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

From the Guidelines

For adults with insomnia disorder, cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment, as it has been shown to improve global and sleep outcomes in the general population and in older adults 1.

Key Points to Consider

• The American College of Physicians recommends a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1.
• If medication is necessary, eszopiclone, zolpidem, and suvorexant may improve short-term global and sleep outcomes for adults with insomnia disorder, but the comparative effectiveness and long-term efficacy of pharmacotherapies for insomnia are not known 1.
• Non-prescription options like melatonin (1-5mg taken 30-60 minutes before bedtime) or diphenhydramine (Benadryl, 25-50mg at bedtime) can be considered as initial treatments.
• Prescription medications such as benzodiazepines (e.g., temazepam) or non-benzodiazepine "Z-drugs" (e.g., zolpidem, eszopiclone, zaleplon) can be used for short-term treatment, while trazodone, mirtazapine, or doxepin may be considered for longer-term use.

Important Considerations

• It is essential to start with the lowest effective dose to minimize side effects like daytime drowsiness, dizziness, or dependency.
• Combining medication with good sleep hygiene practices, such as maintaining a regular sleep schedule, avoiding screens before bed, limiting caffeine and alcohol, and creating a comfortable sleep environment, is crucial for effective management of insomnia.
• If insomnia persists beyond 2-3 weeks despite treatment, it is necessary to consult a healthcare provider, as it may indicate an underlying condition requiring 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™) Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset.

Best insomnia meds are:

• Eszopiclone: significantly decreased sleep latency and improved measures of sleep maintenance
• Zolpidem: superior to placebo on objective (polysomnographic) measures of sleep latency, sleep duration, and number of awakenings
• Ramelteon: indicated for the treatment of insomnia characterized by difficulty with sleep onset 2, 3, 4

From the Research

Insomnia Medications

• Non-benzodiazepines, such as zolpidem, zopiclone, and zaleplon, are considered good options for the treatment of insomnia due to their hypnotic efficacy and excellent safety profiles 5.
• These medications generally cause less disruption of normal sleep architecture than benzodiazepines and may have less risk of psychomotor and memory impairment 5.
• Eszopiclone, a nonbenzodiazepine hypnotic agent, has been shown to significantly improve sleep onset and maintenance in adult and elderly patients with primary insomnia 6, 7.
• Comparative studies have found that eszopiclone is generally well tolerated and has a low risk of dependence and abuse 8, 7.

Safety and Efficacy

• The choice of hypnotic medication should be based on the patient's primary sleep complaint, health history, adverse effects, and cost 5.
• Eszopiclone has been found to have a favorable safety profile, with common adverse events including unpleasant taste, dry mouth, somnolence, and dizziness 7.
• Meta-analytic integrations have demonstrated that eszopiclone is effective in reducing sleep onset latency, wake time after sleep onset, and increasing total sleep time 7.
• However, increased caution is required in elderly individuals with cognitive and motor impairments and individuals who are at increased risk of using eszopiclone in a non-recommended way 7.

Treatment Options

• Pharmacologic and nonpharmacologic therapies both have roles in the treatment of insomnia, and the choice of treatment should be individualized based on the patient's needs and preferences 9.
• Nonpharmacologic therapies, such as cognitive-behavioral therapy, can be effective in the treatment of insomnia, but may require more time and effort from the patient 9.
• Newer medications, such as selective melatonin receptor agonists, are being developed and may offer alternative treatment options for insomnia 9.