Insomnia and Sleep Disorders in Primary Care Settings - Episode 6

Treatment Options for Insomnia

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An expert in sleep medicine provides insight on the use of traditional insomnia medications in patients as well as DORAs, and common challenges experienced with these treatment options.

Paul Doghramji, MD, FAAFP: There have been a lot of medications that have come out that we use that are prescription for our patients who have insomnia. There are many that came out decades ago that were not indicated for insomnia, that were used for insomnia. There are many that have come out in the last couple of decades that are specifically indicated for insomnia. There are various categories of drugs. Some are off-label, some are on-label. The most common off-label medication that's used for insomnia is trazodone. It's interesting that it's the number one used sleep medication in this country, which again has no indication for insomnia. Let's talk about the medications that are indicated for insomnia because they're good medications and they're very helpful for our patients. Like I said, they are on-label. First are the benzodiazepines and some of them are still quite effective. One of them which is temazepam is probably the leading benzodiazepine to help our patients with insomnia. Then there are the benzodiazepine receptor agonists. They're non-benzodiazepines in their molecule, but they work similarly. They're called the Z-drugs, zaleplon, zolpidem, and eszopiclone. They have slightly different characteristics. Primarily the difference is their half-life and they can be used for our patients with insomnia. There's one targeting histamine and that's doxepin that's used to help patients only stay asleep better at the 10 mg dose. There's also a melatonin receptor agonist which is called ramelteon that's also been invented. There's only one in its class as well that's indicated only for sleep initiation. Also, in the last 10 years or there have been three medications that have come out in the most newest mechanism of action and that's the dual orexin receptor antagonists. The first one that came out is suvorexant. The second one that came out is lemborexant and the third newest one is daridorexant. These are dual orexin receptor antagonists that work by antagonizing orexin in the orexin nucleus, lowering the amount of wakefulness that's going on to help the patient get to sleep and stay asleep.

When the Z-drugs came out, zaleplon, zolpidem, and eszopiclone, they did help us fill a gap in our treatment. There are a lot of patients that were doing very poorly with the previous ones, whether they were anti-depressants, whether they were barbiturates, et cetera. They did well, but they had problems. Either they would have middle-of-the-night behaviors that patients would have where they would wake up and do bizarre things and not remember, they would have some falls in the beginning, in the night, they would have next day spillover effect, there was rebound insomnia, there was maybe some habituation that was going on. They had their problems. They helped, but they had their problems. We found something that did help some patients. Clearly, there was still a gap in treatment and that's why I think that we now have the dual orexin receptor antagonists that may fit some of the gaps in our treatment. But again, there have been challenges with the Z-drugs, but also, by the way, some of the challenges with the medicines that are used off-label. We’ve talked about trazodone. They can certainly have a lot of adverse effects to them. There's another one which is commonly used, quetiapine. That can have some issues with it as well. We all know about them. Gabapentin can also be used for sleep or is being used for sleeping off-label. There are a lot of medicines that have come out that have been used off-label in the past. There's plenty of challenges with them, and that's why maybe the introduction of a new type of medication is now seemingly attractive to clinicians when they're trying to treat their patients for their insomnia.

Transcript Edited for Clarity