From the Guidelines
For difficulty staying asleep, I strongly recommend starting with low-dose doxepin (3-6mg) as it has been suggested by clinicians as a treatment for sleep maintenance insomnia in adults, as stated in the American Academy of Sleep Medicine clinical practice guideline 1. This guideline provides a summary of clinical practice recommendations and GRADE components of decision-making, which supports the use of doxepin for sleep maintenance insomnia. Some key points to consider when using doxepin for sleep maintenance insomnia include:
- Starting with a low dose of 3mg and titrating up to 6mg as needed
- Taking the medication 30 minutes before bedtime to help maintain sleep throughout the night
- Implementing good sleep hygiene practices, such as maintaining a consistent sleep schedule, avoiding screens before bed, keeping the bedroom cool and dark, and limiting caffeine and alcohol
- Using the medication intermittently rather than nightly to prevent tolerance Other options, such as eszopiclone (2-3mg) and zolpidem (10mg), may also be considered, as they have been suggested by clinicians as treatments for sleep onset and sleep maintenance insomnia in adults 1. However, it is essential to weigh the potential benefits and risks of each medication and consider factors such as the patient's medical history, potential side effects, and the risk of dependence. Additionally, if sleep problems persist beyond 2-4 weeks of medication use, it is crucial to consult a sleep specialist to rule out underlying conditions that may require different treatment approaches.
From the FDA Drug Label
Eszopiclone tablets are indicated for the treatment of insomnia. In controlled outpatient and sleep laboratory studies, eszopiclone tablets administered at bedtime decreased sleep latency and improved sleep maintenance. The best pharmaceutical option for staying asleep difficulties is eszopiclone (PO), as it has been shown to improve sleep maintenance in clinical trials 2.
- Key benefits: decreased sleep latency and improved sleep maintenance.
From the Research
Staying Asleep Difficulties: Best Pharmacological Options
The best pharmacological options for staying asleep difficulties, also known as sleep maintenance insomnia, are discussed in several studies 3, 4, 5, 6, 7.
- Non-benzodiazepines: Eszopiclone, zolpidem, and zaleplon are non-benzodiazepine hypnotics that have a lower risk of tolerance, dependence, abuse, and residual effects compared to benzodiazepines 3, 4.
- Melatonin receptor agonists: Ramelteon is a melatonin receptor agonist that is effective for sleep-onset latency and has a minimal adverse effect profile, making it a valuable first-line option 5, 6, 7.
- Orexin receptor antagonists: Suvorexant is an orexin receptor antagonist that improves sleep maintenance and has mild adverse effects, including somnolence 5, 7.
- Low-dose doxepin: Low-dose doxepin is a sedating antidepressant that can improve sleep maintenance, but should only be used when the patient has comorbid depression 5, 7.
Comparison of Pharmacological Options
A comparison of the pharmacological options for staying asleep difficulties is presented in the following points:
- Efficacy: Ramelteon and suvorexant have been shown to be effective in improving sleep maintenance 6, 7.
- Safety: Ramelteon has a minimal adverse effect profile, while suvorexant has mild adverse effects, including somnolence 6, 7.
- Tolerability: Non-benzodiazepines, such as eszopiclone and zolpidem, are generally well-tolerated, but may have some risk of dependence and abuse 3, 4.