Pharmacological Treatment Strategies
- What type of symptom pattern an individual has?
- What response patient has with previous treatment?
- The kind of treatment form patient prefers
- Affordability of treatment
- Other available treatments
- Availability of treatment
- Contraindications, side effects, drug interactions
- Co-morbid disorders and concurrent medications
First-Line Chronic Insomnia Treatment
These medicines reduce the latency to sleep onset. Additionally, they increase the total sleep duration. Benzodiazepines primarily reduce anxiety. They reduce the activity of brain nerves by enhancing the effect of GABA (gamma-aminobutyric acid). They have sedative, anxiolytic, muscle relaxation, and anticonvulsant properties.
It is always advisable to take sleep medication as prescribed by the physician.
Examples of some Benzodiazepines:
- Zopiclone: This sleeping pill helps to reduce sleep onset time. It also reduces mid-night awakenings. Generally, it is prescribed for 2-4 weeks. It may cause dependence. The most common side effects include dry mouth and daytime sleepiness. Please consult your physician for safe use.
- Zolpidem: This sleeping pill decreases the time to sleep onset. Additionally, it has myorelaxant, anticonvulsant, and anxiolytic properties. It also decreases nocturnal awakenings. It is helpful for staying asleep. The major side effects include a headache, drowsiness and dry mouth.
- Zaleplon: This medication causes relaxation. It helps to fall and stay asleep. Comparatively, it helps by reducing time to sleep onset than reducing intermittent sleep awakenings.
- Eszopiclone: This is an active stereoisomer of zopiclone and agonist at benzodiazepine (BNZ) receptors. However, there are multiple adverse effects associated with its use. Some major adverse effects include a headache, drowsiness and lack of coordination. Hence, risk-benefit evaluation is a must for prescribing.
Second-Line Chronic Insomnia Treatment
Many times first-line chronic insomnia treatment is insufficient. Often chronic insomnia patients especially elderly patients require additional medicinal help. This can be achieved by judicial use of antidepressants or antihistamines. The antidepressants particularly relieve symptoms of depression, social anxiety disorder or anxiety disorders. Generally, the antidepressants like tricyclic antidepressants restore the balance of neurotransmitters in the brain. They also block the effects of histamine and enhance sleep.
Chronic Insomnia Treatment: New Recommendations 2017
The new clinical practice guidelines published by American Academy of Sleep Medication recommend the strategic approach.
- Short/intermediate-acting BzRAs or ramelteon:
- Alternative BzRAs or ramelteon
- Sedating low-dose antidepressant (AD)
- Combination of BzRA + antidepressant (AD)
As per these recommendations, there is no preferable agent in Short/intermediate-acting BzRAs or ramelteon class. Each patient has his/her own response to these drugs. There are multiple factors play role in the selection of chronic insomnia treatment. For example, drug half-life, cost, symptoms, past response etc.
The chronic insomnia treatment guideline emphasizes the alternative approach if initial regimen fails to obtain the desired response. The selection of new regimen would be dependent on the failure of initial prescription. The chronic insomnia treatment guideline also recommends the use of combinations and treatment of co-morbid conditions. For example, antidepressants for the treatment of insomnia and co-existing depression.
It has been observed that some of hypnotics are associated with disruptive sleep-related behaviors including sleepwalking, eating, driving, and sexual behavior. Hence, risk-benefits should always be considered while planning regimen for chronic insomnia.