From the Guidelines
The best pharmacological treatment for insomnia is eszopiclone, zolpidem, or suvorexant, as they have been shown to improve short-term global and sleep outcomes in adults with insomnia disorder 1.
Key Points
- Eszopiclone is suggested for sleep onset and sleep maintenance insomnia in adults, with recommended doses of 2 mg and 3 mg 1.
- Zolpidem is suggested for sleep onset and sleep maintenance insomnia in adults, with a recommended dose of 10 mg 1.
- Suvorexant is suggested for sleep maintenance insomnia in adults, with recommended doses of 10,15, and 20 mg 1.
Considerations
- The choice of medication should be based on individual patient factors, such as the optimal pharmacokinetic profile, assessments of benefits versus harms, and past treatment history 1.
- Cognitive behavioral therapy for insomnia (CBT-I) is a standard of treatment and should be considered as a primary intervention for all patients with chronic insomnia 1.
- Pharmacotherapy should be considered mainly in patients who are unable to access or respond to CBT-I, or who have specific treatment goals or comorbidities that require medication 1.
Safety and Efficacy
- The evidence for the efficacy and safety of pharmacologic treatments for insomnia is generally weak, with most trials being small and short-term 1.
- Observational studies have suggested that the use of hypnotics for insomnia may be associated with increased risk for dementia, fractures, and major injury 1.
- The FDA has reported that most pharmacotherapies for insomnia have risks for cognitive and behavioral changes, including driving impairment, and other adverse effects 1.
From the Research
Pharmacological Treatment Options for Insomnia
The following pharmacological treatments are available for insomnia:
- Suvorexant and low-dose doxepin are recommended for sleep maintenance insomnia 2
- Ramelteon is recommended for sleep onset insomnia 2
- Quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine may improve sleep while treating comorbid disorders, but have limited evidence as treatments for insomnia disorder 2
- Newer generation nonbenzodiazepines (e.g. zolpidem, zaleplon) are used as first-line pharmacotherapy for chronic insomnia 3
- Benzodiazepines remain a recommended hypnotic agent, although newer non-benzodiazepine agents may also be utilized 4
Considerations for Pharmacological Treatment
When considering pharmacological treatment for insomnia, the following factors should be taken into account:
- The potential risks and benefits of long-term hypnotic use should be individualized and balanced with the risks of untreated persistent insomnia and associated functional limitations 5
- The lowest possible dose should be used for the shortest possible time when using sedative hypnotic agents 4
- Special care should be exercised when treating the elderly due to altered pharmacokinetics in this age group 4
- Cognitive behavioral therapy for insomnia (CBT-I) is the mainstay of treatment and is a safe and effective approach, but may have difficulties with access and higher cost 6, 3, 5