What are the most effective medications for insomnia (sleep disorder)?

From the Guidelines

For insomnia, I strongly recommend starting with cognitive behavioral therapy for insomnia (CBT-I) as the first-line treatment, as it has been shown to improve global and sleep outcomes in adults with chronic insomnia disorder 1.

Key Points to Consider

• CBT-I has been found to be effective in improving sleep outcomes, including reduced sleep onset latency and wake after sleep onset, and improved sleep efficiency and sleep quality 1.
• If CBT-I is unsuccessful, a shared decision-making approach can be used to decide whether to add pharmacological therapy, considering the benefits, harms, and costs of short-term use of medications 1.
• Pharmacologic options, such as eszopiclone, zolpidem, and suvorexant, may improve short-term global and sleep outcomes, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not well established 1.

Important Considerations

• It is essential to discuss the potential harms associated with pharmacologic treatments, including cognitive and behavioral changes, and to use the lowest effective dose to prevent dependence 1.
• Good sleep hygiene practices, such as maintaining a regular sleep schedule, avoiding screens before bed, and practicing relaxation techniques, should be combined with medication or CBT-I to improve sleep outcomes.
• If insomnia persists beyond a few weeks, it is crucial to consult a healthcare provider to rule out underlying conditions that may require different treatment.

From the FDA Drug Label

The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™)

Best insomnia meds are eszopiclone and zolpidem, as they have been shown to be effective in reducing sleep latency and improving sleep maintenance in clinical trials 2 3.

• Eszopiclone was superior to placebo on measures of sleep latency and sleep maintenance, including polysomnographic (PSG) parameters of latency to persistent sleep (LPS) and wake time after sleep onset (WASO).
• Zolpidem was superior to placebo on objective (polysomnographic) measures of sleep latency, sleep duration, and number of awakenings.

From the Research

Non-Benzodiazepine Hypnotics

• Non-benzodiazepines, such as zolpidem, zopiclone, and zaleplon, demonstrate hypnotic efficacy similar to that of benzodiazepines along with excellent safety profiles 4.
• These medications generally cause less disruption of normal sleep architecture than benzodiazepines and may have less psychomotor and memory impairment 4.
• Rebound insomnia and withdrawal symptoms occur infrequently upon discontinuation of non-benzodiazepines and may be less common and milder than those seen upon discontinuation of some benzodiazepines 4.

Long-Term Treatment of Insomnia

• For the long-term treatment of insomnia, zolpidem and zopiclone are particularly good options because they do not develop tolerance rapidly and have a low abuse potential 4.
• Eszopiclone, a nonbenzodiazepine hypnotic agent, has been shown to significantly improve both sleep onset and sleep maintenance compared with placebo in adult and elderly patients with primary insomnia, with no evidence of tolerance during 12 months' treatment 5.

Pharmacological Management of Insomnia

• The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations 6.
• Newer hypnotics have been shown to have a better safety profile and longer-term efficacy compared to older medications for insomnia 6.
• The choice of which hypnotic to use should be based on the patient's primary sleep complaint, health history, adverse effects, and cost 4.

Comparative Tolerability of Newer Agents

• Newer treatment options for insomnia, including non-benzodiazepine hypnotics and the melatonin receptor agonist ramelteon, are generally well tolerated and present favorable safety profiles compared to older benzodiazepines and barbiturates 7.
• Commonly cited impairments of memory formation and decrements in psychomotor performance are related to the mechanism of action of hypnotics and are both dose- and time-dependent 7.