What is the first line sleep medication?

From the Guidelines

For first-line sleep medication, I recommend starting with eszopiclone (Lunesta) 1-3 mg or zolpidem (Ambien) 5-10 mg, as these non-benzodiazepine "Z-drugs" have a favorable safety profile compared to traditional benzodiazepines, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1.

Key Considerations

• The American Academy of Sleep Medicine recommends eszopiclone and zolpidem as first-line treatments for sleep onset and sleep maintenance insomnia in adults 1.
• These medications work by enhancing GABA activity in the brain, promoting sleep onset and maintenance.
• Medication should complement good sleep hygiene practices, including consistent sleep schedules, avoiding screens before bed, limiting caffeine and alcohol, and creating a comfortable sleep environment.
• It's essential to use sleep medications at the lowest effective dose for the shortest duration possible (ideally less than 2-4 weeks for prescription options) to prevent tolerance, dependence, and side effects like daytime drowsiness, dizziness, or cognitive impairment.

Alternative Options

• Zaleplon (Sonata) 5-10 mg is also a recommended option for sleep onset insomnia 1.
• Other medications like suvorexant, ramelteon, and doxepin may be considered for specific cases of insomnia, but their use should be guided by the individual patient's needs and medical history.

Important Notes

• Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the initial treatment for chronic insomnia disorder, with medication considered as an adjunct therapy if necessary 1.
• The choice of medication should be based on the individual patient's needs, medical history, and potential side effects.

From the FDA Drug Label

14.1 Transient Insomnia Normal adults experiencing transient insomnia (n=462) during the first night in a sleep laboratory were evaluated in a double-blind, parallel group, single-night trial comparing two doses of zolpidem (7. 5 and 10 mg) and placebo. Both zolpidem doses were superior to placebo on objective (polysomnographic) measures of sleep latency, sleep duration, and number of awakenings Normal elderly adults (mean age 68) experiencing transient insomnia (n=35) during the first two nights in a sleep laboratory were evaluated in a double-blind, crossover, 2-night trial comparing four doses of zolpidem (5,10,15 and 20 mg) and placebo All zolpidem doses were superior to placebo on the two primary PSG parameters (sleep latency and efficiency) and all four subjective outcome measures (sleep duration, sleep latency, number of awakenings, and sleep quality).

Zolpidem can be used as a first-line sleep medication for transient insomnia. The recommended doses are 7.5 mg and 10 mg for normal adults, and 5 mg for elderly adults 2.

• Key benefits:
  • Improves sleep latency
  • Increases sleep duration
  • Reduces number of awakenings
• Important consideration: The dose for elderly adults should not exceed 5 mg to minimize potential adverse effects.

From the Research

First Line Sleep Medication

• The most effective therapies for insomnia utilize cognitive behavioral therapy in conjunction with pharmacotherapy to minimize the needed dose and any resulting side effects 3.
• Non-benzodiazepine hypnotics such as zolpidem, eszopiclone, zaleplon are the most used as adjunctive treatment 3.
• Zolpidem is a helpful drug for the treatment of insomnia in conjunction with cognitive-behavioral therapy, but it has a wide variety of adverse effects 3.
• The nonbenzodiazepine benzodiazepine receptor agonists have provided advantages over the older medications and are currently first-line medication treatment for insomnia 4.

Treatment Options

• Pharmacologic and nonpharmacologic therapies both have roles in the treatment of insomnia 4.
• Cognitive-behavioral therapy is effective in the treatment of insomnia, alone and in combination with pharmacotherapy 4, 5.
• Cognitive behavioral therapy for insomnia (CBT-i) produces results that are equivalent to sleep medication, with no side effects, fewer episodes of relapse, and a tendency for sleep to continue to improve long past the end of treatment 5.
• Ramelteon has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time, making it a valuable first-line option 6.

Safety and Efficacy

• Benzodiazepines are discouraged in the geriatric population, especially for long-term use 6.
• Although non-BzRAs have improved safety profiles compared with benzodiazepines, their side effects include dementia, serious injury, and fractures, which should limit their use 6.
• The decision to treat chronic insomnia disorder with long-term hypnotics should be individualized and balance the potential risks of continuing hypnotic medication use with the risks of untreated persistent insomnia and associated functional limitations 7.