What medications are recommended for treating insomnia?

Recommended Medications for Insomnia

For treating insomnia in adults, FDA-approved medications including eszopiclone, zolpidem, suvorexant, and ramelteon are recommended based on the type of sleep disturbance (onset vs. maintenance), with non-benzodiazepine options preferred over benzodiazepines due to their better safety profile. 1

First-Line Pharmacologic Options Based on Insomnia Type

For Sleep Onset Insomnia:

• Eszopiclone (2-3 mg): Effective for difficulties falling asleep 1, 2
• Zolpidem (10 mg): Recommended for sleep onset issues 1
• Zaleplon (10 mg): Specifically indicated for sleep onset insomnia 1
• Ramelteon (8 mg): Particularly useful for sleep onset difficulties with fewer side effects than other options 1, 3

For Sleep Maintenance Insomnia:

• Suvorexant (10-20 mg): Dual orexin receptor antagonist effective for maintaining sleep 1, 4
• Eszopiclone (2-3 mg): Beneficial for both falling and staying asleep 1, 2
• Zolpidem (10 mg): Helps with both sleep onset and maintenance 1
• Doxepin (3-6 mg): Low-dose option specifically for sleep maintenance 1

For Both Sleep Onset and Maintenance:

• Eszopiclone (2-3 mg): Comprehensive coverage for both types of insomnia 1, 2, 5
• Zolpidem (10 mg): Effective for both difficulties falling asleep and staying asleep 1
• Temazepam (15 mg): Benzodiazepine option for both onset and maintenance issues 1

Medications to Avoid

• Trazodone: Not recommended for insomnia treatment despite common off-label use 1, 6
• Diphenhydramine: Over-the-counter antihistamine not recommended due to limited efficacy and side effects 1
• Melatonin supplements: Not recommended as primary treatment for adult insomnia 1
• Valerian: Insufficient evidence to support use 1
• L-tryptophan: Not recommended based on available evidence 1
• Tiagabine: Not recommended for insomnia treatment 1

Clinical Considerations

Safety Profile Considerations:

• Non-benzodiazepine agents (Z-drugs) generally have better safety profiles than benzodiazepines 7, 8
• Dual orexin receptor antagonists (suvorexant) offer an alternative mechanism with potentially fewer dependency issues 7
• Melatonin receptor agonists (ramelteon) are well-tolerated but may have limited effectiveness 7

Special Populations:

• Elderly patients: Consider lower doses (e.g., eszopiclone 1-2 mg, suvorexant 5-10 mg) due to altered pharmacokinetics and increased sensitivity 1, 5
• Hepatic impairment: Dose reduction recommended, particularly with eszopiclone in severe impairment 5

Common Pitfalls to Avoid:

• Long-term use of benzodiazepines without reassessment
• Failure to address underlying causes of insomnia
• Overlooking potential for tolerance, dependence, or rebound insomnia
• Not considering drug interactions, particularly with other CNS depressants
• Using antidepressants as first-line agents for insomnia without comorbid depression 6

Monitoring and Follow-up

• Assess effectiveness after 2-4 weeks of treatment
• Monitor for side effects including daytime drowsiness, cognitive impairment, and falls
• Evaluate for tolerance or dependence with long-term use
• Consider periodic medication holidays or tapering strategies for chronic use

Remember that pharmacologic therapy should ideally be short-term while addressing underlying causes of insomnia, though some medications like eszopiclone have demonstrated sustained efficacy for up to 6-12 months without significant tolerance development 5.