What are alternative sleep medications to Lunesta (eszopiclone)?

Alternative Sleep Medications to Lunesta (Eszopiclone)

For patients requiring alternatives to Lunesta (eszopiclone) for insomnia treatment, cognitive behavioral therapy for insomnia (CBT-I) should be considered first-line therapy, followed by pharmacological options including zolpidem, zaleplon, suvorexant, or doxepin if necessary. 1

First-Line Non-Pharmacological Treatment

• CBT-I should be the initial treatment approach for chronic insomnia before considering any medication, as recommended by the American College of Physicians 1
• CBT-I has demonstrated effectiveness in improving sleep outcomes including reduced sleep onset latency, wake after sleep onset, and improved sleep efficiency 1

Pharmacological Alternatives

Z-Drugs (Non-Benzodiazepine Hypnotics)

• Zolpidem (Ambien):

  • Effective for both sleep onset and sleep maintenance insomnia with a half-life of approximately 2.4 hours 2
  • Available in immediate-release (10 mg standard dose) and extended-release formulations 1
  • Meta-analysis shows zolpidem improves subjective sleep latency by approximately 19.55 minutes compared to placebo 1
  • FDA approved for short-term use (4-5 weeks) 1

• Zaleplon (Sonata):

  • Ultra-short half-life of approximately 1 hour, making it primarily effective for sleep onset insomnia 2
  • Minimal residual effects due to rapid elimination 2
  • Best for patients who have difficulty falling asleep but not staying asleep 2

Orexin Receptor Antagonists

• Suvorexant (Belsomra):
  • Moderate-quality evidence shows suvorexant improves treatment response and sleep outcomes 1
  • Recommended at lower doses (5-10 mg) as a second-line treatment option 3
  • Particularly effective for sleep maintenance, reducing wake after sleep onset by 16-28 minutes compared to placebo 3
  • Most common adverse effect is somnolence (7% vs 3% for placebo) 3

Other Medication Options

• Doxepin (Silenor):

  • Low-dose doxepin (3-6 mg) provides strong evidence for sleep maintenance 3
  • Moderate-quality evidence shows doxepin improved Insomnia Severity Index scores 1
  • Low-to-moderate quality evidence shows improved sleep outcomes 1
  • Particularly effective for reducing wake after sleep onset by 22-23 minutes 3

• Ramelteon (Rozerem):

  • Melatonin receptor agonist that decreases sleep onset latency in older adults 1
  • Low-quality evidence showed no statistically significant difference between ramelteon and placebo for sleep outcomes in the general population 1

Special Considerations

• For elderly patients:

  • Consider lower doses (zolpidem 5 mg, suvorexant 5 mg, doxepin 3 mg) 1, 3
  • Eszopiclone and zolpidem improved global and sleep outcomes in older adults 1
  • No dose adjustment needed for orexin inhibitors based on age alone 3

• For sleep maintenance issues:

  • Suvorexant, doxepin, or extended-release zolpidem may be more appropriate than shorter-acting agents 3, 2

• Safety concerns:

  • All hypnotic medications carry risks of adverse effects including daytime impairment, "sleep driving," behavioral abnormalities, and potential for dependence 1
  • FDA labels warn of potential cognitive and behavioral changes with orexin inhibitors 3
  • Observational studies have shown hypnotic drugs may be associated with infrequent but serious adverse effects such as dementia, injury, and fractures 1

Duration of Treatment

• FDA has approved pharmacologic therapy for short-term use (4-5 weeks) 1
• Patients should not continue using these medications for extended periods without reevaluation 1
• If insomnia does not improve within 7-10 days of treatment, further evaluation is recommended 1

Algorithm for Selection

1. Start with CBT-I as first-line therapy 1
2. If CBT-I alone is unsuccessful, consider adding pharmacotherapy based on:
   • Primary complaint: sleep onset vs. maintenance issues
   • Patient age and comorbidities
   • Previous medication responses
   • Side effect profiles and contraindications 1, 3
3. For sleep onset issues: Consider zaleplon or immediate-release zolpidem 2
4. For sleep maintenance issues: Consider suvorexant, doxepin, or extended-release zolpidem 3, 2
5. Use the lowest effective dose for the shortest duration possible 2