Is zolpidem still the top medication used for insomnia? Trends in dispensing of zolpidem and low-dose trazodone for new and continued use among commercially insured US adults, 2011-2021

Background: For decades, zolpidem has been the top medication used for insomnia, but documented safety risks have led to a growing preference to use the sedating antidepressant trazodone off-label for insomnia. Recent guidelines have discouraged trazodone use for insomnia due to a lack of efficacy and harms data, but it is unknown if these recommendations have impacted the use of trazodone and zolpidem for insomnia in recent years.

Objectives: To measure trends over the past decade (2011-2021) in the dispensing of zolpidem and low-dose trazodone for insomnia and the proportion of dispensing for new use.

Methods: Using the 2011-2021 Merative™ MarketScan® Research Databases, containing medical and pharmacy claims for a nationally representative sample of commercially insured US individuals, we calculated the annual percentage of adults (≥18y) who were dispensed zolpidem or low-dose trazodone (≤100 mg/day used for insomnia) among all adults who contacted the healthcare system in the year and had a year of prior medical and drug coverage. Among adults who received a dispensing, we calculated the annual proportion who were new users (no dispensing in the past year). To quantify trends over the 11-year period, we used binomial regression adjusted for age and sex to estimate the mean annual percent change (MAPC) in the prevalence of dispensing (among all adults) and proportion of new users (among adults who received a dispensing). We conducted subgroup analyses by sex (M, F) and age ( < 65y, ≥65y).

Results: From 2011 to 2021, among an annual mean of 15.3 million adults in MarketScan, the percentage of adults dispensed zolpidem steadily declined from 4.56% (95% CI 4.55% to 4.57%) to 1.67% (1.66% to 1.67%), while the percentage of adults dispensed trazodone ≤100 mg/day steadily increased from 1.24% (1.24% to 1.25%) to 2.14% (2.13% to 2.15%), exceeding zolpidem in all sex and age groups by 2021. The MAPC in dispensing was -0.25% (-0.25% to -0.25%) for zolpidem and 0.09% (0.09% to 0.09%) for trazodone. Among adults who received a dispensing, the proportion of new users from 2011 to 2021 declined more drastically for zolpidem (43% to 31%; MAPC of -1.36%, -1.37% to -1.34%) than for trazodone (54% to 50%; MAPC of -0.98%, -1.00% to -0.96%). Trends were consistent by sex and age and were most pronounced among older adults (≥65y) who also had the highest dispensing of both drugs in all years.

Conclusions: From 2011-2021, dispensing of zolpidem markedly declined, as did the proportion of dispensing to new users (1 in 3 adults who received zolpidem in 2021). Dispensing of low-dose trazodone steadily increased, surpassing zolpidem to become the top medication for insomnia despite this use not being guideline recommended. In 2021, 1 in 2 adults who received a dispensing of low-dose trazodone were new users.