Lifestyle Modifications:
- Maintain sleep schedule
- Do not go to bed unless tired
- Sleep long enough, but not too much
- Optimize bedroom lighting, temp and sound
- Develop a ritual
- Do not stay in bed for more than 15 minutes if you can’t sleep
- Don’t go to bed hungry.
- Only use the bedroom for sleep
- Avoid naps
- Avoid stimulants
- Avoid alcohol
- Exercise regularly, but not close to bedtime.
BZDs used for sleep are effective and generally well tolerated. Not considered first line because of potential of dependance, decreased REM, risk of angioedema and psychosis.
| Benzodiazepine | Onset of Action | Peak Onset | Half-life parent (hrs) | Half-life metabolite (hrs) | Comparative Oral Dose |
| Long Acting | |||||
| Flurazepam | Rapid | 0.5-2 | inactive | 47-100 | 30 mg |
| Intermediate Acting | |||||
| Temazepam | Slow | 0.75-1.5 | 10-20 | – | 30mg |
| Short Acting | |||||
| Triazolam | Int. | 0.75-2 | 1.6-5.5 | – | 0.5mg |
Sleep aids:
| Medication | Sleep onset | Sleep maintenance | Cyp interactions | Notes |
| ramelteon (Rozerem) | X | Melatonin agonist, hepatic concerns Do not use with fluvoxamine | ||
| tasimelteon (Hetlioz) | Also for non-24, melatonin agonist | |||
| eszopiclone (Lunesta) | X | 3A4 substrate | Gaba agonist, Decrease dose with 3A4 inhibitors | |
| zaleplon (Sonata) | X | Gaba agonist | ||
| zolpidem (Ambien) | X | 3A4 substrate | Gaba agonist Decrease dose in women, with 3A4 inhibitors in older patients | |
| -zolpidem (Edular SL tablet) | X | 3A4 substrate | ||
| -zolpidem (Zolpmist SL spray) | X | 3A4 substrate | ||
| -zolpidem (Ambien XR) | X | 3A4 substrate | Must have 4-8 hours of planned sleep. | |
| -zolpidem (Intermezzo SL tablet) | X | 3A4 substrate | ||
| doxepin (Silenor) | X | Especially good for elderly or depressed. Do not give with MAOIs | ||
| melatonin | X | Especially good for elderly. | ||
| suvorexant (Belsoma) | X | 3A4 / 2C9 | Decrease digoxin dose. | |
| mirtazapine | Good in depression. | |||
- Depressed patients: mirtazapine, dozepin +/- trazodone
- Older patients: doxepin, melatonin, ramelteon
Here’s a chart I copied with adverse effects of various sleeping aids, but I didn’t write down where it was from.
