Medication selection for insomnia in adults

CBT-I: cognitive behavioral therapy for insomnia; DORA: dual orexin receptor antagonist; BZRA: benzodiazepine receptor agonist.

* When used, medications should be part of a holistic approach that includes healthy sleep habits, adequate opportunity for sleep, treatment of relevant comorbidities, and CBT-I when appropriate and available. Treatment selection is individualized based on the nature of the insomnia symptoms, past treatment responses, medication availability and cost, side effects, comorbidities, and patient preferences. Duration of effect varies based on elimination half-life, patient age, and other factors. Refer to UpToDate topic and tables for dosing and administration details.

¶ BZRAs include benzodiazepines and nonbenzodiazepine BZRAs such as zolpidem. Among the benzodiazepine hypnotics approved for insomnia that may be used as second-line therapies, temazepam has the most favorable safety profile.

Δ All patients should be aware of the risk of next morning sedation with insomnia medications. Agents with a dual indication for sleep onset and sleep maintenance difficulties (eg, DORAs, zolpidem extended release, eszopiclone, zopiclone) have a higher risk of next-morning residual sedation than other first-line agents such as doxepin.