Insomnia Treatment Guidelines

Introduction to Insomnia Treatment

The American Academy of Sleep Medicine explicitly states that over-the-counter antihistamine sleeping aids (including promethazine) are not recommended due to lack of demonstrated efficacy and safety concerns 1, 2, 3
Evidence for antihistamine efficacy and safety is "very limited, with very few available studies from the past 10 years using contemporary study designs and outcomes" 1, 2

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the standard of care and should be offered before or alongside any pharmacotherapy 3, 4, 5, 6
The American Academy of Sleep Medicine recommends CBT-I as the first-line treatment for insomnia 3, 4

For sleep onset difficulty, short-acting benzodiazepine receptor agonists (BzRAs): zaleplon, zolpidem, are recommended 7
For sleep onset difficulty, ramelteon (melatonin receptor agonist) is a suitable option, particularly for patients with substance use history 7, 6
For sleep maintenance difficulty, low-dose doxepin (3-6 mg) is recommended due to its improved sleep efficiency and favorable safety profile in older adults 5, 6
For sleep maintenance difficulty, eszopiclone or temazepam (longer half-lives) may be considered 7
Sedating antidepressants: trazodone, mirtazapine, low-dose doxepin, are recommended as second-line options for patients with comorbid depression or anxiety 7, 6

The American Academy of Sleep Medicine recommends using the lowest effective dose and shortest possible duration for insomnia treatment 1, 5, 6
Patient education on treatment goals, safety concerns, and potential side effects is crucial 7, 6
Regular follow-up to assess efficacy and monitor for adverse effects is necessary 6
Gradual tapering when discontinuing insomnia treatment is recommended to minimize rebound insomnia 1