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Hypnotic agents are effective for insomnia but at the expense of adverse effects
Clinical Question
Are hypnotic agents safe and effective in managing insomnia in adults?
Bottom line
In this network meta-analysis, agents for managing insomnia in adults come with significant trade-offs of effectiveness and tolerability. Since only half the studies were at low risk of bias, the recommendations from guidelines from the US Departments of Defense and Veterans Administration and the American College of Physicians to reserve hypnotic agents as second-line therapy seems wise. (LOE = 1a)
Overuse alert: This POEM aligns with the Canadian Geriatric Society’s Choosing Wisely Canada recommendation: Don’t use benzodiazepines or other sedative-hypnotics in older adults as first choice for insomnia, agitation, or delirium. Choosing Wisely Canada’s primary care and hospital toolkits provide tools to reduce unnecessary benzodiazepines use in older adults.
Reference
Study design: Meta-analysis (randomized controlled trials)
Funding: Government
Setting: Various (meta-analysis)
Synopsis
This team searched multiple databases and residencies to identify randomized trials of pharmacologic agents or placebo as monotherapy in managing insomnia in adults. The authors also conducted a network meta-analysis only on double-blind trials. Ultimately, they included 170 randomized trials (47,950 participants) of which 154 (44,089) were double blind. The included trials assessed the effectiveness and tolerability of pharmacological treatments in the acute management of insomnia (median 2 weeks), as well as the long-term management of insomnia (median 25 weeks). The studies evaluated a wide range of agents, including benzodiazepines, nonbenzodiazepines, lemborexant, doxepin, melatonin, doxylamine, and suvorexant. Of the 170 trials, 82 (48.3%) trials were rated at low risk of bias, 33 (19.4%) at unclear risk, and 55 (32.4%) at high risk. Since the studies used a variety of different outcome measures, the authors did a bunch of statistical gymnastics to estimate standardized effect sizes for each agent’s effectiveness and tolerability. The data presented by the authors are voluminous and generally demonstrate significant trade-offs between effectiveness and tolerability.
Reviewer
Henry C. Barry, MD, MS
Professor
Michigan State University
East Lansing, MI
Comments
Long term use of hypnotics.
Long term use of hypnotics carry the risk of habituation and side effects in the elderly.
Insomia
Unfortunately, new patients often come with years of regular benzodiazepine use and heavy dependency. They naturally resist being weaned off.
hypnotics
pros and cons
what is afficacy
Prescribers of medications to treat insomnia need to realize that when patients say they fall asleep faster with the medication, it is only by 10-15 minutes (based on placebo controlled trials). The apparent benefit is due to the anterograde amnesia that is caused by the drugs and removes any memory of lying awake. For the problem of early morning wakening, these drugs do work effectively at prolonging sleep.
typo
what is efficacy
benzos use for sleep in older patients
too many side effects and not recommended