New paradigms in the pharmacological treatment of insomnia

Insomnia is a chronic disorder that may require long-term treatment with hypnotic drugs. Newer drugs, such as zolpidem, zaleplon, zopiclone and eszopiclone, provide tools to maintain efficacy over a period of at least 6 months, without the marked rebound or dependence effects that are seen with traditional benzodiazepines over this period. However, even with newer drugs, the need for long-term therapy should be balanced against the symptom variability that occurs in insomnia patients over time. Patients may not require a hypnotic drug every night, because there will be nights when no insomnia occurs and when medication is superfluous. Non-nightly (discontinuous) dosing strategies allow symptoms to be addressed as they arise. This article focuses on data obtained for a variety of non-nightly administration schedules of zolpidem. Results from trials treating more than 6000 patients demonstrate that discontinuous treatment with zolpidem is effective and that intermittent replacement with placebo can be carried out safely. In addition, large-scale studies show that zolpidem is effective when taken ‘as needed’ in daily life settings and that there is a trend for patients to spontaneously self-limit drug intake when using these flexible schedules. Non-nightly zolpidem, therefore, offers an approach to treatment of patients with chronic insomnia that does not result in the inappropriate daily use of drugs.