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Doxepin is a tricyclic antidepressant and is believed to exert sleep maintenance effects due to a strong binding affinity for histamine H1 receptors, which allows the use of the drug as a sedative at doses lower than those required for major depressive disorder.
Nonbenzodiazepine Benzodiazepine-Receptor Agonists
Zolpidem, eszopiclone, and zaleplon are thought to induce sleep by subunit modulation of the GABA-A receptor chloride channel macromolecular complex. The main site of modulatory drug action is located within the GABA-A receptor complex on the alpha-subunit, which is known as the benzodiazepine (BZ) or omega receptor. Eszopiclone has a longer half-life (6 hours) than the other drugs in the class which contributes to improving sleep maintenance.
Melatonin Receptor Agonists
Ramelteon and tasimelteon selectively target the melatonin receptors MT1 and MT2, which are located in the suprachiasmatic nucleus (SCN) of the hypothalamus. The SCN functions as the internal clock of the body and regulates the 24-hour sleep-wake cycle. The MT1 and MT2 receptors are believed to be involved in the promotion of sleep and the maintenance of the normal circadian rhythm (shift between day and night), respectively, when acted upon by endogenous melatonin.
Orexin Receptor Antagonists
Suvorexant and lemborexant exert their therapeutic effects through antagonism of orexin receptors. Suvorexant and lemborexant block the binding of wake-promoting neuropeptides orexin A and orexin B to the OX1R and OX2R receptors, subsequently suppressing the wake drive.
Dietary or herbal supplements
Melatonin is an endogenous hormone secreted by the pineal gland that interacts with melatonin receptors. Synthesis and secretion of endogenous melatonin are controlled by enzymes secreted by the hypothalamus which are activated by darkness and depressed by environmental light. The activity of melatonin at the MT1, MT2 and MT3 receptors is believed to contribute to its sleep-promoting properties, as these receptors (mainly MT1 and MT2) are involved in the regulation of circadian rhythms and sleep regulation. Commercial melatonin products are primarily synthesized because of the potential for contamination from animal-based infectious prions and viruses, which may cause serious illness.
Non-prescription (OTC) drugs
Diphenhydramine and doxylamine are first-generation sedating antihistamines (H1-blockers) that competitively antagonize the effects of histamine on the H1 receptor to produce their non-specific centrally-mediated sedative effects.
Short-term, prescription treatment (e.g., 7 to 10 days)
In general, short-term treatment with a sleep agent is an appropriate alternative if non-pharmacological sleep therapy has failed. Individualized pharmacotherapy is recommended and is based upon factors such as the specific sleep disturbance (e.g., delayed sleep onset, difficulty maintaining sleep), treatment goals, past treatment response and tolerability, comorbid conditions, concomitant drug therapy, and cost. Eszopiclone, lemborexant, suvorexant, and zolpidem controlled-release are the only prescription nonbenzodiazepine drugs shown to improve both sleep onset and sleep maintenance. Regardless of treatment selection, patients should be re-evaluated for a comorbid condition if insomnia has not improved in 7 to 10 days.
Long-term, prescription treatment
Long-term efficacy for insomnia has been established in controlled studies of eszopiclone, ramelteon, lemborexant, and suvorexant. Due to their pharmacokinetic properties, eszopiclone, lemborexant, and suvorexant are beneficial for improving both sleep onset and sleep maintenance. Clinically, other prescription sleep agents without long-term efficacy data may be appropriate in select patients for long-term treatment with close monitoring for efficacy and safety.
Short-term, non-prescription treatment (e.g., 7 to 10 days) with non-prescription drugs or herbal/dietary supplements
Melatonin has shown efficacy in the short-term treatment of insomnia with limited adverse effects. In a meta-analysis evaluating melatonin in primary sleep disorders, melatonin demonstrated a significant benefit in reducing sleep latency, increasing total sleep time, and improving sleep quality compared to placebo. Meta-regression showed that trials using higher melatonin doses reported significantly greater effects on total sleep time, and a trend towards greater effects on sleep latency. Sleep quality was not affected by higher doses. Patients should be re-evaluated if insomnia does not improve within 7 to 10 days after starting pharmacological therapy regardless of treatment. Based on trials of melatonin 2 mg/day PO, the American Academy of Sleep Medicine (AASM) guidelines recommend against melatonin used as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. Diphenhydramine and doxylamine lack clinical evidence supporting safety and efficacy for the treatment of insomnia.
Non-24-hour sleep-wake disorder
Tasimelteon is FDA approved for the treatment of non-24-hour sleep-wake disorder. Tasimelteon significantly improved total sleep time and daytime nap duration in controlled studies. Strategically timed melatonin has also been recommended for the treatment of non-24-hour sleep-wake disorder but has weak evidence.
Summary of Insomnia Treatments
† Off-label use
a Limited efficacy
Zolpidem was more likely to improve sleep quality but also more likely to cause withdrawal symptoms compared to zaleplon (7.1% vs. 1.5%).
No significant difference in adverse reactions between zaleplon and zolpidem.
Latency to persistent sleep (LPS):
Sleep onset latency (SOL):
Subjective sleep improvement or next-morning residual effects did not differ between the two formulations.
Improved sleep onset latency:
Improved sleep time:
Improved sleep quality:
No significant side effects observed.
Diphenhydramine and doxylamine:
Failed to demonstrate consistent, positive improvements in objective and self-reported sleep measures.
Melatonin demonstrated consistent positive improvements in sleep quality with limited adverse effects.
Diphenhydramine and doxylamine lack safety and efficacy data for the treatment of insomnia.
Sedative-hypnotics can cause varying degrees of CNS depression. Patients should be instructed to avoid driving or operating machinery or performing other tasks requiring mental alertness after taking their dose. Because zolpidem, eszopiclone, lemborexant, and suvorexant have been associated with next-day psychomotor impairment, patients should be instructed to avoid driving or operating heavy machinery the day following a dose per the time specifications recommended for each product by the manufacturers. Concurrent use of other CNS depressants, including ethanol, may increase the risk for next-day impairment, psychomotor impairment, or other CNS-related toxicities with these drugs. There is a potential risk for respiratory depression with nonbenzodiazepine benzodiazepine-receptor agonists (i.e., zaleplon, eszopiclone, and zolpidem) if CNS depression is severe. Most hypnotic agents should be used with caution in patients with impaired/depressed respiratory function or sleep apnea since CNS depression can affect respiratory drive; however, tasimelteon and melatonin have not been precautioned in such patients.
Complex sleep behaviors (performing tasks while not fully awake and often having no memory of the event) such as making phone calls, engaging in sexual activity, eating while asleep, or sleep-driving have occurred with the use of hypnotics, such as zolpidem, eszopiclone, zaleplon, ramelteon, lemborexant, and suvorexant. All sedative-hypnotic medications have the potential to cause sleep-related behaviors; however, the exact incidences among various sedative products are unknown. Therefore, patients should be informed of the risks prior to receiving any medication from this class. Alcohol may increase the risk of these events. Due to the risk to the patient and the general public, the sleep agent should be discontinued in patients who experience a complex sleep behavior.
Symptoms consistent with narcolepsy have occurred during use of orexin receptor antagonists including lemborexant and suvorexant. Symptoms include sleep paralysis (an inability to move or speak for up to several minutes during sleep-wake transitions), hypnagogic/hypnopompic hallucinations (vivid and disturbing perceptions when falling asleep or waking up), and cataplexy-like symptoms (periods of leg weakness lasting from seconds to a few minutes). Prescribers should explain the nature of these events to patients prior to prescribing orexin receptor antagonists.
Immediately evaluate patients with suicidal ideation or any new behavioral changes. A variety of abnormal thinking and behavioral changes have been reported with the use of sedative/hypnotics. These changes have included decreased inhibition, aggressiveness, bizarre behavior, agitation, hallucinations, and depersonalization. Amnesia and other neuropsychiatric symptoms may occur unpredictably. Worsening of pre-existing depression, suicidal ideation, and completed suicides have occurred in association with the use of sedative-hypnotics. The exact incidences among various sedative products are unknown; however, patients should be informed of the risks prior to receiving any medication from this class. Sedative-hypnotics should be prescribed in the smallest quantity consistent with good patient management to reduce the risk of overdose.
Alternatives to zolpidem, zaleplon, eszopiclone, lemborexant, and suvorexant should be considered in patients with a history of substance abuse since these agents are controlled substances with the potential for abuse and dependence. There are postmarketing reports of abuse, dependence, and withdrawal with administration of zolpidem, zaleplon and eszopiclone. If therapy with these drugs is continued for more than 2 weeks, the possibility of a withdrawal syndrome should be considered and abrupt discontinuation of therapy avoided. Because of the potential for dependence, close monitoring is recommended. In an abuse liability study of recreational polydrug users, suvorexant produced similar subjective measures of abuse liability (e.g., drug liking) as zolpidem. In an abuse potential study of recreational sedative abusers receiving lemborexant doses of 10 mg to 30 mg, lemborexant produced similar subjective measures of abuse liability (e.g., drug liking) as zolpidem 30 mg and suvorexant 40 mg and a statistically greater response than the placebo group. Prolonged use of suvorexant and lemborexant did not result in physical dependence and there were no reported withdrawal symptoms after discontinuation of the drugs. Conditions that may increase the risk for prescription sedative abuse include prolonged use, a history of drug abuse or alcoholism, use of higher than recommended doses, or coadministration of the prescribed sedative with alcohol or other abused drugs.
Concomitant administration of sedative-hypnotics with other drugs having CNS depressant properties (e.g., psychotropics, anticonvulsants, antihistamines, narcotic analgesics, anesthetics, ethanol) is expected to produce additive CNS depressant effects and may lead to psychomotor impairment or respiratory depression. Patients should be advised not to take these medications with alcohol. Patients should not take other hypnotic agents or non-prescription/dietary supplement sleep aids concurrently. Patients should also be encouraged to confine their activities to those necessary to prepare for bed after taking their hypnotic agent. Some agents may also cause pharmacokinetic interactions; for example, doxepin increases concentrations of ramelteon and patients should be closely monitored if these medications are used concurrently.
Many drugs from this class are primary CYP substrates. Concomitant administration in patients receiving CYP inhibitors or inducers may alter drug exposure, with the potential for affecting efficacy or tolerability.
Primary CYP Substrates
Metabolic Drug Interactions
Use cautiously with inducers or inhibitors of CYP2D6
Use cautiously with inducers or inhibitors of CYP2C19 or CYP2D6
Max dose with strong CYP3A4 inhibitors is 2 mg/night
Monitor for decreased efficacy when using strong CYP3A4 inducers
Avoid use with moderate or strong CYP3A4 inhibitors
Max dose with weak CYP3A4 inhibitors is 5 mg/night
Avoid use with moderate or strong CYP3A inducers
Use with strong CYP1A2 inducers or inhibitors not recommended
Contraindicated with strong CYP1A2 inhibitors (e.g., fluvoxamine)
Use cautiously with inducers or inhibitors of CYP1A2, CYP3A4, and CYP2C9
Use with strong CYP3A4 inhibitors not recommended
Limit dose with moderate CYP3A4 inhibitors to 5 mg/night, if efficacious
Use with strong CYP1A2 inhibitors not recommended
Use with strong CYP3A4 inducers not recommended
Use cautiously with strong CYP3A4 inducers or inhibitors
All non-benzodiazepine sedative/hypnotics are extensively metabolized in the liver. Sedative/hypnotics vary in their recommendations for use based upon the severity of hepatic impairment.
Mild hepatic impairment (Child-Pugh Class A)
Initial dosage reductions are required in patients receiving zaleplon or zolpidem. No dose adjustments are necessary in patients receiving eszopiclone, lemborexant, ramelteon, suvorexant, or tasimelteon. No quantitative guidelines are available for diphenhydramine, doxylamine, or doxepin. Melatonin is generally not recommended in patients with hepatic disease.
Moderate hepatic impairment (Child-Pugh Class B)
Initial dosage reductions are required in patients receiving zaleplon or zolpidem. Maximum dose reductions are recommended in patients receiving lemborexant. No dose adjustments are necessary in patients receiving eszopiclone, ramelteon, suvorexant, or tasimelteon. No quantitative guidelines are available for diphenhydramine, doxylamine, or doxepin. Melatonin is generally not recommended in patients with hepatic disease.
Severe hepatic impairment (Child-Pugh Class C)
Zaleplon and ramelteon are not recommended since systemic exposure is significantly increased. The dose of eszopiclone should not exceed 2 mg/day because systemic exposure is doubled. Suvorexant, tasimelteon, and lemborexant are not recommended because these drugs have not been studied in severe hepatic impairment. Avoid zolpidem since the drug may contribute to encephalopathy. Quantitative guidelines are not available for diphenhydramine, doxylamine, or doxepin; monitor for side effects and adjust the dose if needed. Melatonin is generally not recommended in patients with hepatic disease; hepatic impairment results in higher endogenous melatonin levels.
The elderly may be particularly at risk for adverse events from some hypnotic agents, so careful selection of drug therapy and the dosage is important when treatment is indicated. Skilled care residents should be treated with extra caution. The federal Omnibus Budget Reconciliation Act (OBRA) regulates medication use in residents of long-term care facilities (LTCFs); the OBRA guidelines recommend that a clinician evaluate factors that may be causing insomnia before initiating a sedative-hypnotic agent. OBRA provides dosing guidance for most sedatives in residents of LTCFs. Also, when a medication is being used to induce sleep or treat a sleep disorder, the facility should attempt periodic tapering of the medication or provide documentation of medical necessity in compliance with OBRA guidelines.
According to the Beers Criteria, nonbenzodiazepine benzodiazepine-receptor agonists (NBRAs) (e.g., zolpidem, zaleplon, eszopiclone) are considered potentially inappropriate medications (PIMs) in geriatric patients and should be avoided. These drugs may produce adverse effects similar to benzodiazepines in older adults, such as syncope, falls, fractures, impaired psychomotor function, and delirium. There are increased risks for emergency department visits, hospitalizations, and motor vehicle crashes, as well as minimal improvement in sleep latency and duration with the use of these agents in older adults. Systemic exposure to these drugs is increased in geriatric patients, and a reduced maximum daily dose should be used if advised by the product label. If an NBRA must be used, consider reducing the use of other CNS-active medications that increase the risk of falls and fractures, and implement other strategies to reduce fall risk. First-generation sedating antihistamines (e.g., diphenhydramine and doxylamine) that are marketed for sleep are considered PIMs in the elderly and should be avoided because they are highly anticholinergic.
During clinical trial evaluations, no safety or efficacy differences were observed for ramelteon or suvorexant in geriatric versus younger adults, and these hypnotics are considered potentially appropriate selections for the elderly population.
Tasimelteon demonstrated a higher risk of adverse effects in the geriatric population in controlled trials, which may be the result of an approximately 2-fold increase in exposure compared to younger adults. In a pooled analysis of lemborexant, the incidence of somnolence was higher in geriatric patients than younger adults receiving the 10 mg dose of lemborexant. Therefore, caution is recommended when using doses higher than 5 mg of lemborexant in geriatric patients.
According to the British Association for Psychopharmacology guidelines, extended-release melatonin is the first-choice treatment when a hypnotic is indicated in patients over 55 years of age; there is a pharmaceutical-grade product approved for use in Europe for short-term treatment of insomnia in older adults. Based on trials of melatonin 2 mg/day, the American Academy of Sleep Medicine (AASM) guidelines recommend against melatonin as a treatment for primary insomnia in adults due to a lack of reliable efficacy data. There is mixed evidence that suggests a possible improvement in sleep latency (but not total sleep time or sleep efficiency) in the elderly population. Most data have not been of sufficient quality to assess for adverse events of melatonin in geriatric adults.
Although systemic exposure to some sleep agents, such as zolpidem, tasimelteon, and melatonin, is higher in women than men, zolpidem is the only agent with a recommended initial dose reduction in women. Systemic exposure to zaleplon is increased in Japanese adults (and possibly other Asian populations), and is thought to be related to body weight differences or may represent differences in enzyme activities resulting from diet, environment, genetic, or other factors. Suvorexant exposure is increased in obese patients compared to non-obese patients, with obese females having the largest increase in exposure. Therefore, the risk of adverse effects from increased exposure to suvorexant, such as next-day impairment, should be considered prior to increasing the dose, particularly in obese patients who are female.
Non-pharmacologic therapy and good sleep hygiene should be used as first-line therapy for sleep disturbances during pregnancy. Pharmacologic treatment should only be used if the benefit to the mother outweighs the potential risk to the fetus, and patients should be advised not to self-treat with non-prescription drugs or supplements. There are no adequate and well-controlled studies evaluating the use of non-benzodiazepine sleep agents during pregnancy; therefore, the use of these agents is not recommended during pregnancy. There have been cases of respiratory depression and sedation in neonates born to mothers using hypnotics late in the third trimester of pregnancy. Moreover, neonates born to mothers who take certain sedative/hypnotics agents (e.g., eszopiclone, zaleplon, zolpidem) chronically during the latter stages of pregnancy may develop physical dependence and may be at risk of developing neonatal withdrawal symptoms in the postnatal period. While doxylamine does not pose a significant risk to the fetus in any trimester, diphenhydramine is known to cross the placenta and should be reserved for when treatment is medically necessary. Melatonin is considered contraindicated in pregnancy because the administration of exogenous melatonin could potentially disrupt circadian entrainment and other pineal gland influences in the fetus. Ramelteon and tasimelteon should also be avoided due to animal studies that indicate a potential risk for fetal harm and the lack of adequate data in human pregnancy. There are no adequate or well-controlled studies of suvorexant or lemborexant in pregnant women. 
Non-benzodiazepine sleep agents are generally not recommended during breast-feeding due to the scant data available; non-pharmacologic methods for treatment should be used first. Doxepin readily distributes into breast milk, leading to potential adverse effects in the nursing infant and should be avoided during lactation. Zaleplon and zolpidem are also excreted in breast milk, but there are small studies suggesting that these two agents may be used during lactation with caution when medically necessary. It is not known if diphenhydramine, doxylamine, eszopiclone, melatonin, ramelteon, suvorexant, lemborexant, or tasimelteon distribute into human breast milk.
The American Academy of Sleep Medicine (AASM) pediatric insomnia guidelines indicate pharmacologic therapy is not a first-line treatment choice for pediatric patients with sleep disturbances; behavioral interventions are considered first-line therapy in pediatric patients. Most sleep disturbances in children can be successfully managed with a combination of behavior therapy and modification of sleep practices alone. Pharmacologic therapy should be patient-specific and a risk-benefit analysis should be performed before initiating therapy.
Melatonin has reduced sleep onset and improved sleep maintenance in children with neurodevelopmental, psychiatric disorders, ADHD, and autism. In general, melatonin is considered well-tolerated and effective in pediatric patients but should be used under prescriptive authority and monitoring. The American Academy of Neurology (AAN) notes that insomnia or disrupted sleep are common in pediatric patients with autism spectrum disorder (ASD); clinicians can consider melatonin in children and adolescents with ASD if behavioral strategies have not been helpful and contributing coexisting conditions and use of concomitant medications have been addressed, starting with a low dose (e.g., 1 to 3 mg/day). Clinicians should counsel parents/caregivers regarding potential adverse effects of melatonin use and the lack of long-term safety data, including an unknown effect on pubertal development. Reported side effects in pediatric patients have included morning drowsiness, increased enuresis, headache, dizziness, diarrhea, rash, and hypothermia.
Safety and efficacy have not been established for doxepin, ramelteon, suvorexant, lemborexant, tasimelteon, eszopiclone, zaleplon, or zolpidem in pediatric patients; the use of these drugs is generally not recommended due to their safety profile and lack of convincing evidence of effectiveness. Clinical trials failed to demonstrate the efficacy of eszopiclone and zolpidem in pediatric patients with ADHD-associated insomnia.
Experts recommend against the use of diphenhydramine and doxylamine for sedation in pediatric patients of any age; in clinical trials, these drugs have not been proven better than placebo and expose infants and children to side effects and toxicities, including anticholinergic effects.
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