Episode 221: Insomnia Pharmacotherapy in Adults

In this episode of Rio Bravo Q Week, Dr. Hector Arias and medical student Moira delve into pharmacotherapy for insomnia in adults, emphasizing that cognitive behavioral therapy for insomnia (CBTI) remains the gold standard treatment. They discuss the risks and limitations of both over-the-counter (OTC) sleep aids—such as sedating antihistamines (diphenhydramine, doxalamine) and melatonin—and prescription medications, including benzodiazepines, Z-drugs (e.g., zolpidem, eszopiclone), low-dose doxepin, and dual orexin receptor antagonists (DORAs) like lemborexant. The hosts highlight significant safety concerns, especially in older adults: anticholinergic burden, fall risk, cognitive impairment, complex sleep behaviors (e.g., sleepwalking, sleep driving), and dependence. They stress that medications should be reserved for short-term use, particularly in acute insomnia or when CBTI is unavailable. The episode underscores the importance of shared decision-making, adherence to guidelines like the BEERS criteria, and caution against off-label prescribing of medications such as trazodone, mirtazapine, gabapentin, and quetiapine, which lack robust evidence for insomnia treatment. The overarching message is that sleep is foundational to health, and clinicians should prioritize non-pharmacological approaches while using medications judiciously and safely. Key takeaways include: 1) CBTI is first-line for all adults with insomnia; 2) OTC sleep aids are not appropriate for chronic insomnia and carry significant risks, especially in older adults; 3) Benzodiazepines and Z-drugs should be used only short-term due to dependence, tolerance, and safety risks; 4) Low-dose doxepin and DORAs offer better safety profiles but still carry risks of complex sleep behaviors; 5) Off-label use of antidepressants for insomnia is common but not supported by strong evidence; 6) Always consider patient age, comorbidities, and safety when selecting a medication; 7) The principle of 'primum non nocere' (first, do no harm) must guide insomnia management; 8) Shared decision-making is essential when considering pharmacotherapy.