26
Table 11. Medications for Insomnia-Related Symptoms
Medication
a
Class/
mechanism Considerations for use
b
Other
population
considerations
Acute anxiety
Doxepin
c
Antihistaminic
tricyclic
antidepressant
American Academy of Sleep
Medicine (AASM) approved for
sleep maintenance insomnia
Avoid in patients with suicidal
ideation and behavior due to
risk for overdose
Caution in older
adults, coronary
artery disease,
arrhythmia
Diphenhydramine
d
Antihistamine AASM does not recommend
for sleep onset or sleep
maintenance insomnia
Avoid in older
adults, may have
paradoxical
effects in children
Doxylamine
d
Antihistamine Avoid in older
adults, may have
paradoxical
effects in children
Hydroxyzine
e
Antihistamine Avoid in patients with history
of QTc prolongation
Avoid in older
adults
Melatonin
d
Sedative-
Hypnotic
AASM does not recommend
for sleep onset or sleep
maintenance insomnia
Avoid during
pregnancy and
breastfeeding ;
insufficient safety
evidence
Ramelteon
c
Agonist of
melatonin
receptors 1
and 2
AASM approved for sleep onset
insomnia
Prone to significant interactions
with cytochrome P450 (CYP)
inhibitors and inducers
Trazodone
e
Antidepressant Start with lower doses to avoid
orthostasis in older adults
AASM does not recommend
for sleep onset or sleep
maintenance insomnia
Use with caution
in older adults
a
Non-BZD sedative–hypnotics (e.g., Z-drugs) are not recommended for patients with sleep
issues who are undergoing BZD taper due to similar receptor action. Further information
on adjunctive medications may be found on UpToDate, which has topics on benzodiazepine
withdrawal and complementary and alternative treatments for anxiety symptoms and
disorders: herbs and medications.
b
Use in individual patients should always include review of medical and medication history
and individual prescribing information to assess for any relative/absolute contraindications.
c
FDA approved.
d
FDA approved, available over the counter.
e
Not FDA approved for insomnia.
