CBT-I: cognitive behavioral therapy for insomnia; DORA: dual orexin receptor antagonist; OTC: over the counter; BZRA: benzodiazepine receptor agonist; IR: immediate release; ER: extended release; MOTN: middle of the night.
* When used, medications should be part of a holistic approach that includes healthy sleep habits, adequate opportunity for sleep, treatment of relevant comorbidities, and CBT-I when appropriate and available. Treatment selection is individualized based on the nature of the insomnia symptoms, past treatment responses, medication availability and cost, side effects, comorbidities, and patient preferences.
¶ BZRAs include benzodiazepines and nonbenzodiazepine BZRAs such as zolpidem. Common reasons to avoid may include older age, history of substance use disorder, or patient preference.
Δ Off-label prescribing of sedating medications for insomnia should be considered primarily for patients who do not have an adequate therapeutic response to first-line medications with regulatory approval for insomnia, when a different mechanism of action is desired, or when there is a specific reason to avoid BZRAs. Doses of such medications for insomnia purposes are generally subtherapeutic for the relevant comorbidity.
◊ Not recommended for chronic use. Avoid use in older adults.