Choosing a drug for insomnia
Approach to choosing a drug for insomnia
|
Factor |
Consideration |
|---|---|
|
age |
avoid using hypnotics in older people |
|
comorbidity |
dementia—avoid using a drug to treat insomnia in dementia major depression—a sedating antidepressant may be considered, see here problem substance use—avoid using a hypnotic |
|
sex |
for psychotropic use in females of childbearing potential, see here and, for patients in the perinatal period, here |
|
type of insomnia and drug half-life |
for sleep-onset (initial) insomnia (ie trouble falling asleep), a drug with a short half-life (eg zolpidem or immediate-release melatonin) may be preferable (and in the case of a hypnotic, less likely to cause hangover symptoms the following day) for sleep-maintenance (middle) insomnia (ie waking often or for prolonged periods throughout the night), late insomnia (ie waking more than 30 minutes before desired wake-up time and not returning to sleep), or a combination of initial and middle or late insomnia, a longer-acting drug (eg zopiclone, temazepam, modified-release melatonin, suvorexant) may be preferable |
|
drug harm–benefit profile |
see advice on hypnotics, melatonin and suvorexant—do not use sedating antidepressants (in the absence of comorbid depression), sedating antihistamines, antipsychotics, gabapentin or pregabalin to treat insomnia (see Other drugs commonly used for insomnia) |
|
Note: NB1: For drug regimens for insomnia in adults, see here. | |
Hypnotics
Before starting a hypnotic (eg temazepam, zopiclone, zolpidem), discuss the potential benefits, limitations and harms with the patient so they can make an informed decision about using one.
Hypnotics are effective in inducing and maintaining sleep and increase total sleep time.
Despite these benefits, many patients find their sleep is not refreshing when aided by a hypnotic and can suffer daytime hangover effects (eg sedation, cognitive impairment, impaired driving). Hypnotics with longer half-lives are more likely to cause daytime impairment. Temazepam, with a half-life of approximately 10 hours, is the only benzodiazepine recommended for insomnia in these guidelines—diazepam and nitrazepam, for example, have much longer half-lives (more than 24 hours).
In addition to the risk of daytime sedation, zolpidem, and potentially all hypnotics, can induce dangerous complex sleep-related behaviours (see Parasomnias), and paradoxical reactions (eg hallucinations, acute rage, agitation)—advise the patient to stop the hypnotic if these effects occur.
Explain to the patient that broken sleep with vivid dreams may occur when the hypnotic is stopped and that it takes several days or weeks for a normal sleep rhythm to re-establish. This rebound insomnia does not indicate that further hypnotic use is needed.
For considerations in using:
- hypnotics in older people, see here
- hypnotics in dementia, see here
- hypnotics in an inpatient setting, see here
- hypnotics in problem substance use, see here
- hypnotics in females of childbearing potential, see here
- benzodiazepines in pregnancy, see here or breastfeeding, see here
- zolpidem or zopiclone in pregnancy, see here or breastfeeding, see here.
If the potential benefits associated with short-term hypnotic use exceed the potential harms, assess for risk of misuse—see Considerations in assessing risk of hypnotic misuse. If the risk is low, use the lowest possible dose intermittently for the shortest possible time—see regimens here. Agree upon a duration of use with the patient before starting the hypnotic, and limit the quantity supplied. Explain the reason for this approach to the patient; the risk of hypnotic tolerance and dependence increases as duration of therapy increases—see also Insomnia in an adult who has taken a hypnotic long term. Zopiclone and zolpidem may have less potential for dependence than benzodiazepines.
Advise the patient to avoid taking a hypnotic concurrently with alcohol or other central nervous system depressants; concurrent use increases the risk of potentially serious adverse effects.
- check for a history of problem substance use (eg check a prescribing register or prescription monitoring service)
- be wary of unfamiliar patients asking for a specific drug—this may indicate drug-seeking behaviour
- consider whether other members of the person’s household who could access the hypnotics could be at risk of misuse.
Melatonin
Melatonin is a hormone that regulates circadian rhythm and sleep. Clinical trial data show that melatonin may reduce sleep-onset time and improve sleep quality in adults with insomnia, but data are conflicting and the clinical significance of improvements is small. Melatonin is well tolerated; it does not appear to have abuse potential and reduces hypnotic use. Melatonin does not appear to cause daytime sedation, although high doses (eg 5 mg) may have hypnotic properties.
For melatonin regimens for insomnia in adults, see here.
For considerations in using melatonin in pregnancy, see here and breastfeeding, see here.
Suvorexant
Suvorexant is an orexin A and B receptor antagonist. Although clinical trial data indicate that suvorexant modestly improves sleep-onset time, reduces wakening after sleep onset, improves sleep efficiency and total sleep time in adults with chronic insomnia, there is limited clinical experience with its use in Australia. Suvorexant should not be combined with other sedatives or alcohol—this increases the risk of adverse effects (eg abnormal dreams).
For a suvorexant regimen for insomnia in adults, see here.
For considerations in using suvorexant in:
Other drugs commonly used for insomnia
Do not use sedating antidepressants (in the absence of comorbid depression), sedating antihistamines, antipsychotics, gabapentin or pregabalin to treat insomnia. Although these drugs are commonly used, there is insufficient evidence of benefit to support this practice and they can cause significant adverse effects:
- antidepressant adverse effects vary, depending on the antidepressant—see Antidepressant adverse effects
- sedating antihistamine adverse effects include daytime sedation, impaired cognition, delirium and paradoxical agitation; tolerance to sedation can rapidly develop
- antipsychotic adverse effects vary, depending on the antipsychotic—see Antipsychotic adverse effects. Antipsychotic use has been associated with abuse—quetiapine is associated with problem use and overdose and is subject to monitoring by drug diversion monitoring systems in some Australian states
- gabapentin and pregabalin (in particular) are associated with dependence and abuse.
For further information on adverse effects, refer to a drug information resource.