Insomnia: Pharmacologic Therapy

 

Am Fam Physician. 2017 Jul 1;96(1):29-35.

  Patient information: See related handout on insomnia.

Author disclosure: No relevant financial affiliation.

Insomnia accounts for more than 5.5 million visits to family physicians each year. Although behavioral interventions are the mainstay of treatment, pharmacologic therapy may be necessary for some patients. Understanding the risks and benefits of insomnia medications is critical. Controlled-release melatonin and doxepin are recommended as first-line agents in older adults; the so-called z-drugs (zolpidem, eszopiclone, and zaleplon) should be reserved for use if the first-line agents are ineffective. For the general population with difficulty falling asleep, controlled-release melatonin and the z-drugs can be considered. For those who have difficulty staying asleep, low-dose doxepin and the z-drugs should be considered. Benzodiazepines are not recommended because of their high abuse potential and the availability of better alternatives. Although the orexin receptor antagonist suvorexant appears to be relatively effective, it is no more effective than the z-drugs and much more expensive. Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition. Persons with sleep apnea or chronic lung disease with nocturnal hypoxia should be evaluated by a sleep specialist before sedating medications are prescribed.

Insomnia is among the most common problems encountered by the family physician, accounting for more than 5.5 million visits annually.1 The American Academy of Sleep Medicine defines insomnia as the subjective perception of difficulty with sleep initiation, duration, consolidation, or quality that occurs despite adequate opportunity for sleep, and that results in some form of daytime impairment.2 The recommended first-line therapies for insomnia are nonpharmacologic, such as stimulus control, relaxation training, or sleep restriction. However, this article focuses on pharmacologic treatment of insomnia; nonpharmacologic methods were discussed in an earlier review.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Although benzodiazepines improve short-term sleep outcomes, they have significant adverse effects and may be addictive.

B

18

The z-drugs (zolpidem [Ambien], eszopiclone [Lunesta], and zaleplon [Sonata]) improve sleep outcomes in the general population.

A

18

Ramelteon (Rozerem) is only modestly effective compared with placebo, but it has few adverse effects.

B

18

Low-dose doxepin (Silenor) improves sleep outcomes and has no significant adverse effects compared with placebo.

A

18


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Although benzodiazepines improve short-term sleep outcomes, they have significant adverse effects and may be addictive.

B

18

The z-drugs (zolpidem [Ambien], eszopiclone [Lunesta], and zaleplon [Sonata]) improve sleep outcomes in the general population.

A

18

Ramelteon (Rozerem) is only modestly effective compared with placebo, but it has few adverse effects.

B

18

Low-dose doxepin (Silenor) improves sleep outcomes and has no significant adverse effects compared with placebo.

A

18


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

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BEST PRACTICES IN SLEEP MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agitation, or delirium.

American Geriatrics Society

Avoid the use of hypnotics as primary therapy for chronic insomnia in adults; instead, offer cognitive behavior therapy and reserve medication for adjunctive treatment when necessary.

American Academy of Sleep Medicine

Do not routinely prescribe antipsychotic medications as a first-line intervention for insomnia in adults.

American Psychiatric Association


Source: For more information on the Choosing Wisely Campaign, see http://www.choosingwisely.org. For supporting citations and to search Choosing Wisely recommendations relevant to primary care, see http://www.aafp.org/afp/recommendations/search.htm.

BEST PRACTICES IN SLEEP MEDICINE: RECOMMENDATIONS FROM THE CHOOSING WISELY CAMPAIGN

RecommendationSponsoring organization

Do not use benzodiazepines or other sedative-hypnotics in older adults as a first choice for insomnia, agi

The Authors

show all author info

ERIC MATHESON, MD, is an associate professor in the Department of Family Medicine at the Medical University of South Carolina, Charleston....

BARRY L. HAINER, MD, is a professor in the Department of Family Medicine at the Medical University of South Carolina.

Author disclosure: No relevant financial affiliation.

Address correspondence to Eric Matheson, MD, Medical University of South Carolina, 9228 Medical Plaza Dr., Charleston, SC 29406 (e-mail: matheson@musc.edu). Reprints are not available from the authors.

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