Sleep restriction creates a degree of sleep deprivation that may enhance sleep onset and maintenance. Caution patients not to drive or perform hazardous activities while sleep-deprived.
8 Has the patient been prescribed appropriate doses of medications with appropriate indications?
Chronic insomnia sufferers often try to get more sleep by using alcohol, food supplement remedies, and OTC antihistamine sleep aids—none of which has demonstrated efficacy for treating insomnia. Although sedating prescription medications may be recommended for comorbid conditions, many also are prescribed off-label to promote sleep.
Examples include sedating antidepressants, antipsychotics, antihistamines, anticonvulsants, and benzodiazepines that are not indicated for insomnia. Little or no evidence supports these medications as safe and efficacious for treating insomnia, and important safety concerns are associated with their use.
The BZRA category includes 5 benzodiazepines and 4 nonbenzodiazepine formulations. Half-lives vary from approximately 1 hour to several days. Compared with benzodiazepines, nonbenzodiazepines have greater selectivity for GABAA receptor complexes incorporating the alpha-1 sub-unit subtype, which may confer some safety and tolerability advantages. One extended-release formulation is available. All may be beneficial for sleep onset, and some have indications for sleep maintenance difficulty.
Ramelteon is a nonsedating selective melatonin receptor agonist approved for treating insomnia characterized by sleep onset difficulty. This agent—which attenuates evening circadian arousal—may help promote sleep onset and enhance sleep during the early part of the night.
Administration. Inadequate dosing of insomnia medications may cause treatment to fail, but prescribing beyond approved ranges is rarely necessary. High sedative doses increase the risk of adverse effects, and patients may sleep no better. Adverse effects may include somnolence, headache, dizziness, nausea, diarrhea, and anterograde amnesia. Rarely patients may exhibit sleep walking or confused behaviors within a few hours after taking a hypnotic dose.
Recommendation. Customize your selection of FDA-approved insomnia medications. Consider whether your patient needs medication for sleep onset or sleep maintenance. In most cases, prescribe within dosing ranges listed in Table 3
Table 3
Insomnia treatment: FDA-approved medications
| Medication | Recommended dosage (mg) | Elimination half-life (hr) |
|---|---|---|
| Benzodiazepine receptor agonists | ||
| Immediate-release benzodiazepines | ||
| Estazolam | 1 to 2 | 8 to 24 |
| Flurazepam | 15 to 30 | 48 to 120 |
| Quazepam | 7.5 to 15 | 48 to 120 |
| Temazepam | 7.5 to 30 | 8 to 20 |
| Triazolam | 0.125 to 0.25 | 2 to 4 |
| Immediate-release nonbenzodiazepines | ||
| Eszopiclone | 1 to 3 | 5 to 7 |
| Zaleplon | 5 to 20 | 1 |
| Zolpidem | 5 to 10 | 1.5 to 2.4 |
| Extended-release nonbenzodiazepine | ||
| Zolpidem ER | 6.25 to 12.5 | 2.8 to 2.9 |
| Selective melatonin receptor agonist | ||
| Ramelteon | 8 | 1 to 2.6 |
Related Resources
- American Academy of Sleep Medicine. www.aasmnet.org.
- National Sleep Foundation. www.sleepfoundation.org.
- NIH National Center for Sleep Disorders Research. www.nhlbi.nih.gov/about/ncsdr.
Drug brand names
- Estazolam • ProSom
- Eszopiclone • Lunesta
- Flurazepam • Dalmane
- Quazepam • Doral
- Ramelteon • Rozerem
- Temazepam • Restoril
- Triazolam • Halcion
- Zaleplon • Sonata
- Zolpidem • Ambien
- Zolpidem ER • Ambien CR
Disclosure
Dr. Neubauer is a consultant to Neurocrine Biosciences, sanofi-aventis, and Takeda Pharmaceuticals North America and a speaker for sanofi-aventis and Takeda Pharmaceuticals North America.