
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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