What is the right drug for insomnia disorder?

Cognitive behavioural therapy (CBT) is considered a first-line treatment for chronic insomnia disorder; 1 Morin CM Inoue Y Kushida C Poyares D Winkelman J Endorsement of European guideline for the diagnosis and treatment of insomnia by the World Sleep Society. Sleep Med. 2021; 81: 124-126 Crossref PubMed Scopus (5) Google Scholar nevertheless, few clinicians are trained to deliver this treatment, and exploring other options seems imperative. In The Lancet, Franco De Crescenzo and colleagues 2 De Crescenzo F Loreto D'Alò G Ostinelli EG et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet. 2022; 400: 170-184 Summary Full Text Full Text PDF Scopus (5) Google Scholar report a large and comprehensive data synthesis on pharmacological treatments for insomnia disorder in which they assessed 154 double-blind trials of 30 different drugs or placebo with 44 089 adult participants (mean age 51·7 [SD 12·2] years, 62·8% women), conducted across a range of international settings. They included almost all available medications as monotherapy, licensed or not, and analysed a substantial number of outcomes for the acute (preferably at 4 weeks) but also long-term (>3 months) treatment of insomnia. Most trials were placebo-controlled; thus comparative efficacy between competing treatments was assessed through network meta-analysis that synthesises both direct and indirect evidence, resulting in more precise estimates. The study produced drug hierarchies for sleep quality, subjective total sleep time, and other efficacy outcomes. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysisOverall, eszopiclone and lemborexant had a favorable profile, but eszopiclone might cause substantial adverse events and safety data on lemborexant were inconclusive. Doxepin, seltorexant, and zaleplon were well tolerated, but data on efficacy and other important outcomes were scarce and do not allow firm conclusions. Many licensed drugs (including benzodiazepines, daridorexant, suvorexant, and trazodone) can be effective in the acute treatment of insomnia but are associated with poor tolerability, or information about long-term effects is not available. Full-Text PDF Open Access