
- Eszopiclone has shown efficacy in treating insomnia coexisting with other conditions and may improve certain measures of the co-morbid conditions beyond standard therapies alone 4
By following this medication selection algorithm and considering the individual patient's specific type of insomnia, clinicians can optimize treatment outcomes while minimizing potential adverse effects.