| Insomnia (label). View labelExact | Typically taken immediately before bedtime, when able to remain in bed for a full night.
Food can delay onset; when delayed onset is a concern, bedtime dosing is often separated from heavy meals. “Middle of the night” redosing is generally avoided. | Non-benzodiazepine hypnotic (“Z-drug”); GABA-A receptor positive allosteric modulator. | CYP3A4, CYP2E1 | Single-dose mean 6 h | No | | - Next-day impairment (driving, work, falls) after initiation and dose changes; dosing is adjusted or discontinued if safety is compromised.
- Complex sleep behaviors; when they occur, discontinuation is typical.
- Mood and suicidality in patients with depression or serious mental illness.
- If continued beyond a brief course, taper attempts and CBT-I reinforcement to reduce rebound insomnia.
| No | 2025-12-28 |
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zolpidemAdjunctive therapyBrands: AMBIEN, AMBIEN CR | Insomnia (label). View labelExact | Take immediately before bedtime, only when able to remain in bed for a full night.
Food (especially high-fat meals) can delay onset; when rapid sleep onset is the goal, avoid taking with or immediately after a heavy meal. | Non-benzodiazepine hypnotic (“Z-drug”); GABA-A receptor positive allosteric modulator. | CYP3A4 | Single-dose mean 2.5 h; Single-dose range 1.4–4.5 h | No | | - Assess next-day impairment (driving, work, falls) after initiation and dose changes; lower the dose or stop if safety is compromised.
- Screen for complex sleep behaviors and discontinue immediately if they occur.
- Reassess for untreated sleep apnea, substance use, and mood episodes when insomnia persists rather than escalating hypnotics.
- If continued beyond a brief course, plan taper attempts and reinforce CBT-I to reduce rebound insomnia.
| No | 2025-12-28 |
|---|
doxepinAdjunctive therapyBrands: Sinequan, Silenor | Depression and anxiety; low-dose formulation approved for insomnia. View labelExact | Depression/anxiety: typical start is 25–50 mg at bedtime; titrate by 25–50 mg every 3–4 days to 75–150 mg/day (single HS dose or divided BID). Max 300 mg/day inpatient with ECG monitoring. | Tricyclic antidepressant; strong antihistamine with serotonin and norepinephrine reuptake inhibition. | CYP2D6, CYP2C19 | Single-dose mean 28 h; Steady-state mean 31 h | 150–250 ng/mL | | - Sedation, next-day impairment, and falls risk (especially in older adults); driving and occupational safety are often reassessed after dose changes.
- Orthostatic vitals during titration and when combined with other hypotensive medications; hydration and slow position changes are commonly emphasized.
- Anticholinergic burden (constipation, urinary retention, confusion); bowel regimen planning and avoiding additive anticholinergic polypharmacy are common considerations when feasible.
- ECG monitoring for patients with cardiac disease, electrolyte abnormalities, or higher antidepressant doses; repeat ECGs are often considered when adding other QT-active agents.
- Therapeutic drug monitoring can be helpful in higher-dose depression regimens, drug interactions (CYP2D6/2C19 inhibitors), unexpected nonresponse, or suspected toxicity.
- Mood activation (mania/hypomania) in bipolar-spectrum illness and suicidal thinking during initiation; coordination via the bipolar disorder hub can support planning.
| No | 2025-12-29 |
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trazodoneAdjunctive therapyBrands: DESYREL, OLEPTRO | Major depressive disorder (label); commonly used off label for insomnia. View labelExact | Insomnia (off label): start 25–50 mg at bedtime; typical 50–150 mg nightly based on tolerability; reassess frequently and avoid open-ended dose escalation. | Serotonin antagonist and reuptake inhibitor (SARI); 5-HT2 antagonism with weak SERT inhibition plus H1/α1 effects. | CYP3A4 | Single-dose mean 7 h; Single-dose range 5–13 h | No | | - Monitor orthostatic symptoms and falls risk during initiation and after dose increases, especially in older adults or those on antihypertensives.
- Reassess mood and suicidality during antidepressant initiation and titration; ensure the dose matches the target (sleep vs depression).
- Review QT-risk co-medications and consider ECG/electrolytes when risk factors stack.
- If used primarily for insomnia, document a stop plan and reassess regularly rather than continuing indefinitely.
| No | 2026-02-22 |
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