| Insomnia (label). View labelExact | Take 8 mg within 30 minutes of bedtime (label). | Melatonin receptor agonist (MT1/MT2); hypnotic for sleep onset insomnia. | CYP1A2, CYP3A4, CYP2C9 | Single-dose mean 1.5 h; Single-dose range 1–2.6 h | No | | - Reassess sleep latency and next-day functioning within a few weeks; stop if benefit is minimal rather than escalating.
- Review interacting medications (especially CYP1A2 inhibitors/inducers) and timing with meals when response changes.
- Monitor mood and suicidality in patients with depression or mood instability when insomnia is part of a mood episode.
- Reinforce CBT-I and sleep hygiene and address sleep apnea/substance use when insomnia persists.
| No | 2026-03-31 |
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| Insomnia (label). View labelExact | Typical dose is 10 mg once nightly within 30 minutes of bedtime, with at least 7 hours remaining before planned awakening; maximum 20 mg nightly (label). | Dual orexin receptor antagonist (DORA); orexin OX1R/OX2R antagonist. | CYP3A4, CYP2C19 | Single-dose mean 12 h; Single-dose range 10–22 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 REM intrusion symptoms (sleep paralysis, hallucinations, cataplexy-like symptoms) and discontinue if they are distressing or dangerous.
- Review interacting medications (CYP3A modulators) and avoid alcohol or other CNS depressants when possible.
- Reassess benefit at each refill decision and stop if insomnia does not improve after an adequate trial.
| No | 2025-12-28 |
|---|
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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