Insomnia Drug Summary

Drug	Dosage	Remarks
Doxepin	3-6 mg PO within 30 minutes before bedtime Max dose: 6 mg/day	Adverse Reactions CNS effects (sedation, dizziness, worsening of suicidal thoughts or behavior, mild mydriasis); GI effects (nausea, gastroenteritis); CV effect (hypertension); Respiratory effect (upper respiratory tract infection [URTI]) Special Instructions Use with caution in patients with history of suicide-related events, epilepsy, head trauma, brain damage, alcoholism, severe CV disease, BPH, DM, sleep apnea and mild-moderate hepatic impairment Avoid using concomitantly with MAOIs Contraindicated in patients with mania, narrow-angle glaucoma and urinary retention

Drug	Dosage	Remarks
Diphenhydramine	25-50 mg PO 30 minutes before bedtime	Adverse Reactions Antimuscarinic effects, GI disturbances, CV and CNS effects Special Instructions For occasional use only Use with caution in patients with angle-closure glaucoma, prostatic hypertrophy, genitourinary obstruction, urinary retention, history of asthma, COPD, hyperthyroidism, hypertension or CV disease, myasthenia gravis, seizure disorder, severe renal or hepatic impairment
Doxylamine	25 mg PO within 30 minutes before bedtime for 2 weeks May be increased to 50 mg if necessary	Adverse Reactions CNS effects (CNS stimulation, depression, headache, lack of coordination, dizziness, psychomotor impairment); GI effects (nausea and vomiting, constipation, diarrhea, epigastric pain, epigastric reflux); CV effects (palpitation, arrhythmia); Respiratory effect (thickened respiratory tract secretions) Special Instructions Should be taken with food Use with caution in patients with glaucoma, urinary retention, hypotension, tinnitus, paresthesia
Promethazine	25 or 50 mg PO as a single nighttime dose	Adverse Reactions CNS effects (drowsiness, dizziness, restlessness, headache, disorientation, extrapyramidal effects); Dermatologic effects (rash, urticaria, pruritus); GI effects (anorexia, gastric irritation); CV effects (palpitation, hypotension, arrhythmias) Special Instructions May be taken with or without food May affect ability to drive or operate machinery the following day Do not use in patients in coma, suffering from CNS depression of any cause, within 14 days of discontinuing MAOI therapy and in children <2 years old Use with caution in patients with asthma, severe CAD, narrow-angle glaucoma, epilepsy, hepatic and renal insufficiency

Drug	Dosage	Remarks
Alprazolam	0.25-0.5 mg PO 8 hourly Up to 4 mg/day PO in divided doses	Adverse Reactions Dependence and withdrawal symptoms can occur especially in patients with history of drug dependence CNS effects (sedation, drowsiness, muscle weakness, ataxia; less commonly slurred speech, vertigo, headache, confusion); symptoms decrease after continued use May cause complex sleep-related behaviors (eg sleepwalking, sleep-driving) Prolonged use of agents with long half-lives may provide next-day anxiolytic action and decrease rebound hypertension but can also cause daytime sleepiness, cognitive impairment, and incoordination Special Instructions Elderly patients should receive lower doses Short-term use (<4 weeks) to avoid dependence and withdrawal symptoms Avoid use in patients with pre-existing CNS depression, respiratory depression, acute pulmonary insufficiency, myasthenia gravis, or sleep apnea Use with caution in patients with chronic pulmonary insufficiency
Brotizolam	0.25 mg PO at bedtime
Chlordiazepoxide	5-10 mg PO 8 hourly or 10-30 mg PO at bedtime Max duration of treatment: 4 weeks including dose tapering of 2 weeks
Diazepam	5-15 mg PO at bedtime
Dipotassium clorazepate	5-10 mg PO at bedtime or 5-30 mg/day PO in divided doses
Estazolam	1-2 mg PO at bedtime
Flunitrazepam	0.5-2 mg PO at bedtime
Lorazepam	1-8 mg PO at bedtime
Lormetazepam	0.5-1.5 mg PO at bedtime Max duration of treatment: 4 weeks including dose tapering
Midazolam	7.5-15 mg PO at bedtime Max dose: 15 mg
Nitrazepam	5-10 mg PO at bedtime
Oxazepam	15-25 mg PO at bedtime Up to 50 mg may be occasionally required
Pinazepam	5 mg PO 12 hourly
Temazepam	20 mg PO at bedtime Max dose: 40 mg
Triazolam	0.125-0.5 mg PO at bedtime Max dose: 0.5 mg

Drug	Dosage	Remarks
Melatonin	2 mg PO at 1-2 hours before bedtime or 1-2 sprays PO 24 hourly before bedtime	Adverse Reactions CNS effects (dizziness, headache, fatigue, depression);GI effects (nausea, unpleasant taste); Other effects (URTI, myalgia, back pain, arthralgia) Anaphylaxis, angioedema amd complex sleep-related behavior have been reported Special Instructions Tablet should be swallowed whole Do not take with a high fat meal or with alcohol Use with caution in patients with respiratory compromise, those receiving other CNS depressants or psychoactive medication Use with caution in patients with mild to moderate hepatic impairment Contraindicated in patients with severe hepatic impairment and those currently taking Fluvoxamine
Ramelteon	8 mg PO at bedtime Max dose: 8 mg/day

Drug	Dosage	Remarks
Daridorexant	25-50 mg PO within 30 minutes before bedtime Max dose: 50 mg/day	Adverse Reactions CNS effects (Somnolence, headache, dizziness) Sleep paralysis, hypnogogic/hypnopompic hallucination, cataplexy-like symptoms, and complex sleep behaviors (sleep-walking, sleep-driving, engaging in other activities while not fully awake) may occur Special Instructions Use with caution in patients with depression, suicidal ideation, history of substance abuse or compromised respiratory function Contraindicated in patients with narcolepsy Suvorexant is not recommended in patients with severe hepatic impairment
Lemborexant	5 mg PO before bedtime Max dose: 10 mg/day
Suvorexant	10-20 mg PO within 30 minutes before bedtime Max dose: 20 mg/day

All dosage recommendations are for non-pregnant and non-breastfeeding women and non-elderly adults with normal renal and hepatic function unless otherwise stated. 
Not all products are available or approved for above use in all countries. 
Products listed in the Drug Summary are based on indications stated in the locally approved product monographs. 
Please refer to local product monographs in Related MIMS Drugs for country-specific prescribing information.