Clinical Practice Guidelines

Introduction

Associations and professional medical organizations like American Academy of Sleep Medicine (AASM) and the American College of Physicians (ACP), rigorously evaluate the latest research and translate it into practical treatment guidelines for healthcare professionals. These evidence-based recommendations offer a clear roadmap, prioritizing safe and effective approaches for insomnia. They also provide informed advice on medication use, emphasizing caution and limited duration for certain drugs. By drawing from the expertise of these trusted bodies, healthcare professionals can confidently navigate the complexities of sleep disorders and help individuals achieve their sleep goals.

Recognized Treatment Guidelines for Insomnia

American Academy of Sleep Medicine (AASM) Guidelines

Clinical Practice Guideline for the Evaluation and Management of Chronic Insomnia in Adults: This comprehensive guideline covers diagnosis, evaluation, and treatment, including CBT-I, medication use, and other non-pharmacological approaches.
Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: This guideline focuses specifically on medications for chronic insomnia, providing evidence-based recommendations on specific drugs, their duration, and safety considerations.

American College of Physicians (ACP) Guidelines

Management of Chronic Insomnia Disorder in Adults: This guideline emphasizes CBT-I as the first-line treatment, advocating for cautious and short-term medication use only after non-pharmacological approaches have been tried.

American Psychiatric Association (APA) Clinical Practice Guidelines

Treatment of Chronic Insomnia in Adults: This guideline provides recommendations within the context of mental health care, emphasizing the importance of addressing underlying mental health conditions that may contribute to insomnia.

European Sleep Medicine Society (ESRS) Guidelines

Guidelines for the Management of Chronic Insomnia in Adults: This European guideline offers a similar framework to the AASM recommendations, with a focus on CBT-I and limited medication use.

NICE (National Institute for Health and Care Excellence) Guidelines

Insomnia: This UK-based guideline emphasizes the importance of comprehensive assessment, non-pharmacological interventions, and tailored treatment plans for individual patients.

Additional Resources:

American Academy of Sleep Medicine (AASM)

The American Academy of Sleep Medicine (AASM) commissioned a task force of four experts in sleep medicine to develop recommendations for pharmacological treatment of insomnia disorder. To determine the direction and strength of a recommendation, the task force assessed quality of evidence, balance of beneficial and harmful effects, and patient values and preferences. The GRADE approach (Grades of Recommendation, Assessment, Development and Evaluation) was used to assess the quality of evidence. A STRONG recommendation under GRADE is one that clinicians should generally abide by. A WEAK recommendation does not necessarily indicate ineffectiveness; rather, it represents a reduced level of confidence in the outcome and appropriateness of the patient-care plan for all patients.

The 2017 AASM guideline is based on a systematic review (including meta-analyses) of pharmacological agents used for the management of insomnia, and provides recommendations for orexin receptor antagonists, BzRAs and benzodiazepines, melatonin agonists, heterocyclics, anticonvulsants, and over-the-counter preparations. The guideline also includes literature reviews of estazolam, quazepam, flurazepam, oxazepam, quetiapine, gabapentin, paroxetine, and trimipramine; for these agents, clinical practice recommendations were not possible due to inadequate data for statistical analyses. The 2017 AASM recommendations are summarized in Table 11-9.

Importantly, the 2017 AASM guideline states that it should be used in combination with previous AASM guidelines on the evaluation and management of chronic insomnia, as it is intended to act as only one element in an ongoing assessment of a patient with insomnia.93 Another important statement from the guideline is that medications for chronic insomnia disorder should be considered mainly in patients who are unable to participate in CBT-I, who still have symptoms despite participation in such treatments, or, in select cases, as a temporary adjunct to CBT-I.

In 2023, the Alliance for Sleep, a committee of 5 US-based sleep medicine experts published a guideline on switching or deprescribing hypnotic medications for insomnia.94 Briefly, this guideline recommends tapering for the following drugs: benzodiazepines when switching to a different drug class (but not to another benzodiazepine), zolpidem and eszopiclone when switching to another Z-drug or another drug class (not required for zaleplon), and trazodone, mirtazapine, TCAs, and quetiapine when switching to a different drug class (within-class switching is not recommended for these drugs). A direct switch is recommended for orexin receptor antagonists, ramelteon, or dopexin.