There are three main types:
Acute insomnia: It results from activating causal factors that are easily recognized in an individual, it lasts for days or weeks (not more than four months).
Primary chronic insomnia: It is caused by many predisposing factors involving stress response mechanism: anxiety and depression or abnormalities in circadian rhythm, it may last for months.
Associated insomnia: It is mainly caused by improper sleep hygiene (inappropriate)sleep habits)and is concerned with an underlying mental or mood disorder like depression cyclothymia, bipolar disorder, anxiety, or schizophrenia.
Benzodiazepine receptors agonists It involves both benzodiazepine and non-benzodiazepine agents. They bind to the gamma-aminobutyric acid receptor complex and differ in their affinity for binding sites. The subunits of GABA receptors are responsible for the sedative-hypnotic,muscle-relaxant, anxiolytic, and anticonvulsant effects of the BzRAs.
Benzodiazepines There are five BZDs approved for the treatment of insomnia, they are estazolam, triazolam, temazepam, quazepam, flurazepam. These drugs differ in the use of their actions. Estazolam and Temazepam are intermediate-acting. Triazolam is short-acting. Flurazepam is long-acting.
Nonbenzodiazepines These are also called ”Z drugs” which are developed to minimize the adverse effects associated with BZDs. The Z drugs currently available are –
Zolpidem, zaleplon, and eszopiclone
Zolpidem was the first Z drug developed for the treatment of insomnia and is currently available as immediate and modified-release tablets. It causes adverse events like drowsiness, nausea, dizziness, nightmares, and agitation which resulted in the discontinuation of the drug.
Zaleplon was the second non-BZD available after zolpidem. It gives advantages for the patients with the middle of night awakenings. Both zaleplon and zolpidem shorten the sleep latency and extend sleep duration, however, the duration of residual sedation was shorter with zaleplon than with zolpidem. common adverse events like headache and dizziness are found in the clinical studies.
Eszopiclone is the non-BZD hypnotic agent used in the treatment of long term insomnia. Studies have revealed that eszopiclone is effective in the treatment of insomnia as measured by sleep latency, total sleep time, wake time after sleep onset. It must be used with the patients who can have at least 7 to 8 hours of sleep before the planned time of awakening. The common adverse effects of eszopiclone include unpleasant taste, headache, dizziness.
Meltonin agonist:Ramelteon Ramelton is prescribed for the treatment of insomnia identified by the difficulty with sleep onset and is the only melatonin(MT), ramelteon does not have the affinity for GABA receptors, it helps reduce sleep latency in patients with chronic insomnia. The common adverse events include dizziness, nausea, fatigue, it does not affect patients’ balance (unlike zolpidem and eszopiclone) and is not associated with cognitive and psychomotor effects.
Tricyclic antidepressant: Doxepin It is prescribed for the treatment of insomnia where it is difficult to maintain sleep. Doxepin has a high affinity with histamine receptors. Some common effects of doxepin are â€“ headaches and feeling drowsy (somnolence) Doxepin is the category C drug used with caution in pregnant women, it should not go beyond 3mg in patients with hepatic impairment.
Orexin receptor antagonist: Suvorexant It is the first new drug category of insomnia known as orexin receptor antagonists. These are neurotransmitters that regulate wakefulness and sleep. It is prescribed to consume 10 mg in insomnia patients once per night. Suvorexant is the category C drug and is not recommended for patients with hepatic or renal impairment.
Off-label treatments for insomnia, Antidepressants: Trazodone is used to treat depression at high doses, however, it is also used in patients with insomnia (25 to 50mg recommended at bedtime). Excessive dosage increases the risk of falls in patients and thus can lead to injuries.
Mirtazapine: It is used in the treatment of major depressive disorder only; however, the dosage of 30mg is prescribed in insomnia patients.
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