What are the best medications for maintenance insomnia?

Best Medications for Maintenance Insomnia

For maintenance insomnia, low-dose doxepin (3-6mg) is the recommended first-line pharmacological treatment due to its effectiveness in reducing wake after sleep onset by 22-23 minutes and improving total sleep time by 26-32 minutes compared to placebo, with a favorable safety profile. 1

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

Before considering medications, it's important to note that:

• CBT-I should be considered the first-line treatment for all forms of chronic insomnia, including maintenance insomnia 2, 1
• CBT-I produces sustained benefits without the risk of tolerance or adverse effects associated with medications 3
• CBT-I components include sleep restriction, stimulus control, cognitive restructuring, sleep hygiene, and relaxation techniques 4

Pharmacological Options for Maintenance Insomnia

When medications are necessary, the following are recommended specifically for sleep maintenance problems:

First-Line Medication:

• Doxepin (3-6mg)
  • Reduces wake after sleep onset by 22-23 minutes 2
  • Improves total sleep time by 26-32 minutes 2
  • Small-to-moderate improvement in sleep quality 2
  • Lower risk of next-day impairment than other options

Alternative Options:

1. Eszopiclone (2-3mg)

   • Improves total sleep time by 28-57 minutes 2
   • Reduces wake after sleep onset by 10-14 minutes 2
   • Moderate-to-large improvement in sleep quality 2
   • Caution: May cause unpleasant taste, daytime sedation

2. Suvorexant

   • Improves total sleep time by 10 minutes 2
   • Reduces wake after sleep onset by 16-28 minutes 2
   • Orexin receptor antagonist with different mechanism than other hypnotics

3. Temazepam (15mg)

   • For severe maintenance insomnia cases only
   • Improves total sleep time by 99 minutes 2
   • Small improvement in sleep quality 2
   • Caution: Benzodiazepine with higher risk of dependence, falls, and cognitive impairment

Important Considerations and Limitations

• Duration of treatment: FDA has approved pharmacologic therapy for short-term use only (4-5 weeks) 2

• Follow-up evaluation: Patients whose insomnia doesn't improve within 7-10 days should be further evaluated 2

• Safety concerns: Hypnotic medications may be associated with serious adverse effects including:

  • Dementia
  • Serious injury and fractures
  • Daytime impairment
  • "Sleep driving" and behavioral abnormalities
  • Worsening depression 2

• Dosing considerations: The FDA recommends lower dosages than those used in many studies, especially for older adults 2

• Benzodiazepines: Should generally be avoided due to risks of dependency, falls, cognitive impairment, and hypoventilation 1

• Trazodone: Not recommended for sleep maintenance insomnia due to lack of supporting evidence for efficacy 1

Special Populations

• Elderly patients: Start with lowest possible doses (e.g., 5mg for appropriate medications) due to altered pharmacokinetics 1
• Patients ≥85 years: Extra caution with screening for frailty and testing for orthostatic hypotension before starting medications 1

Monitoring and Follow-up

• Follow-up within 2-4 weeks to assess:

  • Frequency and severity of insomnia episodes
  • Daytime functioning
  • Medication side effects
  • Need for treatment adjustment 1

• Use standardized sleep assessment tools to track progress 1

• Maintain consistent medication timing to establish routine and improve adherence 1

Remember that the evidence for long-term use of any medication for insomnia is insufficient, and patients should be discouraged from using these drugs for extended periods 2.