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Primary Insomnia (cont.)

Primary Insomnia Medications

Pharmacologic treatment usually provides rapid symptomatic relief.

Hypnotics (agents that promote sleep) and benzodiazepines (compounds with antianxiety, hypnotic, anticonvulsant, and muscle relaxant properties) are the mainstays of short-term treatment of primary insomnia.

Hypnotics

Basic principles for the treatment of insomnia include the following:

  • Use the lowest effective dose.
  • Use intermittent dosing (2 to 3 nights per week).
  • Use for short term (2 to 3 weeks at a time).
  • Discontinue after slow taper if the person has been taking it regularly.
  • Use drugs with short and/or intermediate half-life to minimize daytime sedation.
Commonly Used Hypnotics
Agent Dose Peak Action
Long acting
Flurazepam (Dalmane) 15 to 30 mg 0.5 to 1 hr
Quazepam (Doral) 7.5 to 15 mg 2 hr
Intermediate acting
Eszopiclone (Lunesta) Nonelderly: 2 to 3 mg
Elderly: 1 to 2 mg
1 hr
Estazolam (ProSom) 1 to 2 mg 2 hr
Temazepam (Restoril) 7.5 to 30 mg 1.2 to 1.6 hr
Lorazepam (Ativan) 0.5 to 2 g 2 to 4 hr
Oxazepam (Serax) 10 to 15 mg 3 hr
Short acting
Triazolam (Halcion) 0.125 to 0.5 mg 1 to 2 hr
Zolpidem* (Ambien) 5 to 10 mg 1.6 hr
Zaleplon* (Sonata) 5 to 10 mg 0.9 to 1.5 hr

*Zolpidem and Zaleplon are not structurally related to benzodiazepines.

Common side effects of hypnotics are as follows:

  • Amnesia (total or partial inability to recall past experiences) and withdrawal effects may occur, especially with short-acting benzodiazepines (not with zolpidem and zaleplon).
  • Residual daytime sedation with intermediate-acting and long-acting drugs may occur, depending on dosage.
  • Rebound insomnia may occur with short-acting and intermediate-acting benzodiazepine after discontinuation.
  • Short-acting agents are recommended for persons with difficulty falling asleep, while intermediate-acting drugs are indicated for problems with sleep maintenance.
  • Avoid long-acting agents, especially in older people, because they cause daytime sedation, impair cognition, and, thereby, increase the risk of falls.

Not everyone should take hypnotic medications. Contraindications of hypnotics are as follows:

Caution and close monitoring is needed in older people and in persons with hepatic, renal, or pulmonary disease.

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Primary Insomnia »

Primary insomnia is sleeplessness that is not attributable to a medical, psychiatric, or environmental cause.

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