What is the stepwise approach for managing insomnia in an adult, including recommended dosages for medications like melatonin, triazolam (benzodiazepine), and zolpidem (non-benzodiazepine hypnotic)?

Stepwise Management of Insomnia in Adults

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

All adults with chronic insomnia should receive CBT-I as initial treatment before any pharmacological intervention. 1

• CBT-I consists of cognitive therapy around sleep, behavioral interventions (sleep restriction and stimulus control), and sleep hygiene education 1
• Multiple delivery methods are effective: individual therapy, group therapy, telephone-based, web-based modules, or self-help books 1
• CBT-I provides superior long-term outcomes compared to medications and has minimal adverse effects 2, 3
• Brief behavioral therapy (BBT) may be used when resources are limited, delivered over 2-4 sessions 2

Second-Line Treatment: Pharmacotherapy

If CBT-I is insufficient or unavailable, pharmacotherapy should be added as a supplement, not a replacement. 1, 2

Medication Selection Algorithm

For sleep onset insomnia (difficulty falling asleep):

• Zolpidem 10 mg (5 mg in women and elderly) - First choice 2, 4
• Zaleplon 10 mg - Alternative first-line option 2
• Ramelteon 8 mg - Melatonin receptor agonist, no tolerance risk 2, 5
• Triazolam 0.25 mg (0.125 mg in elderly) - Use cautiously due to rebound anxiety risk 2, 6

For sleep maintenance insomnia (difficulty staying asleep):

• Zolpidem 10 mg (5 mg in women and elderly) - First choice 2, 4
• Eszopiclone 2-3 mg - Alternative first-line option 2
• Temazepam 15 mg - Benzodiazepine option 2
• Doxepin 3-6 mg - Second-line, particularly effective for sleep maintenance 2, 5
• Suvorexant - Orexin receptor antagonist, second-line 2

Critical Dosing Guidelines

Zolpidem (FDA-approved dosing): 4

• Women: 5 mg once nightly
• Men: 5-10 mg once nightly (start with 5 mg)
• Elderly/debilitated: 5 mg maximum
• Take immediately before bedtime with 7-8 hours remaining for sleep
• Maximum total dose: 10 mg per night
• Do not readminister during the same night

Triazolam (FDA-approved dosing): 6

• Standard adult dose: 0.25 mg before retiring
• Low body weight patients: 0.125 mg
• Exceptional non-responders only: 0.5 mg (never exceed this dose)
• Elderly/debilitated: 0.125-0.25 mg maximum (start at 0.125 mg)

Medications NOT Recommended

Avoid these agents entirely: 2, 7

• Over-the-counter antihistamines (diphenhydramine) - lack efficacy data and cause daytime sedation, delirium risk in elderly
• Trazodone - not recommended by guidelines
• Tiagabine - not recommended
• Herbal supplements (valerian) - insufficient evidence
• Melatonin supplements - insufficient evidence
• Barbiturates and chloral hydrate - outdated, dangerous
• Antipsychotics as first-line - problematic metabolic side effects

Treatment Duration and Monitoring

Short-term pharmacotherapy only (typically <4 weeks for acute insomnia): 2

• Use the lowest effective dose for the shortest period possible 2
• Monitor patients every 2-4 weeks initially to assess response and side effects 5
• Reassess need for pharmacotherapy after 8-12 weeks of CBT-I 5, 7
• Gradually taper medications when discontinuing to prevent withdrawal and rebound insomnia 5

Special Population Considerations

Elderly patients (>55 years): 1, 4, 6

• More likely to report sleep maintenance problems than sleep onset problems 1
• Require lower doses of all medications due to increased sensitivity 5, 7
• Higher risk of falls, cognitive impairment, and complex sleep behaviors 5
• Zolpidem: 5 mg maximum 4
• Triazolam: 0.125-0.25 mg maximum 6

Patients with hepatic impairment: 4

• Mild-moderate: Zolpidem 5 mg maximum
• Severe: Avoid zolpidem entirely (may contribute to encephalopathy)

Women: 4

• Zolpidem clearance is lower in women
• Maximum dose: 5 mg (not 10 mg)
• Higher morning blood levels increase next-day impairment risk

Critical Safety Warnings

Combining multiple sedative medications significantly increases risks: 5

• Complex sleep behaviors (sleep-driving, sleep-eating)
• Cognitive impairment and memory problems
• Falls and fractures (particularly in elderly)
• Daytime sedation and motor vehicle accidents

FDA warnings for benzodiazepine and non-benzodiazepine hypnotics: 1

• Possible driving impairment and motor vehicle accidents
• Cognitive and behavioral changes
• Observational data suggest associations with dementia and fractures
• Recommend short-term use only

Avoid food interactions: 4

• Zolpidem absorption is slowed by food ingestion
• Take on empty stomach immediately before bedtime

Common Clinical Pitfalls to Avoid

• Never use pharmacotherapy as first-line treatment - CBT-I must be attempted first 1, 2
• Never continue long-term pharmacotherapy without periodic reassessment - tolerance develops, effectiveness diminishes 5, 7
• Never use long-acting benzodiazepines - increased risks without clear benefit 2
• Never combine multiple GABA-ergic medications - additive risks, no additional benefit once tolerance develops 5
• Never prescribe without implementing behavioral strategies - medications should supplement, not replace CBT-I 2, 5
• Never ignore underlying sleep disorders - consider sleep study if treatment-resistant to rule out sleep apnea 5

Treatment-Resistant Insomnia Algorithm

If patient fails multiple medications: 5

1. Reassess diagnosis - rule out sleep apnea, restless legs syndrome, psychiatric comorbidities
2. Intensify CBT-I implementation - ensure all components are being utilized
3. Consider adding low-dose doxepin 3-6 mg (works via H1 antagonism, different mechanism) 5
4. Gradually taper existing medications to address tolerance 5
5. Avoid further benzodiazepine use if tolerance is evident 5