What are safe medications to help a patient with insomnia?

Safe Medications for Insomnia Management

Cognitive behavioral therapy for insomnia (CBT-I) should be the first-line treatment for insomnia, with pharmacotherapy considered as a second-line option when necessary. 1, 2

First-Line Non-Pharmacological Approach

• CBT-I is recommended as the initial intervention for treating insomnia, which includes components such as stimulus control therapy, sleep restriction therapy, cognitive therapy, and relaxation techniques 1
• Sleep hygiene alone is insufficient for treating chronic insomnia but should be used in combination with other therapies 1

Recommended Pharmacological Options (When Needed)

For Sleep Onset Insomnia:

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs) are recommended as first-line pharmacotherapy 3, 1:
  • Zaleplon 10 mg 1, 2
  • Zolpidem 10 mg (5 mg for elderly) 1, 2, 4
• Ramelteon 8 mg is also recommended for sleep onset difficulties 1, 2

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3 mg (1-2 mg for elderly) is effective for both sleep onset and maintenance insomnia 1, 2, 5
• Zolpidem 10 mg can be used for both sleep onset and maintenance 1, 2, 4
• Temazepam 15-30 mg (7.5 mg for elderly) 1
• Doxepin 3-6 mg is specifically recommended for sleep maintenance issues 1, 2

Medications Not Recommended

• Over-the-counter antihistamines (diphenhydramine) are not recommended for chronic insomnia due to lack of efficacy and safety data 3, 1, 2
• Melatonin and herbal supplements (e.g., valerian) are not recommended by guidelines for chronic insomnia due to insufficient efficacy and safety data 3, 1, 2
• Trazodone is specifically not recommended despite common use in clinical practice 1, 2
• Older drugs including barbiturates, barbiturate-type drugs, and chloral hydrate are not recommended 3, 1

Important Safety Considerations

• Eszopiclone may cause next-morning psychomotor and memory impairment that can persist for up to 11.5 hours after dosing 5
• Zolpidem can cause next-day residual effects including decreased performance on cognitive tests 4
• All hypnotic medications should be used at the lowest effective dose and for the shortest duration possible 2
• Patients should be warned about potential side effects including:
  • Sleepiness during the day 5
  • Confusion and memory impairment 5, 4
  • Sleep-walking and other sleep-related activities (eating, talking, driving) 5

Monitoring and Follow-Up

• Follow patients regularly (every few weeks initially) to assess effectiveness, side effects, and need for ongoing medication 3, 1
• Efforts should be made to employ the lowest effective maintenance dosage and to taper medication when conditions allow 3
• Long-term administration may be nightly, intermittent (e.g., three nights per week), or as needed 3
• Patient education should include treatment goals, safety concerns, potential side effects, drug interactions, and rebound insomnia potential 3, 5

Special Considerations

• Elderly patients generally require lower doses of sleep medications due to altered metabolism and increased sensitivity to side effects 1, 5, 4
• Chronic hypnotic medication may be indicated for long-term use in those with severe or refractory insomnia or chronic comorbid illness 3
• Whenever possible, patients should receive an adequate trial of cognitive behavioral treatment during long-term pharmacotherapy 3