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Beyond the Guidelines: Management of Chronic Insomnia

Recent guidelines from the American Academy of Sleep Medicine (AASM) make a strong recommendation only for multicomponent cognitive behavioral therapy (CBT), according to a Beyond the Guidelines article prepared by 2 clinicians with expertise in sleep disorders. A limited number of medications were described in the guidelines as potentially useful based on weak evidence, but others are probably not effective. Using the case of a patient with chronic insomnia who had been treated with medications, the experts examine the guidelines and discuss the place in therapy for CBT and pharmacologic therapy.

“Cognitive behavioral therapy for insomnia combines behavioral strategies, including stimulus control instructions and sleep restriction therapy, with cognitive therapy strategies, sleep hygiene education, and relaxation training and other counter-arousal methods,” write the experts. “Treatment progresses using information typically gathered with sleep diaries completed by the patient throughout the course of treatment (typically 4 to 6 sessions). The authors conditionally suggested that clinicians not use sleep hygiene by itself, given lack of supporting efficacy data and the likelihood that this commonly used treatment would delay the initiation of an evidence-based approach.”

The medications described by AASM as potentially useful for chronic insomnia disorder in adults are doxepin (for sleep maintenance), eszopiclone (sleep onset or sleep maintenance), ramelteon (sleep onset), suvorexant (sleep maintenance), temazepam (sleep onset or sleep maintenance), triazolam (sleep onset), zaleplon (sleep onset), and zolpidem (sleep onset or sleep maintenance). Based on weak evidence, the guidelines recommend not using diphenhydramine, melatonin, tiagabine, trazodone, tryptophan, and valerian.

“Guidelines for insomnia pharmacotherapy do not compare medications head-to-head, making it difficult to pick the right medication for the right patient,” the authors write. “They also often do not address cost. For instance, the AASM guideline recommends the melatonin agonist ramelteon but not the much cheaper melatonin despite the same average improvements in sleep onset. The analysis of melatonin used a dose of 2 mg, which is a smaller dose than often used for sedative effect. Melatonin has efficacy in persons with circadian rhythm disorders, which makes it attractive when these overlap with insomnia. The AASM recommends against trazodone given lack of numerous high-quality studies. Its risks may seem more palatable than the misuse potential of benzodiazepines, and hence off-label use of these medications for insomnia can make sense for some individuals. The use of Z-drugs or orexin receptor antagonists may be attractive in some patients, but orexin receptor antagonists are often nonformulary.”

Source: Annals of Internal Medicine