What medications are recommended to help with falling asleep?

Medications for Falling Asleep

For patients with difficulty falling asleep, short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon are recommended as first-line pharmacological treatments. 1

First-Line Pharmacological Options

• Zolpidem (10mg, 5mg in elderly) is effective for both sleep onset and sleep maintenance insomnia 1
• Zaleplon (10mg) is specifically recommended for sleep onset insomnia 1
• Eszopiclone (2-3mg) is effective for both sleep onset and sleep maintenance insomnia 1
• Ramelteon (8mg) is recommended specifically for sleep onset insomnia and works on melatonin receptors without risk of tolerance 1, 2

Second-Line Options

• Temazepam (15mg) can be used for both sleep onset and sleep maintenance insomnia when first-line agents are ineffective 1
• Doxepin (3-6mg) is suggested primarily for sleep maintenance insomnia 1
• Suvorexant (orexin receptor antagonist) is recommended for sleep maintenance issues 1, 2

Treatment Algorithm

1. Begin with cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for all adults with chronic insomnia due to its superior long-term efficacy and minimal risk of adverse effects 1, 2
2. If medication is necessary, start with short/intermediate-acting BzRAs (zolpidem, zaleplon, eszopiclone) or ramelteon 1
3. For sleep onset difficulty specifically, consider zaleplon, ramelteon, or zolpidem 1
4. If first-line agents fail, try alternative BzRAs or consider sedating antidepressants for patients with comorbid depression/anxiety 1

Special Considerations for Older Adults

• Lower doses should be used in elderly patients (e.g., zolpidem 5mg instead of 10mg) 1, 3
• Benzodiazepines should be avoided when possible in older adults due to increased risk of falls, cognitive impairment, and dependence 4, 3
• Ramelteon has a minimal adverse effect profile, making it a valuable first-line option for older adults 3

Medications to Avoid

• Over-the-counter antihistamines (e.g., diphenhydramine) are not recommended due to lack of efficacy data and safety concerns 1, 3
• Trazodone is not recommended for sleep onset insomnia 1
• Tiagabine (anticonvulsant) is not recommended for sleep onset or maintenance insomnia 1
• Herbal supplements (e.g., valerian) and melatonin have insufficient evidence of efficacy 1
• Older hypnotics including barbiturates and chloral hydrate are not recommended 1

Important Clinical Considerations

• Short-term hypnotic treatment should be supplemented with behavioral and cognitive therapies 1, 5
• Use medications for the shortest duration possible at the lowest effective dose 5, 6
• Monitor patients regularly to assess effectiveness and side effects 1
• Long-term use of benzodiazepines and non-benzodiazepine hypnotics can lead to tolerance and diminished efficacy 2, 7
• Sleep hygiene education (regular exercise, daytime bright light exposure, comfortable sleep environment, avoiding heavy meals/alcohol/nicotine near bedtime) should be part of any insomnia treatment plan 4

Common Pitfalls to Avoid

• Using sedating agents without considering their specific effects on sleep onset versus maintenance 1
• Failing to consider drug interactions and contraindications 1
• Continuing pharmacotherapy long-term without periodic reassessment 1, 2
• Abrupt discontinuation of benzodiazepines or z-drugs, which can precipitate withdrawal symptoms 2
• Focusing solely on pharmacological approaches without addressing behavioral components 2, 5