Table 8. Special recommendations for pharmacological treatment of insomnia.
| Recommendation | Consensus rate | Voting rounds |
|---|---|---|
| The use of zolpidem should NOT exceed 4 weeks, intermittent use or “if necessary” is recommended. | 100.00% | 1 |
| The initial dosage of immediate-release zolpidem for the elderly should be 5 mg. | 100.00% | 1 |
| In young adults, doses greater than 10 mg of regular-release zolpidem and 12.5 mg of controlled-release zolpidem are not recommended. | 94.12% | 1 |
| It is recommended that zolpidem be tapered due to the risk of rebound insomnia. | 94.12% | 1 |
| Zolpidem is associated with non-REM sleep parasomnias and addiction syndrome. | 100.00% | 1 |
| Zopiclone should be administered on a short-term basis, if possible intermittently or on an “as needed” basis. | 82.35% | 1 |
| The initial dosage of zopiclone for the elderly should be 3.75 mg. | 100.00% | 1 |
| It is recommended that the dose reduction of zopiclone be gradual due to the risk of rebound insomnia. | 82.35% | 1 |
| Eszopiclone should be administered on a short-term basis, if possible intermittently or on an “as needed” basis. | 88.24% | 1 |
| The dosage of eszopiclone, for the elderly population, should not exceed 2mg. | 100.00% | 1 |
| Lemborexant is NOT recommended as a treatment for insomnia in patients with narcolepsy. | 82.35% | 1 |
| The recommended doses of doxepin should be between 3 and 6 mg used close to bedtime, even in formulated presentations (since there are no industrialized presentations in Brazil). | 100.00% | 1 |
| Doxepin is recommended at the lowest therapeutic dose in adults over 65 years of age. | 94.12% | 1 |
| Trazodone doses used to treat insomnia should be lower than the doses recommended for treating major depression, at intervals between 25 and 150mg used close to bedtime. | 100.00% | 1 |
| Trazodone is NOT recommended for pregnant or breastfeeding women or for use in children and adolescents. | 94.12% | 1 |
| Amitriptyline may be useful for managing comorbid insomnia in patients with depressive disorders. | 94.12% | 1 |
| Mirtazapine is effective in the management of insomnia comorbid with depressive disorders. | 94.12% | 1 |
| The long elimination half-life of mirtazapine may cause residual drowsiness with cognitive and motor impairment. | 94.12% | 1 |
| Mirtazapine should be avoided in patients with metabolic disorders due to the risk of weight gain. | 100.00% | 1 |
| Melatonin can be used to treat initial insomnia in the elderly and children with autism spectrum disorder. | 100.00% | 1 |
| Ramelteon is recommended as a treatment for sleep-onset insomnia comorbid with OSA (COMISA). | 100.00% | 1 |
| Ramelteon is recommended as a treatment for sleep-onset insomnia comorbid with COPD. | 88.24% | 1 |
| Quetiapine may be recommended for the management of insomnia in comorbidity with other psychiatric disorders that justify its prescription. | 100.00% | 1 |
Abbreviations: COMISA, Comorbid insomnia and obstructive sleep apnea; COPD, Chronic obstructive pulmonary disease.