Fast Five Quiz: Insomnia

Stephen Soreff, MD

Disclosures

October 10, 2019

Sedative-hypnotic medications do not usually cure insomnia, but they can provide symptomatic relief, often as an adjunct with CBT. Some patients cannot adhere to or do not respond to CBT, and are also candidates for these agents. The nonbenzodiazepine receptor agonists (eg, eszopiclone, zolpidem, zaleplon) are believed to be less habit-forming than benzodiazepines and, therefore, represent important advances in the long-term treatment of chronic insomnia. The use of benzodiazepines has been shown to lead to addiction.

The most appropriate use of nonbenzodiazepine receptor agonists is for transient and short-term insomnia in combination with nonpharmacologic treatment. Most authorities now agree that they should infrequently be the only therapy for chronic insomnia.

Ramelteon (Rozerem), a melatonin receptor agonist, is approved by the US Food and Drug Administration for use in persons with insomnia. It has been shown to have no potential for abuse and, as such, is the first nonscheduled prescription drug available in the United States for the treatment of insomnia. This medication is suited for patients with sleep-onset insomnia, particularly for elderly patients with gait disorders who have an increased risk for falls and in patients with a history of substance abuse. The typical starting dose is 8 mg before bedtime. Ramelteon is not effective for sleep-maintenance insomnia.

Many clinicians believe that sedating antidepressants have fewer adverse effects than nonbenzodiazepine receptor agonists; however, this is not the case. Tricyclic drugs and mirtazapine can cause daytime sedation, weight gain, dry mouth, postural hypotension, and cardiac arrhythmias. Trazodone can cause priapism in men, daytime sedation, and hypotension.

Antihistamines are the major ingredient of over-the-counter sleep aids and are the ingredient in cold and sinus formulas sold as bedtime use medications. Nevertheless, common antihistamines (ie, first-generation H1-receptor antagonists such as diphenhydramine, hydroxyzine, and doxylamine) are not indicated for the treatment of sleeplessness.

Read more about the pharmacologic treatment of insomnia.

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