Insomnia : Drug Summary | MIMS Thailand

Antidepressants

Drug

Dosage

Remarks

Doxepin

3-6 mg PO within 30 minutes before bedtime
Max dose: 6 mg/day

Adverse Reactions

CNS effects (sedation, dizziness, worsening of suicidal thoughts or behavior, mild mydriasis); GI effects (nausea, gastroenteritis); CV effect (hypertension); Respiratory effect (upper respiratory tract infection [URTI])

Special Instructions

Use with caution in patients with history of suicide-related events, epilepsy, head trauma, brain damage, alcoholism, severe CV disease, BPH, DM, sleep apnea and mild-moderate hepatic impairment
Avoid using concomitantly with MAOIs
Contraindicated in patients with mania, narrow-angle glaucoma and urinary retention

Antihistamines

Drug	Dosage	Remarks
Diphenhydramine	25-50 mg PO 30 minutes before bedtime	Adverse Reactions Antimuscarinic effects, GI disturbances, CV and CNS effects Special Instructions For occasional use only Use with caution in patients with angle-closure glaucoma, prostatic hypertrophy, genitourinary obstruction, urinary retention, history of asthma, COPD, hyperthyroidism, hypertension or CV disease, myasthenia gravis, seizure disorder, severe renal or hepatic impairment
Doxylamine	25 mg PO within 30 minutes before bedtime for 2 weeks May be increased to 50 mg if necessary	Adverse Reactions CNS effects (CNS stimulation, depression, headache, lack of coordination, dizziness, psychomotor impairment); GI effects (nausea and vomiting, constipation, diarrhea, epigastric pain, epigastric reflux); CV effects (palpitation, arrhythmia); Respiratory effect (thickened respiratory tract secretions) Special Instructions Should be taken with food Use with caution in patients with glaucoma, urinary retention, hypotension, tinnitus, paresthesia
Promethazine	25 or 50 mg PO as a single nighttime dose	Adverse Reactions CNS effects (drowsiness, dizziness, restlessness, headache, disorientation, extrapyramidal effects); Dermatologic effects (rash, urticaria, pruritus); GI effects (anorexia, gastric irritation); CV effects (palpitation, hypotension, arrhythmias) Special Instructions May be taken with or without food May affect ability to drive or operate machinery the following day Do not use in patients in coma, suffering from CNS depression of any cause, within 14 days of discontinuing MAOI therapy and in children <2 years old Use with caution in patients with asthma, severe CAD, narrow-angle glaucoma, epilepsy, hepatic and renal insufficiency

Benzodiazepines

Drug	Dosage	Remarks
Alprazolam	0.25-0.5 mg PO 8 hourly Up to 4 mg/day PO in divided doses	Adverse Reactions Dependence and withdrawal symptoms can occur especially in patients with history of drug dependence CNS effects (sedation, drowsiness, muscle weakness, ataxia; less commonly slurred speech, vertigo, headache, confusion); symptoms decrease after continued use May cause complex sleep-related behaviors (eg sleepwalking, sleep-driving) Prolonged use of agents with long half-lives may provide next-day anxiolytic action and decrease rebound hypertension but can also cause daytime sleepiness, cognitive impairment, and incoordination Special Instructions Elderly patients should receive lower doses Short-term use (<4 weeks) to avoid dependence and withdrawal symptoms Avoid use in patients with pre-existing CNS depression, respiratory depression, acute pulmonary insufficiency, myasthenia gravis, or sleep apnea Use with caution in patients with chronic pulmonary insufficiency
Brotizolam	0.25 mg PO at bedtime
Chlordiazepoxide	5-10 mg PO 8 hourly or 10-30 mg PO at bedtime Max duration of treatment: 4 weeks including dose tapering of 2 weeks
Diazepam	5-15 mg PO at bedtime
Dipotassium clorazepate	5-10 mg PO at bedtime 5-30 mg/day PO in divided doses
Estazolam	1-2 mg PO at bedtime
Flunitrazepam	0.5-2 mg PO at bedtime
Lorazepam	1-8 mg PO at bedtime
Lormetazepam	0.5-1.5 mg PO at bedtime Max duration of treatment: 4 weeks including dose tapering
Midazolam	7.5-15 mg PO at bedtime Max dose: 15 mg
Nitrazepam	5-10 mg PO at bedtime
Oxazepam	15-25 mg PO at bedtime Up to 50 mg may be occasionally required
Pinazepam	2.5-5 mg PO at bedtime
Temazepam	7.5-30 mg PO at bedtime Max dose: 40 mg
Triazolam	0.125-0.5 mg PO at bedtime Max dose: 0.5 mg

Non-Benzodiazepine Hypnotics

Drug	Dosage	Remarks
Eszopiclone	1-3 mg PO at bedtime Max dose: 3 mg/day	Adverse Reactions CNS effects (headache, dizziness, pain, nervousness); GI effects (unpleasant taste, xerostomia, dyspepsia, nausea and vomiting, diarrhea); Other effects (rash, pruritus, infection, accidental injury) Dependence and withdrawal symptoms can occur especially in patients with history of drug dependence Anaphylaxis, angioedema, and complex sleep-related behavior have been reported Special Instructions Has quick onset Must be taken immediately before bedtime Tablet should be swallowed whole Do not take with a high fat meal or with alcohol Use with caution in patients with respiratory compromise, those receiving other CNS depressants or psychoactive medication Reduce dosage in patients with severe hepatic impairment
Zaleplon	5-10 mg PO at bedtime Max dose: 20 mg/day	Adverse Reactions CNS effects (amnesia, anxiety, dizziness, hallucinations, somnolence, impaired coordination); Other effects (rash, photosensitivity reactions, peripheral edema, GI upset) Dependence and withdrawal symptoms can occur especially in patients with history of drug dependence Anaphylaxis, angioedema, and complex sleep-related behavior have been reported Special Instructions Has quick onset Must be taken immediately before bedtime Do not take with a high fat meal or with alcohol Intended for short-term use only Use with caution in patients with depression, mild-moderate hepatic impairment, respiratory compromise, those receiving other CNS depressants or psychoactive medication Not recommended in patients with severe hepatic impairment
Zolpidem	5-10 mg PO at bedtime Max dose: 10 mg/day Extended release: 6.25-12.5 mg PO at bedtime Max dose: 12.5 mg/day	Adverse Reactions CNS effects (headache, drowsiness, dizziness, lethargy, abnormal dreams, amnesia); Other effects (rash, GI upset) Dependence can occur especially in patients with history of drug dependence Abnormal thinking/behavioral changes and complex sleep-related behavior have been reported Special Instructions Has quick onset Must be taken immediately before bedtime Do not take with a high fat meal or with alcohol Intended for short-term use only Use with caution in patients with respiratory compromise, those receiving other CNS depressants or psychoactive medication Not recommended in patients with severe hepatic impairment, acute, and/or severe resp insufficiency
Zopiclone	3.75-7.5 mg PO at bedtime Max dose: 7.5 mg/day	Adverse Reactions CNS effects (psychiatric and paradoxical reactions, amnesia, rebound insomnia and withdrawal symptoms, somnolence, dizziness, headache); Other effects (bitter taste, GI upset) Special Instructions Same as Eszopiclone Intended for short-term use only Contraindicated in patients with severe hepatic/renal impairment, respiratory insufficiency, sleep apnea syndrome and myasthenia gravis

Melatonin Receptor Agonists

Drug

Dosage

Remarks

Melatonin

2 mg PO at 1-2 hours before bedtime
or
1-2 sprays PO 24 hourly before bedtime

Adverse Reactions

CNS effects (dizziness, headache, fatigue, depression);GI effects (nausea, unpleasant taste); Other effects (URTI, myalgia, back pain, arthralgia)
Anaphylaxis, angioedema amd complex sleep-related behavior have been reported

Special Instructions

Tablet should be swallowed whole
Do not take with a high fat meal or with alcohol
Use with caution in patients with respiratory compromise, those receiving other CNS depressants or psychoactive medication
Use with caution in patients with mild to moderate hepatic impairment
Contraindicated in patients with severe hepatic impairment and those currently taking Fluvoxamine

Ramelteon

8 mg PO at bedtime
Max dose: 8 mg/day

Dual Orexin Receptor Antagonists

Drug	Dosage	Remarks
Daridorexant	25-50 mg PO within 30 minutes before bedtime Max dose: 50 mg/day	Adverse Reactions Somnolence, headache, dizziness Sleep paralysis, hypnogogic/hypnopompic hallucination, cataplexy-like symptoms, and complex sleep behaviors (sleep-walking, sleep-driving, engaging in other activities while not fully awake) may occur Special Instructions Use with caution in patients with depression, suicidal ideation, history of substance abuse or compromised respiratory function Contraindicated in patients with narcolepsy Suvorexant is not recommended in patients with severe hepatic impairment
Lemborexant	5 mg PO before bedtime Max dose: 10 mg/day
Suvorexant	5-20 mg PO within 30 minutes before bedtime Max dose: 20 mg/day

Insomnia Drug Summary