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{{Insomnia}}
{{Insomnia}}
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{{CMG}} ; {{AE}} {{Adnan Ezici}}
==Overview==
==Overview==
Pharmacologic medical therapies for insomnia include (either) [[benzodiazepines]] (e.g., [[triazolam]], [[temazepam]], etc.), nonbenzodiazepine receptor agonists (e.g., [[zaleplon]], [[zolpidem]], [[eszopiclone]]), [[antidepressants]] ([[doxepin]]), [[melatonin]], melatonin agonists ([[ramelteon]]), orexin receptor antagonists (i.e., lemborexant, [[suvorexant]]), and/or [[antihistamines]]. 
==Medical Therapy==
==Medical Therapy==
In many cases, insomnia is caused by another disease or psychological problem. In this case, medical or psychological help may be useful.
Many insomniacs rely on [[sleeping tablet]]s and other [[sedative]]s to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as [[benzodiazepine]]s and newer [[nonbenzodiazepine]] drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.


According to [[clinical practice guideline]]s by the [[American Academy of Sleep Medicine]], "Psychological and behavioral interventions are effective for adults of all ages, including older adults, and chronic hypnotic users... These treatments should be utilized as an initial intervention when appropriate and when conditions permit".<ref name="pmid18853708">{{cite journal| author=Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M| title=Clinical guideline for the evaluation and management of chronic insomnia in adults. | journal=J Clin Sleep Med | year= 2008 | volume= 4 | issue= 5 | pages= 487-504 | pmid=18853708 | doi= | pmc=PMC2576317 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18853708 }} </ref>
In comparing the options, [[systematic review]]s:
* 2022 reported "eszopiclone and lemborexant had a favorable profile, but eszopiclone might cause substantial adverse events and safety data on lemborexant were inconclusive. Doxepin, seltorexant, and zaleplon were well tolerated, but data on efficacy and other important outcomes were scarce"<ref name="pmid35843245">{{cite journal| author=De Crescenzo F, D'Alò GL, Ostinelli EG, Ciabattini M, Di Franco V, Watanabe N | display-authors=etal| title=Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. | journal=Lancet | year= 2022 | volume= 400 | issue= 10347 | pages= 170-184 | pmid=35843245 | doi=10.1016/S0140-6736(22)00878-9 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=35843245 }} </ref>


===Behavior Therapy===
* 2007 found that [[benzodiazepine]]s and  [[nonbenzodiazepine]]s have similar efficacy which was [[statistical_significance | insignificantly]] more than for [[antidepressant]]s.<ref name="pmid17619935">Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007  Sep;22(9):1335-50. Epub 2007 Jul 10. PMID 17619935</ref>  Benzodiazepines had an [[statistical_significance | insignificant]] tendency for more [[adverse drug reaction]]s.<ref name="pmid17619935"/>
[[Clinical practice guideline]] by the [[American Academy of Sleep Medicine]] (AASM) noted about [[cognitive therapy|cognitive behavior therapy]] for insomnia:
* “Initial approaches to treatment should include at least one behavioral intervention such as stimulus control therapy or relaxation therapy, or the combination of cognitive therapy, stimulus control therapy, sleep restriction therapy with or without relaxation therapy—otherwise known as cognitive behavioral therapy for insomnia (CBT-I).<ref name="pmid18853708">{{cite journal| author=Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M| title=Clinical guideline for the evaluation and management of chronic insomnia in adults. | journal=J Clin Sleep Med | year= 2008 | volume= 4 | issue= 5 | pages= 487-504 | pmid=18853708 | doi= | pmc=PMC2576317 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18853708  }} </ref>


[[Cognitive therapy|Cognitive behavior therapy]] for insomnia has been studied in a [[meta-analysis]] of 20 [[randomized controlled trial]]s that compared a combination of two modalities of CBT-i versus various control therapies. Different modalities of CBT-i were defined as cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation techniques. The meta-analysis found:
===Benzodiazepines===
* Sleep onset latency improved by 19 (95% [[Confidence interval|CI]], 142 to 25) minutes
{{main|Benzodiazepine}}
* Wake after sleep onset was reduced by 26 (95% [[Confidence interval|CI]], 15 to 37) minutes
The most commonly used class of hypnotics prescribed for insomnia are the [[benzodiazepine]]s. [[Benzodiazepine]]s bind unselectively to the [[GABAA receptor|GABA<sub>A</sub> receptor]].<ref name="pmid17619935"/> This includes drugs such as [[triazolam]], [[temazepam]], [[diazepam]], [[lorazepam]], [[flurazepam]], [[nitrazepam]] and [[midazolam]].  These medications can be addictive, especially after taking them over long periods of time.<ref name="pmid33683929">{{cite journal |vauthors=Sutton EL |title=Insomnia |journal=Ann Intern Med |volume=174 |issue=3 |pages=ITC33–ITC48 |date=March 2021 |pmid=33683929 |doi=10.7326/AITC202103160 |url=}}</ref>
* Total sleep time increased by 8 (95% [[Confidence interval|CI]], 1 to 16) minutes
*Preferred regimen (1): [[Triazolam]] 0.125, 0.25 mg PO
* Sleep efficiency percentage improved by 10% (95% [[Confidence interval|CI]], 8% to 12%)
**A benzodiazepine with rapid onset and short duration that might be prescribed for sleep onset insomnia
*Preferred regimen (2): [[Temazepam]] 7.5, 15, 22.5, 30 mg PO
**A benzodiazepine with slow onset and intermediate duration that might be prescribed for both sleep onset and sleep maintenance insomnia.


Sleep restriction therapy for insomnia has been studied in a [[meta-analysis]] of 4 [[randomized controlled trial]]s that reported "Weighted effect sizes for self-reported sleep diary measures of sleep onset latency, wake time after sleep onset, and sleep efficiency were moderate-to-large after therapy. Total sleep time indicated a small improvement"; however, the authors add "variability in the sleep restriction therapy implementation methods precludes any strong conclusions regarding the true impact of therapy"<ref name="pmid24629826">{{cite journal| author=Miller CB, Espie CA, Epstein DR, Friedman L, Morin CM, Pigeon WR et al.| title=The evidence base of sleep restriction therapy for treating insomnia disorder. | journal=Sleep Med Rev | year= 2014 | volume= 18 | issue= 5 | pages= 415-24 | pmid=24629826 | doi=10.1016/j.smrv.2014.01.006 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24629826  }} </ref>.
===Non-benzodiazepine Receptor Agonists===
{{main|Nonbenzodiazepine}}
[[Nonbenzodiazepine Receptor Agonists]] prescription drugs, including the [[zolpidem]], [[zaleplon]], and [[eszopiclone]], are more selective for the [[GABAA receptor|GABA<sub>A</sub> receptor]]<ref name="pmid17619935"/> and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both [[Addiction#Psychological addiction|psychological dependence]] and [[physical dependence]], and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.<ref name="pmid33683929">{{cite journal |vauthors=Sutton EL |title=Insomnia |journal=Ann Intern Med |volume=174 |issue=3 |pages=ITC33–ITC48 |date=March 2021 |pmid=33683929 |doi=10.7326/AITC202103160 |url=}}</ref>
*Preferred regimen (1): [[Zaleplon]] 5 or 10 mg PO
**A non–benzodiazepine receptor agonist with rapid onset and ultra-short duration that might be prescribed for sleep-onset insomnia
*Preferred regimen (2): [[Zolpidem]] with different routes of administration (the lower dose is recommended for women to reduce effects on the next day)
**1.75, 3.5 mg immediate-release sublingual tablet
***A non–benzodiazepine receptor agonist with rapid onset and ultra-short duration that might be prescribed for night-time awakening
**5, 10 mg PO
***A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
**5, 10 mg sublingual tablet
***A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
**6.25, 12.5 mg controlled-release tablet
***A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
*Preferred regimen (3): [[Eszopiclone]] 1, 2, 3 mg PO (Initial dose is 1 mg)
**A non–benzodiazepine receptor agonist with rapid onset and intermediate duration that might be prescribed for both sleep onset and sleep maintenance insomnia


====Implementing behavior therapy====
{| class="wikitable" align="right"
Behavior therapy may require as many as 16 sessions<ref name="pmid16785771">{{cite journal| author=Wu R, Bao J, Zhang C, Deng J, Long C| title=Comparison of sleep condition and sleep-related psychological activity after cognitive-behavior and pharmacological therapy for chronic insomnia. | journal=Psychother Psychosom | year= 2006 | volume= 75 | issue= 4 | pages= 220-8 | pmid=16785771 | doi=10.1159/000092892 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16785771  }} </ref>.
|+ Randomized controlled trial of treatment options for insomnia.<ref name="pmid19454639">{{cite journal| author=Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C et  al.| title=Cognitive behavioral therapy, singly and combined with  medication, for persistent insomnia: a randomized controlled trial. | journal=JAMA | year= 2009 | volume= 301 | issue= 19 | pages= 2005-15 | pmid=19454639
| url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=clinical.uthscsa.edu/cite&email=badgett@uthscdsa.edu&retmode=ref&cmd=prlinks&id=19454639 | doi=10.1001/jama.2009.682 }} </ref>


A shorter number of sessions has been studied:
! rowspan=2|Treatment!! colspan=2|Outcome at 6 months
* "Brief behavioral therapy for insomnia" (BBTI) consists of "a 45 to 60-minute individual intervention session followed by a 30-minute follow-up session 2 weeks later and 20-minute telephone calls after 1 and 3 weeks." Goals of therapy were “reduce time in bed, get up at same time every day regardless of sleep duration, do not go to bed unless sleepy, do not stay in bed unless asleep.” In a trial of 82 older adults (mean age 71.7) BBTI led to a response rate of 67% which yielded a relative benefit increase of 2.7 and number needed to treat in their population of 2.4.<ref name="pmid21263078">{{cite journal| author=Buysse DJ, Germain A, Moul DE, Franzen PL, Brar LK, Fletcher ME et al.| title=Efficacy of brief behavioral treatment for chronic insomnia in older adults. | journal=Arch Intern Med | year= 2011 | volume= 171 | issue= 10 | pages= 887-95 | pmid=21263078 | doi=10.1001/archinternmed.2010.535 | pmc=PMC3101289 | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=21263078  }} </ref>
|-
! Responders!! Remitters
|-
| 6 weeks of [[Cognitive behavioral therapy|CBT]]|| 55% || 40%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]|| 63% || 44%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 weeks of [[zolpidem]]||style="background:lightgreen"| 81% ||style="background:lightgreen"| 68%
|-
| 6 months of [[Cognitive behavioral therapy|CBT]]<br/>6 months of [[zolpidem]]|| 65% || 42%
|-
| colspan=3 | Adapted from Table 4 of Morin et al.<ref name="pmid19454639"/>
|-
|}


===Medications===
===Antidepressants===
Many insomniacs rely on [[sleeping tablet]]s and other [[sedative]]s to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as [[benzodiazepine]]s and newer [[nonbenzodiazepine]] drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.
 
In comparing the options, a [[systematic review]] found that [[benzodiazepine]]s and  [[nonbenzodiazepine]]s have similar efficacy which was [[statistical_significance | insignificantly]] more than for [[antidepressant]]s.<ref name="pmid17619935">Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007  Sep;22(9):1335-50. Epub 2007 Jul 10. PMID 17619935</ref>  Benzodiazepines had an [[statistical_significance | insignificant]] tendency for more [[adverse drug reaction]]s.<ref name="pmid17619935"/>
 
====Benzodiazepines====
{{main|Benzodiazepine}}
The most commonly used class of hypnotics prescribed for insomnia are the [[benzodiazepine]]s. [[Benzodiazepine]]s bind unselectively to the [[GABAA receptor|GABA<sub>A</sub> receptor]].<ref name="pmid17619935"/> This includes drugs such as [[temazepam]], [[diazepam]], [[lorazepam]], [[flurazepam]], [[nitrazepam]] and [[midazolam]].  These medications can be addictive, especially after taking them over long periods of time.
 
====Non-benzodiazepines====
{{main|Nonbenzodiazepine}}
[[Nonbenzodiazepine]] prescription drugs, including the [[nonbenzodiazepine]]s [[zolpidem]](Stilnoct) and [[zopiclone]](Imovane), are more selective for the [[GABAA receptor|GABA<sub>A</sub> receptor]]<ref name="pmid17619935"/> and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines.  These drugs appear to cause both [[Addiction#Psychological addiction|psychological dependence]] and [[physical dependence]], and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.
 
====Antidepressants====
{{main|Antidepressants}}
{{main|Antidepressants}}
Some [[antidepressant]]s such as [[mirtazapine]], [[trazodone]] and [[doxepin]] have a sedative effect, and are prescribed [[off label]] to treat insomnia.  The major drawback of these drugs is that they have [[antihistaminergic]], [[anticholinergic]] and [[antiadrenergic]] properties which can lead to many side effects. Some also alter sleep architecture.  
Some [[antidepressant]]s such as [[mirtazapine]], [[trazodone]] and [[doxepin]] have a sedative effect, and are prescribed [[off label]] to treat insomnia.  The major drawback of these drugs is that they have [[antihistaminergic]], [[anticholinergic]] and [[antiadrenergic]] properties which can lead to many side effects. Some also alter sleep architecture.  
*Preferred regimen (1): [[doxepin]] 3, 6 mg PO<ref name="pmid33683929">{{cite journal |vauthors=Sutton EL |title=Insomnia |journal=Ann Intern Med |volume=174 |issue=3 |pages=ITC33–ITC48 |date=March 2021 |pmid=33683929 |doi=10.7326/AITC202103160 |url=}}</ref>
**A tricyclic antidepressant with slow onset and long duration that might be prescribed for sleep maintenance insomnia
===Melatonin and Melatonin Agonists===
[[Melatonin]] has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including ramelteon ([[Rozerem]]), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and a lower likelihood of causing morning sedation.
*Preferred regimen (1): [[ramelteon]] 8 mg PO<ref name="pmid33683929">{{cite journal |vauthors=Sutton EL |title=Insomnia |journal=Ann Intern Med |volume=174 |issue=3 |pages=ITC33–ITC48 |date=March 2021 |pmid=33683929 |doi=10.7326/AITC202103160 |url=}}</ref>
**A melatonin agonist with rapid onset and short duration that might be prescribed for sleep-onset insomnia


====Melatonin====
===Orexin Receptor Antagonists===
[[Melatonin]] has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including Ramelteon ([[Rozerem]]), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and lower likelihood of causing morning sedation.
*Preferred regimen (1): Lemborexant 5, 10 mg PO (initial dose is 5 mg)<ref name="pmid33683929">{{cite journal |vauthors=Sutton EL |title=Insomnia |journal=Ann Intern Med |volume=174 |issue=3 |pages=ITC33–ITC48 |date=March 2021 |pmid=33683929 |doi=10.7326/AITC202103160 |url=}}</ref>
**An orexin receptor antagonist with slow onset and long duration that might be prescribed for sleep maintenance insomnia
*Preferred regimen (2): Suvorexant 5, 10, 20 mg PO (initial dose is 10 mg)
**An orexin receptor antagonist with slow onset and long duration that might be prescribed for sleep maintenance insomnia


====Antihistamines====
===Antihistamines===
The [[antihistamine]] [[diphenhydramine]] is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.
The [[antihistamine]] [[diphenhydramine]] is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.


====Atypical antipsychotics====
===Atypical antipsychotics===
Low doses of certain [[atypical antipsychotics]] such as [[quetiapine]] (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.
Low doses of certain [[atypical antipsychotics]] such as [[quetiapine]] (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.


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Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. <ref>{{cite web|url=http://www.cidervinegar.org/2007/06/cider-vinegar-rocks.html|title=Cider Vinegar and Insomnia}}</ref>
Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. <ref>{{cite web|url=http://www.cidervinegar.org/2007/06/cider-vinegar-rocks.html|title=Cider Vinegar and Insomnia}}</ref>


===Complimentary and alternative therapies===
Some traditional remedies for insomnia have included drinking warm milk before bedtime, taking a warm bath in the evening; exercising vigorously for half an hour in the afternoon, eating a large lunch and then having only a light evening meal at least three hours before bed, avoiding mentally stimulating activities in the evening hours, and making sure to get up early in the morning and to retire to bed at a reasonable hour.
Many believe that listening to slow paced music will help insomniacs fall asleep. <ref name="pmid16269944">{{cite journal |author=Robinson SB, Weitzel T, Henderson L |title=The Sh-h-h-h Project: nonpharmacological interventions |journal=Holistic nursing practice |volume=19 |issue=6 |pages=263-6 |year=2005 |pmid=16269944 |doi=}}</ref>
The more relaxed a person is, the greater the likelihood of getting a good night's sleep. [[Relaxation techniques]] such as [[meditation]] have been shown to help people sleep. Such techniques can lower stress levels from both the mind and body, which leads to a deeper, more restful sleep.
[[Traditional Chinese medicine]] has included treatment for insomnia. A typical approach may utilize [[acupuncture]], dietary and lifestyle analysis, [[Herbalism|herbology]] and other techniques, with the goal of resolving the problem at a subtle level.
In the Buddhist tradition, people suffering from insomnia or nightmares may be advised to meditate on "loving-kindness", or ''[[metta]]''. This practice of generating a feeling of love and goodwill is claimed to have a soothing and calming effect on the mind and body<ref>{{cite journal |author=Lutz A, Greischar LL, Rawlings NB, Ricard M, Davidson RJ |title=Long-term meditators self-induce high-amplitude gamma synchrony during mental practice |journal=Proc. Natl. Acad. Sci. U.S.A. |volume=101 |issue=46 |pages=16369-73 |year=2004 |pmid=15534199 |doi=10.1073/pnas.0407401101 |url=http://www.pnas.org/cgi/content/full/101/46/16369 }}</ref>. This is claimed to stem partly from the creation of relaxing positive thoughts and feelings, and partly from the pacification of negative ones. In the ''Mettā (Mettanisamsa) Sutta''<ref>http://www.accesstoinsight.org/tipitaka/an/an11/an11.016.than.html</ref>, Siddhartha Gautama, the Buddha, tells the gathered monks that easeful sleep is one benefit of this form of meditation.
Using [[aromatherapy]], including jasmine oil, [[lavender oil]], [[Mahabhringaraj]] and other relaxing [[essential oil]]s, may also help induce a state of restfulness. [[Horlicks]] is marketed as a sleeping aid.
==References==
==References==
{{Reflist|2}}
{{Reflist|2}}

Latest revision as of 19:13, 22 July 2022

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] ; Associate Editor(s)-in-Chief: Adnan Ezici, M.D[2]

Overview

Pharmacologic medical therapies for insomnia include (either) benzodiazepines (e.g., triazolam, temazepam, etc.), nonbenzodiazepine receptor agonists (e.g., zaleplon, zolpidem, eszopiclone), antidepressants (doxepin), melatonin, melatonin agonists (ramelteon), orexin receptor antagonists (i.e., lemborexant, suvorexant), and/or antihistamines.

Medical Therapy

Many insomniacs rely on sleeping tablets and other sedatives to get rest. All sedative drugs have the potential of causing psychological dependence where the individual cannot psychologically accept that they can sleep without drugs. Certain classes of sedatives such as benzodiazepines and newer nonbenzodiazepine drugs can also cause physical dependence which manifests in withdrawal symptoms if the drug is not carefully titrated down.

In comparing the options, systematic reviews:

  • 2022 reported "eszopiclone and lemborexant had a favorable profile, but eszopiclone might cause substantial adverse events and safety data on lemborexant were inconclusive. Doxepin, seltorexant, and zaleplon were well tolerated, but data on efficacy and other important outcomes were scarce"[1]

Benzodiazepines

The most commonly used class of hypnotics prescribed for insomnia are the benzodiazepines. Benzodiazepines bind unselectively to the GABAA receptor.[2] This includes drugs such as triazolam, temazepam, diazepam, lorazepam, flurazepam, nitrazepam and midazolam. These medications can be addictive, especially after taking them over long periods of time.[3]

  • Preferred regimen (1): Triazolam 0.125, 0.25 mg PO
    • A benzodiazepine with rapid onset and short duration that might be prescribed for sleep onset insomnia
  • Preferred regimen (2): Temazepam 7.5, 15, 22.5, 30 mg PO
    • A benzodiazepine with slow onset and intermediate duration that might be prescribed for both sleep onset and sleep maintenance insomnia.

Non-benzodiazepine Receptor Agonists

Nonbenzodiazepine Receptor Agonists prescription drugs, including the zolpidem, zaleplon, and eszopiclone, are more selective for the GABAA receptor[2] and may have a cleaner side effect profile than the older benzodiazepines; however, there are controversies over whether these non-benzodiazepine drugs are superior to benzodiazepines. These drugs appear to cause both psychological dependence and physical dependence, and can also cause the same memory and cognitive disturbances as the benzodiazepines along with morning sedation.[3]

  • Preferred regimen (1): Zaleplon 5 or 10 mg PO
    • A non–benzodiazepine receptor agonist with rapid onset and ultra-short duration that might be prescribed for sleep-onset insomnia
  • Preferred regimen (2): Zolpidem with different routes of administration (the lower dose is recommended for women to reduce effects on the next day)
    • 1.75, 3.5 mg immediate-release sublingual tablet
      • A non–benzodiazepine receptor agonist with rapid onset and ultra-short duration that might be prescribed for night-time awakening
    • 5, 10 mg PO
      • A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
    • 5, 10 mg sublingual tablet
      • A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
    • 6.25, 12.5 mg controlled-release tablet
      • A non–benzodiazepine receptor agonist with rapid onset and short duration that might be prescribed for both sleep onset and sleep maintenance insomnia
  • Preferred regimen (3): Eszopiclone 1, 2, 3 mg PO (Initial dose is 1 mg)
    • A non–benzodiazepine receptor agonist with rapid onset and intermediate duration that might be prescribed for both sleep onset and sleep maintenance insomnia
Randomized controlled trial of treatment options for insomnia.[4]
Treatment Outcome at 6 months
Responders Remitters
6 weeks of CBT 55% 40%
6 months of CBT 63% 44%
6 months of CBT
6 weeks of zolpidem
81% 68%
6 months of CBT
6 months of zolpidem
65% 42%
Adapted from Table 4 of Morin et al.[4]

Antidepressants

Some antidepressants such as mirtazapine, trazodone and doxepin have a sedative effect, and are prescribed off label to treat insomnia. The major drawback of these drugs is that they have antihistaminergic, anticholinergic and antiadrenergic properties which can lead to many side effects. Some also alter sleep architecture.

  • Preferred regimen (1): doxepin 3, 6 mg PO[3]
    • A tricyclic antidepressant with slow onset and long duration that might be prescribed for sleep maintenance insomnia

Melatonin and Melatonin Agonists

Melatonin has proved effective for some insomniacs in regulating the sleep/waking cycle, but lacks definitive data regarding efficacy in the treatment of insomnia. Melatonin agonists, including ramelteon (Rozerem), seem to lack the potential for abuse and dependence. This class of drugs has a relatively mild side effect profile and a lower likelihood of causing morning sedation.

  • Preferred regimen (1): ramelteon 8 mg PO[3]
    • A melatonin agonist with rapid onset and short duration that might be prescribed for sleep-onset insomnia

Orexin Receptor Antagonists

  • Preferred regimen (1): Lemborexant 5, 10 mg PO (initial dose is 5 mg)[3]
    • An orexin receptor antagonist with slow onset and long duration that might be prescribed for sleep maintenance insomnia
  • Preferred regimen (2): Suvorexant 5, 10, 20 mg PO (initial dose is 10 mg)
    • An orexin receptor antagonist with slow onset and long duration that might be prescribed for sleep maintenance insomnia

Antihistamines

The antihistamine diphenhydramine is widely used in nonprescription sleep aids, with a 50 mg recommended dose mandated by the FDA. In the United Kingdom, Australia, New Zealand, South Africa, and other countries, a 50 to 100 mg recommended dose is permitted. While it is available over the counter, the effectiveness of these agents may decrease over time and the incidence of next-day sedation is higher than for most of the newer prescription drugs. Dependence does not seem to be an issue with this class of drugs.

Atypical antipsychotics

Low doses of certain atypical antipsychotics such as quetiapine (Seroquel) are also prescribed for their sedative effect but the danger of neurological and cognitive side effects make these drugs a poor choice to treat insomnia.

Herbal medicines

Some insomniacs use herbs such as valerian, chamomile, lavender, hops, and passion-flower. Valerian has undergone multiple studies and appears to be modestly effective.[5][6][7]

Other substances

Cannabis has also been suggested as a very effective treatment for insomnia. [8]

Alcohol may have sedative properties, but the REM sleep suppressing effects of the drug prevent restful, quality sleep. Middle-of-the-night awakenings due to polyuria or other effects from alcohol consumption are common, and hangovers can also lead to morning grogginess.

Insomnia may be a symptom of magnesium deficiency, or lower magnesium levels. A healthy diet containing magnesium, can help to improve sleep in individuals without an adequate intake of magnesium.[9]

Other reports cite the use of an elixir of cider vinegar and honey but the evidence for this is only anecdotal. [10]

References

  1. De Crescenzo F, D'Alò GL, Ostinelli EG, Ciabattini M, Di Franco V, Watanabe N; et al. (2022). "Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis". Lancet. 400 (10347): 170–184. doi:10.1016/S0140-6736(22)00878-9. PMID 35843245 Check |pmid= value (help).
  2. 2.0 2.1 2.2 2.3 Buscemi N, Vandermeer B, Friesen C, Bialy L, Tubman M, Ospina M, Klassen TP, Witmans M. The efficacy and safety of drug treatments for chronic insomnia in adults: a meta-analysis of RCTs. J Gen Intern Med. 2007 Sep;22(9):1335-50. Epub 2007 Jul 10. PMID 17619935
  3. 3.0 3.1 3.2 3.3 3.4 Sutton EL (March 2021). "Insomnia". Ann Intern Med. 174 (3): ITC33–ITC48. doi:10.7326/AITC202103160. PMID 33683929 Check |pmid= value (help).
  4. 4.0 4.1 Morin CM, Vallières A, Guay B, Ivers H, Savard J, Mérette C; et al. (2009). "Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia: a randomized controlled trial". JAMA. 301 (19): 2005–15. doi:10.1001/jama.2009.682. PMID 19454639.
  5. Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I (2000). "Critical evaluation of the effect of valerian extract on sleep structure and sleep quality". Pharmacopsychiatry. 33 (2): 47–53. PMID 10761819.
  6. Morin CM, Koetter U, Bastien C, Ware JC, Wooten V (2005). "Valerian-hops combination and diphenhydramine for treating insomnia: a randomized placebo-controlled clinical trial". Sleep. 28 (11): 1465–71. PMID 16335333.
  7. Meolie AL, Rosen C, Kristo D; et al. (2005). "Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence". Journal of clinical sleep medicine : JCSM : official publication of the American Academy of Sleep Medicine. 1 (2): 173–87. PMID 17561634.
  8. http://www.cannabis.net/medical-marijuana/pot-docs.html
  9. Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann D (1998). "Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study". Sleep. 21 (5): 501–5. PMID 9703590.
  10. "Cider Vinegar and Insomnia".