What are the recommended sleep medications for insomnia?

Recommended Sleep Medications for Insomnia

For the treatment of chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) should be first-line treatment, with pharmacologic options considered when CBT-I alone is insufficient or while waiting for CBT-I to take effect. 1

First-Line Pharmacologic Options

Short/Intermediate-Acting Benzodiazepine Receptor Agonists (BzRAs)

• For sleep onset insomnia: Zaleplon (10 mg), zolpidem (10 mg), and triazolam (0.25 mg) are effective for reducing time to fall asleep 1, 2
• For sleep maintenance insomnia: Eszopiclone (2-3 mg), zolpidem (10 mg), and temazepam (15 mg) are effective for improving sleep duration and reducing nighttime awakenings 1, 3
• These medications improve total sleep time by approximately 28-99 minutes compared to placebo 1
• Should be used at the lowest effective dose and for the shortest duration possible 1

Melatonin Receptor Agonist

• Ramelteon (8 mg) is recommended for sleep onset insomnia 1, 4
• Has minimal adverse effect profile compared to BzRAs, making it valuable for older adults 5
• Does not show evidence of abuse potential or significant cognitive/motor impairment 1

Orexin Receptor Antagonist

• Suvorexant is effective for sleep maintenance insomnia 1
• Improves total sleep time by approximately 10 minutes and reduces wake after sleep onset by 16-28 minutes compared to placebo 1

Second-Line Pharmacologic Options

Sedating Antidepressants

• Doxepin (3-6 mg) is effective for sleep maintenance insomnia, reducing wake after sleep onset by 22-23 minutes compared to placebo 1
• Other sedating antidepressants (trazodone, amitriptyline, mirtazapine) should be considered primarily when comorbid depression/anxiety is present 1
• Evidence does not support trazodone (50 mg) for primary insomnia without comorbid depression 1

Special Considerations for Older Adults

• Start with lower doses in older adults (e.g., zolpidem 5 mg instead of 10 mg) 1
• Benzodiazepines should be avoided or used with extreme caution due to increased risk of falls, cognitive impairment, and dependence 1, 5
• Ramelteon may be particularly suitable for older adults due to its favorable safety profile 5
• Doxepin (3-6 mg) is effective and generally well-tolerated in older adults 1

Not Recommended for Insomnia

• Over-the-counter antihistamines (diphenhydramine) are not recommended due to lack of efficacy data and risk of side effects, particularly in older adults 1
• Herbal supplements (valerian) and melatonin lack sufficient evidence for efficacy 1
• Tiagabine is not recommended based on available evidence 1
• Barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended due to safety concerns 1

Duration of Treatment

• FDA has approved most sleep medications for short-term use (4-5 weeks) 1
• Long-term use of hypnotics should be approached cautiously with regular follow-up to assess continued need, effectiveness, and adverse effects 1
• If long-term treatment is necessary, consider intermittent dosing (e.g., 3 nights per week) when possible 1

Common Pitfalls and Caveats

• Avoid prescribing sleep medications without addressing underlying causes of insomnia and implementing non-pharmacologic strategies 1
• Be aware of potential for dependence, tolerance, and rebound insomnia with BzRAs 1, 2
• Consider drug interactions, especially in patients on multiple medications 1
• Residual daytime sedation can occur with many sleep medications, potentially affecting driving and other activities requiring alertness 1, 5
• Older adults are at increased risk for adverse effects due to altered pharmacokinetics and increased sensitivity to peak drug effects 1

Algorithm for Medication Selection

1. Identify predominant insomnia pattern:

   • Sleep onset difficulty → Consider zaleplon, zolpidem, triazolam, or ramelteon 1
   • Sleep maintenance difficulty → Consider eszopiclone, zolpidem, temazepam, suvorexant, or doxepin 1

2. Consider patient factors:

   • Older adult → Prefer ramelteon or low-dose doxepin; use caution with BzRAs 1, 5
   • History of substance abuse → Avoid BzRAs; consider ramelteon 1
   • Comorbid depression/anxiety → Consider sedating antidepressant 1

3. Start with lowest effective dose and reassess regularly for efficacy and side effects 1

4. Plan for discontinuation by tapering medication when appropriate 1