Insomnia

One risk of medication is next-day sedation. The risk of next-morning drowsiness applies to all drugs taken for insomnia, and the lowest dose that treats the patient's symptoms should be prescribed. All hypnotics, including nonbenzodiazepine benzodiazepine receptor agonists and dual orexin receptor antagonists, confer a dose-proportional increase in daytime somnolence and motor impairment. Although no sex-based adjustment is advised for dual orexin receptor antagonists, all hypnotics doses confer added risk in the context of hepatic impairment and coadministration of other medications.

Medication may become less effective after a period of time, leading to tolerance. In order to combat this problem in the short term, patients may be given a gradually increased dose or switched to a different hypnotic. The dose should be titrated with caution, due to concerns about dependence for some agents.

Both nonbenzodiazepine benzodiazepine receptor agonists and dual orexin receptor antagonists are classified as controlled substances. It is not established whether either class confers lower liability than the other. Misuse or abuse is most likely for a patient with comorbid substance use disorder.

All hypnotics have some potential to produce dependence. This complication is especially of concern with some at-risk patient populations (e.g., people who misuse drugs). Cognitive behavioral therapy may be an effective choice for helping patients discontinue or lower their use of hypnotics.

Long-term exposure to ramelteon has been associated with mild, transient increase in prolactin in women.[232]Richardson G, Wang-Weigand S. Effects of long-term exposure to ramelteon, a melatonin receptor agonist, on endocrine function in adults with chronic insomnia. Hum Psychopharmacol. 2009 Mar;24(2):103-11. http://www.ncbi.nlm.nih.gov/pubmed/19090503?tool=bestpractice.com

Immediately following discontinuation of medication, patients may experience 1 or 2 nights of rebound insomnia. This effect should be short-term.