Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Management of Chronic Insomnia Disorder in Adults

Ann Intern Med; ePub 2016 May 3; Qaseem, Kansagara, et al

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The American College of Physicians (ACP) has issued a clinical practice guideline that presents evidence and offers recommendations on the management of chronic insomnia disorder in adults. Among the strongest recommendations is that all adult patients receive cognitive behavioral therapy for insomnia (CBT-1) as the initial treatment for chronic insomnia disorder. The 2 ACP recommendations from this guideline are:

• Recommendation 1: ACP recommends that all adult patients receive cognitive behavioral therapy for insomnia (CBT-I) as the initial treatment for chronic insomnia disorder (Grade: strong recommendation, moderate-quality evidence).

• Recommendation 2: ACP recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom cognitive behavioral therapy for insomnia (CBT-I) alone was unsuccessful (Grade: weak recommendation, low-quality evidence).

Citation: Qaseem A, Kansagara D, Forciea MA, Cooke M, Denberg TD, et al. Management of chronic insomnia disorder in adults: A clinical practice guideline from the American College of Physicians. [Published online ahead of print May 3, 2016]. Ann Intern Med. doi:10.7326/M15-2175.

Commentary: The guidelines clearly recommend behavioral therapies as first line treatment for insomnia based on both evidence of effectiveness and low likelihood of harm. What is important to note from the evidence review is that there is very little evidence for long-term treatment of insomnia with medications. Most studies of medicines for insomnia have been relatively short-term studies and the FDA has approved pharmacologic therapy for short-term, 4-5 week, use. There is also evidence from observational trials of adverse effects of long-term medication use for insomnia, including dementia, injury, fractures and daytime impairment of cognition and depression.1,2 These side effects can be greater in older adults, so if medications are used for sleep in older adults, they should be used with caution and at the lowest dose possible. —Neil Skolnik, MD

1. Chen PL, Lee WJ, Sun WZ, Oyang YJ, Fuh JL. Risk of dementia in patients with insomnia and long-term use of hypnotics: a population- based retrospective cohort study. PLoS One. 2012;7:e49113. doi:10.1371/journal.pone.0049113.

2. Kang DY, Park S, Rhee CW, Kim YJ, Choi NK, Lee J, et al. Zolpidem use and risk of fracture in elderly insomnia patients. J Prev Med Public Health. 2012;45:219-26. doi:10.3961/jpmph .2012.45.4.219.

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