Insomnia

Pharmacotherapy for Insomnia Charles F. Reynolds, III, M.D.

Distinguished Professor of Psychiatry &
UPMC Endowed Professor in Geriatric Psychiatry (Emeritus), University of Pittsburgh School of Medicine;
Adjunct Professor of Psychiatry,
Tufts University School of Medicine/MMC

Pharmacologic Treatments for Insomnia

Drug

Comment

• BZD
• Zolpidem
• Zopiclone
• Temazepam

• Doxepin
• Ramelteon

• Suvorexant • Quetiapine

• Olanzapine

• Melatonin
• Valerianroot
• Antihistamines

Doghramji, K., & Reynolds III, C. F. (2012). Management of Treatment-Resistant Insomnia. Management of Treatment-Resistant Major Psychiatric Disorders, 285.

• FDA-approvedsedativeantidepressant • Lowdose

• Orexinreceptorantagonist
• Usedoccasionallywithreservations

• OTC

    

Pros and Cons of BZDs

Wide safety margin when used for short periods of time

Relative contraindications: Obstructive sleep apnea, SUD, and advanced liver disease

Sedation, amnesia, sleepwalking, sleep violence, sleep-related eating disorders, respiratory depression, and rebound insomnia

Doghramji, K., & Reynolds III, C. F. (2012). Management of Treatment-Resistant Insomnia. Management of Treatment-Resistant Major Psychiatric Disorders, 285.

     

Sedative Antidepressants

Drug

Dose

5 mg–10 mg

Comment

Doxepin

Trazodone

• FDAapprovedforsleep maintenance insomnia

Helpful in co-occurring depression

Doghramji, K., & Reynolds III, C. F. (2012). Management of Treatment-Resistant Insomnia. Management of Treatment-Resistant Major Psychiatric Disorders, 285.

New Agent

Drug

Dose

10 mg–20 mg

Comment

Suvorexant: Dual orexin receptor antagonist

• Decreases sleep latency and amount of wake time after sleep onset

• Increases sleep efficiency and time

• Little evidence of tolerance and rebound

• May cause sleepiness

Herring, W. J., Snyder, E., Budd, K., Hutzelmann, J., Snavely, D., Liu, K., … & Michelson, D. (2012). Orexin receptor antagonism for treatment of insomnia: a randomized clinical trial of suvorexant. Neurology, 79(23), 2265-2274.

Ramelteon

     

Melatonin receptor agonist: FDA approved for insomnia

Do not use with fluvoxamine

Do not use in severe liver failure

Doghramji, K., & Reynolds III, C. F. (2012). Management of Treatment-Resistant Insomnia. Management of Treatment-Resistant Major Psychiatric Disorders, 285.

 

Sedative Antipsychotics

Use with caution in:
• MI,ischemia,conductionabnormalities

• Cognitiveimpairment

Doghramji, K., & Reynolds III, C. F. (2012). Management of Treatment-Resistant Insomnia. Management of Treatment-Resistant Major Psychiatric Disorders, 285.

Key Points

• Ramelteonmaybeusefulinpatientswithdifficultyfallingasleep. • Suvorexant is an orexin receptor antagonist that reduces

intermittent wakefulness and wake time after sleep onset.
• Sedativeantipsychoticsarenotrecommendedinolderadults.

Next Presentation

Other Treatment Modalities for Insomnia

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