“Cognitive behavioral therapy, which includes setting realistic goals for sleep, limiting time spent in bed, addressing maladaptive beliefs about sleeplessness, and practicing relaxation techniques, is the first-line therapy for insomnia.” NEJM 2015
Table of Contents
Insomnia Medications
1st line drugs in older adults
-Melatonin, controlled release 1 mg, for sleep onset.
-Doxepin 3 to 6 mg for sleep maintenance. It has no significant adverse effects.
Ramelteon (Rozerem) 8 mg is also a Melatonin agent.
2nd line drugs for older adults
Limit use of z-drugs (Nonbenzodiazepine hypnotics) to patients in which the first-line agents are ineffective.
Z drugs help with both sleep onset and sleep maintenance.
Eszopiclone (Lunesta) 1 to 3 mg
Zaleplon (Sonata) 5 to 10 mg
Zolpidem (Ambien) 5 to 10 mg
Zolpidem, extended-release (Ambien CR) 6.25 to 12.5 mg
Zolpidem, sublingual (Intermezzo) 1.75 or 3.5 mg
Insomnia Treatment based on type of sleep difficulty
Difficulty Falling Asleep
-Controlled-release melatonin.
-The z-drugs.
Difficulty Staying Asleep.
-Doxepin, low-dose
-The z-drugs
Drugs to avoid / Don’t work
-Benzodiazepines: Avoid because of high abuse potential. Better alternatives are available.
-Suvorexant (Belsomra). Is more expensive than the Z-drugs but is no more effective.
-Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition.
“Patients with sleep apnea or chronic lung disease with nocturnal hypoxia should be evaluated by a sleep specialist before sedating medications are prescribed.” AAFP 2017
-Mirtazapine and trazodone are not recommended.
“The evidence for trazodone is weak, and it should not be considered as first-line therapy.” AAFP 2017
Mechanism of action of drugs
Benzodiazepines – Work through the (GABA)A receptor in neurons, resulting in hyperpolarization of the cell.
Nonbenzodiazepine hypnotics – The z-drugs: zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta). Work through GABAA receptor.
Suvorexant (Belsomra). Is an orexin receptor antagonist.
Doxepin is a TCA.
References
N Engl J Med 2015; 373:1437-1444. Insomnia Disorder. http://www.nejm.org/doi/full/10.1056/NEJMcp1412740
Am Fam Physician. 2017 Jul 1;96(1):29-35. Insomnia: Pharmacologic Therapy. http://www.aafp.org/afp/2017/0701/p29.html