From the Guidelines
Eszopiclone is the recommended drug of choice for insomnia treatment when CBT-I and trazodone have failed, due to its efficacy in treating sleep onset and sleep maintenance insomnia, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. When considering treatment options for insomnia, it's essential to weigh the benefits and risks of each medication.
- Eszopiclone, at a dose of 2-3 mg, has been shown to be effective in treating sleep onset and sleep maintenance insomnia in adults, with a moderate to high strength of recommendation 1.
- Zolpidem, another option, is also effective for sleep onset and sleep maintenance insomnia, but its use should be approached with caution due to the potential for tolerance and dependence.
- Other alternatives, such as low-dose doxepin (3-6 mg) or ramelteon (8 mg), may be considered, especially for patients with specific comorbidities or concerns about dependence. It's crucial to emphasize the importance of using these medications for short-term treatment (generally 2-4 weeks) and to continue practicing good sleep hygiene while using medication, as well as regular follow-up with a healthcare provider to monitor effectiveness and side effects 1.
From the Research
Treatment Options for Insomnia
If CBT-I has failed and trazodone hasn't worked, there are other treatment options available for insomnia.
- Ramelteon, a melatonin receptor agonist, is a well-tolerated option for the treatment of patients with insomnia characterized by difficulty in sleep onset 2.
- Suvorexant, a dual orexin receptor antagonist, is recommended for sleep maintenance insomnia 3.
- Low-dose doxepin, an H1 antagonist, is also recommended for sleep maintenance insomnia 3.
Safety Considerations
When considering treatment options, it's essential to assess the safety profile of each drug, including next-day residual effects, potential for abuse, tolerance, and dependence 4.
- Non-benzodiazepines, such as eszopiclone, zolpidem, and zaleplon, have a lower risk of tolerance, dependence, abuse, and residual effects compared to benzodiazepines 4.
- Ramelteon is not scheduled and has a low risk of abuse, tolerance, and dependence 2, 4.
Off-Label Drugs
Off-label drugs, such as trazodone, may be used to treat insomnia, but they have a lack of controlled clinical efficacy and safety studies, and should be used with caution 4, 3.
- Quetiapine, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine may improve sleep while treating comorbid disorders, but have limited evidence for the treatment of insomnia disorder 3.