From the Guidelines
Melatonin is currently considered the sleeping pill that provides the least disruption to sleep architecture while promoting restorative sleep. A typical dose ranges from 0.5-5mg taken 30-60 minutes before bedtime. For best results, start with a low dose (0.5-1mg) and increase gradually if needed, as higher doses don't necessarily work better and may cause morning grogginess. Melatonin works by reinforcing your body's natural sleep-wake cycle rather than sedating you like prescription medications. Unlike benzodiazepines and non-benzodiazepine hypnotics (Z-drugs), melatonin doesn't significantly suppress REM sleep or slow-wave sleep, which are crucial for memory consolidation and physical restoration. It has minimal side effects, no risk of dependence, and doesn't cause rebound insomnia when discontinued. For optimal effectiveness, combine melatonin with good sleep hygiene practices such as maintaining a regular sleep schedule, avoiding screens before bedtime, and creating a dark, cool sleeping environment. If melatonin proves ineffective, prescription options like low-dose doxepin or suvorexant may be considered as they cause less sleep architecture disruption than traditional sleeping pills, as suggested by studies 1.
Some key points to consider when prescribing sleeping pills include:
- The American Academy of Sleep Medicine clinical practice guideline recommends the use of melatonin, low-dose doxepin, or suvorexant for the treatment of chronic insomnia in adults 1.
- Nonbenzodiazepine BZRAs, such as zolpidem, zaleplon, eszopiclone, and zopiclone, may improve sleep efficiency and sleep quality, but their use is associated with risks of adverse events, including sleepwalking and sleep driving 1.
- Benzodiazepines are not recommended for the treatment of chronic insomnia disorder due to their potential for dependence and other adverse effects 1.
- The FDA has released safety announcements on the risks associated with the use of nonbenzodiazepine BZRAs and other sleeping pills, emphasizing the need for careful consideration and monitoring when prescribing these medications 1.
Overall, the choice of sleeping pill should be based on a careful evaluation of the individual patient's needs and medical history, as well as consideration of the potential benefits and risks of each medication, as discussed in studies 1.
From the Research
Sleep Architecture and Restorative Sleep
The current evidence suggests that eszopiclone is a sleeping pill that provides the least disruption to sleep architecture and produces the most restorative sleep.
- Key benefits of eszopiclone include:
- Improves sleep onset and maintenance compared to placebo in adult and elderly patients with primary insomnia 2
- Produces improvements in daytime functioning in patients with co-morbid insomnia 2
- Has a favorable safety profile with minimal risk of dependence and abuse 3
- Is not limited to short-term use, unlike other hypnotics 4, 2
Comparison with Other Hypnotics
While there are other hypnotics available, such as zolpidem and zaleplon, eszopiclone has been shown to be effective in improving sleep parameters without significant disruptions to sleep architecture.
- A review of newer sedative-hypnotics notes that eszopiclone is a useful therapeutic option in the management of adult and elderly patients with primary or co-morbid insomnia 5
- A comparative tolerability study of newer agents for insomnia found that eszopiclone is generally well tolerated with a favorable safety profile 3
Efficacy and Safety
The efficacy and safety of eszopiclone have been evaluated in several studies, including a Cochrane review that found eszopiclone to be effective in improving sleep onset and maintenance with minimal risk of harm 6
- Meta-analytic integrations of participant-reported data on sleep efficacy outcomes demonstrated better results for eszopiclone compared to placebo 6
- Adverse events during treatment that were documented more frequently under eszopiclone compared to placebo included unpleasant taste, dry mouth, somnolence, and dizziness 6