Section Free - Video Lectures

07. Pharmacotherapy for Insomnia

Published on May 1, 2020 Expired on April 1, 2023

Charles F. Reynolds III, M.D.

Editor, American Journal of Geriatric Psychiatry Distinguished Professor of Psychiatry emeritus - University of Pittsburgh School of Medicine

Key Points

Ramelteon may be useful in patients with difficulty falling asleep.
Suvorexant is an orexin receptor antagonist that reduces intermittent wakefulness and wake time after sleep onset.
Sedative antipsychotics are not recommended in older adults.

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Slides and Transcript

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Let’s talk now about the pharmacotherapy for insomnia remembering that in general pharmacotherapy is prescribed on a short-term basis depending upon the clinical presentation and is often co-prescribed with behavioral treatments or cognitive behavioral treatments for insomnia as an adjunct to behavioral management.

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There are several classes of pharmacological treatments for insomnia disorder ranging from benzodiazepine receptor agonists and the so-called Z-drugs like zolpidem or zopiclone, other benzodiazepines specifically for insomnia such as temazepam. There are also FDA-approved sedative antidepressants such as doxepin and low-dose ramelteon and a newer agent, suvorexant, which is an orexin receptor antagonist. Sedating antipsychotic medications like quetiapine or olanzapine are occasionally used but many of us have significant reservations about the use of sedating antipsychotic agents and I’ll talk a bit more about that momentarily. Pay attention also to any OTC, over-the-counter, medications that your patient may be using such as melatonin, valerian root or antihistamines like diphenhydramine.

References:

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

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Let’s talk a little bit about each of these classes and their positives and negatives if you will. With respect to the use of benzodiazepines for a short period of time, in general, their margin of safety is wide. They are relatively contraindicated in patients who have obstructive sleep apnea or substance use disorders or advanced liver disease. Be mindful of the adverse side effects of benzodiazepine usage including excessive sedation during the day, anterograde amnesia, some instances of sleepwalking and sleep violence, sleep-related eating disorders and respiratory depression as well as rebound insomnia after their use is discontinued.

References:

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

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Sedative antidepressants include the FDA-approved agent doxepin and trazodone. These are helpful in patients with co-occurring depression. And as I’ve mentioned, doxepin is FDA approved for sleep maintenance insomnia generally in low doses in the ballpark of 5 to 10 mg.

References:

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

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Suvorexant is a newer agent on the market. It’s a dual orexin receptor antagonist. And in placebo-controlled clinical trials in adults and in older patients, it’s been found to decrease sleep latency and the amount of wake time after sleep onset. It increases overall sleep efficiency and sleep time with little evidence of tolerance or rebound. The usual dose of suvorexant is 10 to 20 mg at the hour of sleep. Its main side effect is excessive sleepiness in a small percentage of patients.

References:

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.

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Ramelteon is the first melatonin receptor agonist approved for the treatment of insomnia. Generally valuable in my experience in patients having difficulty falling asleep. It should not be used concurrently with fluvoxamine or severe liver failure.

References:

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

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I don’t recommend the use of sedative antipsychotics like quetiapine or olanzapine in patients with sleep issues and they need to be used obviously cautiously in patients with MI, ischemia, conduction abnormalities or cognitive impairment particularly those with dementia.

References:

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

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Some key take home points here about the pharmacotherapy of insomnia. Ramelteon may be particularly useful in patients with difficulty falling asleep. Suvorexant may work by a different mechanism of action, orexin receptor antagonism, and appears to be helpful in reducing intermittent wakefulness, wake time after sleep onset but a small percentage of patients do experience daytime sleepiness as a side effect. With respect to risk-benefit ratio, I do not recommend the use of sedative antipsychotics because of the issues of safety particularly in older adults and those living with dementia.

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Slide 9 of 9

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Next Section

08. Other Treatment Modalities for Insomnia

Learning Objectives:

After completing this activity, the learner will be able to:

Assess insomnia adequately to recommend the best approach for each patient.
Summarize pharmacologic and nonpharmacologic treatments for insomnia and other sleep-wake disorders.

Original Release Date: May 1, 2020

Review and Re-release Date: March 1, 2023

Expiration Date: April 1, 2023

Relevant Financial Disclosures:

Charles F. Reynolds, III declares the following interests:

- Merck; ecology of insomnia conference: consulting

All of the relevant financial relationships listed above have been mitigated by Medical Academy and the Psychopharmacology Institute.

Contact Information: For questions regarding the content or access to this activity, contact us at support@psychopharmacologyinstitute.com

Instructions for Participation and Credit:

Participants must complete the activity online during the valid credit period that is noted above.

Follow these steps to earn CME credit:

View the required educational content provided on this course page.
Answer the quiz for promoting retention of knowledge.
Complete the Post Activity Evaluation for providing the necessary feedback for continuing accreditation purposes and for the development of future activities. NOTE: Completing the Post Activity Evaluation after the quiz is required to receive the earned credit.
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Accreditation Statement

This activity has been planned and implemented in accordance with the accreditation requirements and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Medical Academy LLC and the Psychopharmacology Institute. Medical Academy is accredited by the ACCME to provide continuing medical education for physicians.

Credit Designation Statement

Medical Academy designates this enduring activity for a maximum of 1 AMA PRA Category 1 credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.