What are the recommended medications and treatments for insomnia?

Medication Guide for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for all adults with chronic insomnia, with pharmacological therapy reserved as second-line treatment only when CBT-I alone is unsuccessful. 1, 2

First-Line Treatment: CBT-I

• CBT-I has demonstrated superior long-term efficacy compared to pharmacological options and carries minimal risk of adverse effects 1
• Key components of CBT-I include:
  • Stimulus control (using bed only for sleep and sex) 2
  • Sleep restriction therapy 2
  • Cognitive therapy to restructure maladaptive thoughts about sleep 3
  • Sleep hygiene education 2
  • Relaxation techniques to reduce psychophysiological arousal 3
• Collection of sleep diary data before and during treatment is recommended to monitor progress 2

Second-Line Treatment: Pharmacological Options

When CBT-I is insufficient or not feasible, medications may be considered with the following guidelines:

Short/Intermediate-Acting Benzodiazepine Receptor Agonists (BzRAs)

• Use at the lowest effective dose for the shortest period possible (4-5 weeks) 1
• Options include:
  • Zaleplon - very short half-life, best for sleep onset issues 3
  • Zolpidem - effective for sleep onset 3, 1
  • Eszopiclone - longer half-life, better for sleep maintenance 3
  • Temazepam - longer half-life, better for sleep maintenance 3

Orexin Receptor Antagonists

• Suvorexant is indicated for insomnia characterized by difficulties with sleep onset and/or maintenance 4
• Recommended starting dose is 10 mg, with maximum dose of 20 mg once per night 4
• Take within 30 minutes of going to bed with at least 7 hours remaining before planned awakening 4

Melatonin Receptor Agonists

• Ramelteon is indicated for insomnia characterized by difficulty with sleep onset 5
• Lower abuse potential makes it suitable for patients with substance use history 1, 2

Non-Scheduled Medications

• Low-dose doxepin (3-6 mg) is particularly effective for sleep maintenance insomnia 6
• Other sedating antidepressants that may be considered:
  • Trazodone (typically 50 mg) 6
  • Mirtazapine - beneficial for patients with comorbid depression and insomnia 6

Special Considerations

Medication Selection Factors

• Symptom pattern (difficulty falling asleep vs. staying asleep) 3, 6
• Patient's age and comorbidities 6
• Previous treatment response 3
• Risk of abuse/dependence, especially in patients with substance use history 2
• Cost and patient preference 3, 6

Safety Concerns

• FDA has approved pharmacologic therapy for short-term use only (4-5 weeks) 1
• Potential adverse effects of BzRAs include:
  • Residual sedation and daytime impairment 1, 4
  • Memory and performance impairment 3
  • Falls and injuries 1
  • Behavioral abnormalities including "sleep driving" 1
• Benzodiazepines should be avoided in patients with history of substance use due to high abuse potential 2
• Antihistamine sleep aids are not recommended due to lack of efficacy and safety data 6
• Herbal substances such as valerian are not recommended due to insufficient evidence 6

Treatment Algorithm

1. Start with CBT-I as first-line treatment 1, 2

   • Implement all components: stimulus control, sleep restriction, cognitive therapy, sleep hygiene
   • Continue for at least 4-8 weeks to evaluate effectiveness

2. If CBT-I is insufficient after adequate trial:

   • For sleep onset insomnia: Consider zaleplon, zolpidem, or ramelteon 3, 5
   • For sleep maintenance insomnia: Consider eszopiclone, temazepam, or low-dose doxepin 3, 6
   • For both onset and maintenance issues: Consider suvorexant 4

3. When using medications:

   • Start with lowest effective dose 6
   • Limit duration to 4-5 weeks when possible 1
   • Continue incorporating behavioral techniques 1
   • Monitor regularly for treatment response, adverse effects, and potential misuse 2
   • Reduce dose or discontinue if daytime somnolence develops 4

4. For patients with substance use history:

   • Exercise extreme caution with medication choices 2
   • Consider non-benzodiazepine options like ramelteon or low-dose doxepin 2, 6
   • Implement more intensive monitoring for signs of misuse 2

By following this evidence-based approach, clinicians can effectively manage insomnia while minimizing risks associated with pharmacological interventions.