Efficacy and safety of pharmacotherapy in chronic insomnia: A review of clinical guidelines and case reports

Abstract

Introduction Chronic insomnia affects 5% to 10% of the US population, increasing the demand for treatment options and the corresponding research to prove their validity.1 This review compares recommendations from 3 clinical guidelines and summarizes hypnotic medications, including their newly reported side effects not mentioned in the guidelines. In addition, we aim to provide an overview of what pharmacotherapies are available for prescribers and patients. Methods A literature search was conducted for articles published prior to January 10, 2022, and case reports and clinical studies were retrieved from PubMed and Google Scholar. Results Definitive conclusions cannot be drawn regarding the safety and efficacy of medications reviewed; however, trends are apparent. All 3 guidelines included in this review remarked most treatment recommendations as weak except for cognitive behavioral therapy for insomnia, which is effective but not readily available. Furthermore, based on the 15 case reports and 13 clinical studies presented in this review, many of the medications used for treatment of insomnia present safety concerns. Discussion Benzodiazepines and benzodiazepine receptor agonists are commonly used hypnotic agents with the “Z-drugs” having robust data establishing their efficacy for the short-term treatment of chronic insomnia. However, significant adverse effects related to the central nervous system (CNS), including developing tolerance, addiction, CNS depression, and amnesia, remain barriers to their long-term use. In comparison, newer agents present more favorable side-effect profiles although with less established efficacy. Additionally, off-label agents, including antidepressants, antihistamines, and natural supplements, are discussed due to their prominent use.

A Comprehensive Review of Novel FDA-Approved Psychiatric Medications (2018-2022)

“…Lemborexant 5 mg and 10 mg demonstrated statistically significant superiority (p < 0.05) on the primary efficacy measure, LPS, compared to placebo, and also demonstrated statistically significant improvement in SEF and WASO compared to placebo. Additionally, DORAs appear to promote both rapid eye movement (REM) and non-REM sleep, whereas GABA-A agonists, such as benzodiazepines (BZDs) and Z-drugs, promote only non-REM sleep [44]. The most common adverse effect of lemborexant is drowsiness, while serious side effects may include decreased daytime alertness, impaired ability to operate a vehicle, sleep paralysis, hallucinations, complex sleep behaviors, and worsening depression and suicidal thoughts [42,43,45].…”