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Commonly Used Medications for the Treatment of Insomnia
Nonbenzodiazepine, selective benzodiazepine receptor agonists
Zaleplon
Common Initial Dose (half-dose is generally recommended in elderly): 10 mg
FDA Approved Maximum Daily Dose 20 mg
When: at bed time or during night
Residual Effects - none
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: none
Zolpidem
Common Initial Dose (half-dose is generally recommended in elderly) 10 mg
FDA Approved Maximum Daily Dose 10 mg
When: at bed time only
Residual Effects - minimal
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: minimal
Traditional benzodiazepine hypnotics
Triazolam
Common Initial Dose (half-dose is generally recommended in elderly) 0.25 mg
FDA Approved Maximum Daily Dose 0.5 mg
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Temazepam
Common Initial Dose (half-dose is generally recommended in elderly) 15 mg
FDA Approved Maximum Daily Dose 30 mg
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Flurazepam
Common Initial Dose (half-dose is generally recommended in elderly) 15-30 mg
FDA Approved Maximum Daily Dose 30 mg
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Anxiolytic benzodiazepines frequently used as hypnotics (off-label)
Clonazepam
Common Initial Dose (half-dose is generally recommended in elderly) 0.5 mg
FDA Approved Maximum Daily Dose 4 mg divided (for anxiety conditions)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Lorazepam
Common Initial Dose (half-dose is generally recommended in elderly) 1 mg
FDA Approved Maximum Daily Dose 6 mg divided (for anxiety conditions)
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Alprazolam
Common Initial Dose (half-dose is generally recommended in elderly) 0.25 mg
FDA Approved Maximum Daily Dose 4 mg divided (for anxiety conditions)
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: mild to severe, depending on dose, duration of use, and individual
Sedating antidepressants frequently used as hypnotics (off-label)
Trazodone
Common Initial Dose (half-dose is generally recommended in elderly) 50 mg
FDA Approved Maximum Daily Dose 400 mg divided (for depression)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable
Amitriptyline
Common Initial Dose (half-dose is generally recommended in elderly) 50 mg
FDA Approved Maximum Daily Dose 300 mg divided (for depression)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable-can be a problem at higher doses
Doxepin
Common Initial Dose (half-dose is generally recommended in elderly) 50 mg
FDA Approved Maximum Daily Dose 300 mg divided (for depression)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable-can be problematic at higher doses
Fluvoxamine
Common Initial Dose (half-dose is generally recommended in elderly) 50 mg
FDA Approved Maximum Daily Dose 300 mg divided (for obsessive-compulsive disorder)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable
Mirtazapine
Common Initial Dose (half-dose is generally recommended in elderly) 15 mg
FDA Approved Maximum Daily Dose 45 mg (for depressions)
When - at bedtime only
Residual Effects - moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable
Nefazodone
Common Initial Dose (half-dose is generally recommended in elderly) 100 mg
FDA Approved Maximum Daily Dose 600 mg divided (for depressions)
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable
Other sedating agents
Diphenhydramine
Common Initial Dose (half-dose is generally recommended in elderly) 25 mg
FDA Approved Maximum Daily Dose 100 mg
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: minimal
Gabapentin
Common Initial Dose (half-dose is generally recommended in elderly) 300 mg
FDA Approved Maximum Daily Dose 1800 mg divided (for seizures)
When - at bedtime only
Residual Effects - minimal to moderate
Withdrawal Effects and Rebound Insomnia at Abrupt Discontinuation: variable
OTC Sleep-Promoting Drugs
Examples of OTC sleep-promoting drugs are the use of sedating antihistamines alone or in combination with analgesics.
Common Side Effects Of Prescription Or Over-The-Counter Sleep Aids
• Fatal overdose, especially when combined with alcohol or with other drugs that affect your central nervous system
• Impaired coordination, memory, driving skills, and thinking
• Interference with breathing
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Physical or psychological dependence (unable to sleep without the medication.)
• Tolerance (Need to take larger and larger doses to achieve the same effect.)
• Potential damage to kidney, liver, and lungs
• Confusion, hallucinations, and similar disturbances, particularly for the elderly
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