Treatments recommended for chronic insomnia resistant to nonmedical interventions

Evidence and recommendations on the use of medications to treat chronic insomnia were recently offered by a clinical practice guideline from the American Academy of Sleep Medicine.

The guideline, which was published in the Feb. 15 Journal of Clinical Sleep Medicine, was developed by an expert task force, based on a systematic literature review, and intended to help clinicians choose a specific pharmacological agent for the treatment of chronic insomnia in adults when such treatment is indicated.

All recommendations were made versus no treatment and apply only to adults. The recommendations were all classified as weak, because the data available to support the recommendations were often less than certain. The suggestions for clinicians are as follows:

• zaleplon, triazolam, and ramelteon for sleep-onset insomnia;
• doxepin and suvorexant for sleep-maintenance insomnia; and
• eszopiclone, zolpidem, and temazepam for sleep-onset and sleep-maintenance insomnia.

The guideline suggests against using trazodone, tiagabine, diphenhydramine, melatonin, tryptophan, or valerian for sleep-onset or sleep-maintenance insomnia. Decisions should be based not only on these recommendations but also on a clinician's experience and the individual circumstances presented by the patient, noted a press release about the guideline.

The guideline authors, who also offered specific recommendations for future research, noted that existing data on insomnia drugs is sorely limited. “The result is that many commonly used drugs, including some which carry FDA approval for treatment of insomnia, are not recommended,” they wrote.

A previous guideline from the academy recommended cognitive behavioral therapy for insomnia (CBT-I) as an effective treatment, and this guideline noted that medications should be considered mainly in patients who are unable to participate in CBT-I, still have symptoms after therapy, or require a temporary adjunct to therapy.