Explain That Insomnia Meds Are Only Modestly Helpful

Sleepless nights worrying about COVID-19 will have more patients asking you about treatments for insomnia.

Explain some level of insomnia is expected in stressful times.

Emphasize sleep hygiene...relaxation, limiting alcohol near bedtime, etc. Share our patient handout, Strategies for a Good Night's Sleep.

Continue to look for meds that can impact sleep (stimulants, SSRIs, etc)...and help manage conditions, such as pain or depression.

Educate that most insomnia meds only increase sleep by about 15 to 30 minutes...but may be an option for a few weeks if insomnia significantly impacts daytime function. Point out risks and costs.

And keep in mind, most sleep meds are on the Beers Criteria.

"Z-drugs" (zolpidem, etc) can cost under $1/dose...but weigh downsides. For example, they have a boxed warning about serious injury or death due to sleepwalking, sleep driving, etc.

If needed, suggest zaleplon to help patients FALL asleep, since it's shorter-acting...or eszopiclone or zolpidem to STAY asleep, since they're longer-acting.

Ramelteon (Rozerem) is a melatonin agonist that may help patients fall asleep...but the generic still costs about $6/dose.

Think about ramelteon if abuse or dependence is a concern.

Orexin antagonists (Belsomra, Dayvigo) block neurotransmitters that promote wakefulness...to help patients fall and stay asleep.

Dayvigo (lemborexant) will be the newest...but it doesn't seem to have an edge over Belsomra (suvorexant). Both are C-IV meds.

Belsomra costs about $12/dose...Dayvigo will likely be similar.

But neither seems to work better than other options...and they have additional adverse effects (sleep paralysis, etc) and interactions.

Supplements and OTCs are popular, but put them in perspective.

Melatonin may help patients fall asleep...especially the elderly. Suggest 3 mg to start...and titrate to 6 mg if needed.

If patients ask, explain valerian is okay to try. But there's not enough evidence that chamomile or kava is helpful.

Avoid first-generation antihistamines (diphenhydramine, etc)...due to limited benefit and risks (confusion, urinary retention, etc).

See our chart, Comparison of Insomnia Treatments, for other meds...such as low-dose doxepin, mirtazapine, or trazodone.

Key References

  • J Clin Sleep Med 2017;13(2):307-49
  • Am Fam Physician 2017;95(10):669-70
  • www.healthquality.va.gov/guidelines/CD/insomnia/VADoDSleepCPGFinal508.pdf (4-27-20)
  • Medication pricing by Elsevier, accessed Apr 2020
Pharmacist's Letter. May 2020, No. 360507

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