What are the recommended doses for medications used to treat sleep disturbances, including melatonin, trazodone, and benzodiazepines?

Recommended Doses for Sleep Medications

For chronic insomnia in adults, start with FDA-approved doses: eszopiclone 2-3 mg, zolpidem 10 mg (5 mg for women/elderly), temazepam 15-30 mg for sleep onset and maintenance; zaleplon 10 mg, ramelteon 8 mg, triazolam 0.25 mg for sleep onset only; suvorexant 10 mg and low-dose doxepin 3-6 mg for sleep maintenance. 1, 2

FDA-Approved Hypnotics: Specific Dosing

For Sleep Onset AND Maintenance Insomnia

• Eszopiclone: 2-3 mg nightly 1, 2
• Zolpidem: 10 mg (standard dose used in trials; note FDA recommends lower doses for women and elderly) 1, 2
• Temazepam: 15-30 mg nightly 1, 2

For Sleep Onset Insomnia Only

• Zaleplon: 10 mg 2
• Ramelteon: 8 mg (particularly suitable for elderly or those with addiction risk) 2, 3
• Triazolam: 0.25 mg 2

For Sleep Maintenance Insomnia Only

• Suvorexant: 10 mg (orexin receptor antagonist) 2, 3
• Low-dose doxepin: 3-6 mg (significantly lower than antidepressant doses) 1, 2, 3

Melatonin Dosing

• Melatonin: 1-6 mg appears effective in older adults, though the American Academy of Sleep Medicine does not formally recommend it due to inconsistent evidence 3
• Melatonin is unregulated and has small impact on sleep latency with potential for residual sedation 4

Trazodone: NOT Recommended

The American Academy of Sleep Medicine explicitly recommends AGAINST trazodone for insomnia treatment despite its widespread off-label use. 2, 3

• Trazodone increased 150% in prescriptions from 1987-1996 despite absence of efficacy studies for insomnia 1
• No systematic evidence supports effectiveness of sedating antidepressants for insomnia 1
• Should only be considered when treating comorbid depression, not as primary insomnia therapy 2

Benzodiazepines: Use With Extreme Caution

Benzodiazepines should be minimized or avoided, particularly in elderly patients, due to unacceptable risks of dependence, falls, cognitive impairment, and paradoxical agitation. 3, 4

If Benzodiazepines Must Be Used:

• Triazolam: 0.25 mg 2
• Estazolam: Specific dose not provided in guidelines 1
• Temazepam: 15-30 mg 2
• Flurazepam: Not recommended due to long half-life 1
• Quazepam: Not recommended due to long half-life 1

Critical Warnings About Benzodiazepines:

• Associated with dementia (hazard ratio 2.34) in observational data 1
• Frequency of benzodiazepine prescriptions declined over 50% from 1987-1996 due to tolerance and dependency concerns 1
• Particularly dangerous in elderly due to reduced clearance and increased sensitivity 1

Critical Dosing Principles

Start Low, Go Slow

• Always use the lowest effective dose 2, 3
• Start at lowest available dose, especially in elderly patients 1
• Some trial doses exceeded FDA recommendations, particularly for women and older/debilitated adults 1

Administration Timing

• Administer on empty stomach to maximize effectiveness 2
• Use for shortest possible duration 2

Special Population Considerations

Elderly Patients (70s and older):

• First choice: Ramelteon 8 mg (favorable safety profile, no dependence risk) 3
• Second choice: Low-dose doxepin 3-6 mg (for sleep maintenance) 3
• AVOID: Diphenhydramine (strong anticholinergic effects increase confusion, urinary retention, fall risk) 3
• AVOID: Benzodiazepines (falls, cognitive impairment, paradoxical agitation) 3

Patients with Addiction History:

• Ramelteon 8 mg is specifically recommended (no abuse potential) 3
• Benzodiazepines and non-benzodiazepine hypnotics carry significant dependence risk and are unsuitable 3

Medications to Explicitly AVOID

• Diphenhydramine: Should be avoided in elderly due to anticholinergic effects 3, 4
• Trazodone: Not recommended by guidelines 2, 3
• Antipsychotics, anticonvulsants, other antidepressants: No systematic evidence for effectiveness; risks outweigh benefits 1
• Valerian, L-tryptophan: Not recommended by American Academy of Sleep Medicine 3

Monitoring Requirements

• Regular follow-up essential to assess medication effectiveness, side effects, and ongoing need 2
• Monitor for signs of depression, compromised respiratory function, or hepatic/heart failure 2
• Watch for next-day sedation, particularly with suvorexant 3
• Assess for falls, cognitive impairment, and daytime somnolence 1, 4

First-Line Treatment Reminder

Cognitive Behavioral Therapy for Insomnia (CBT-I) remains the first-line treatment before any pharmacotherapy is initiated 2, 4, 5

• Sleep hygiene education alone is ineffective and must be combined with other therapies 2
• Pharmacotherapy should only be offered if CBT-I is unavailable or has failed 5