Patients complaining of insomnia or poor sleep could be experiencing any of several stressors that include physical, psychological, and environmental factors, and identifying them is the secret to successful treatment, said Carolyn D’Ambrosio, MD, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, in a presentation at America College of Physicians (ACP-IM) Internal Medicine Meeting 2025.
Insomnia
Insomnia may be caused by primary sleep disorders such as restless legs syndrome, periodic limb movements of sleep, and sleep apnea, D’Ambrosio said. However, insomnia is often a symptom of something else, such as poor sleep habits, use of alcohol, caffeine, and social media, or other medications that disrupt sleep, she noted.
Other potential causes include chronic medical conditions that cause discomfort at night, circadian rhythm disorders, psychiatric conditions such as depression and anxiety, and stressful events such as marriage, divorce, bereavement, or relocation.
Consequently, treatments for insomnia work best if a cause is correctly identified, D’Ambrosio said. Strategies include cognitive behavioral therapy, sleep hygiene, reducing stimulants, and sleep restriction, as well as control of stimuli (meaning no devices in the bedroom), she said.
For some patients with insomnia, a short-term course of medication is helpful to allow them to sleep while addressing the larger causes, D’Ambrosio said in her presentation. D’Ambrosio generally prescribes a 30-day supply of a sleep medication and then renews it just once.
Dual orexin receptor antagonists including daridorexant, lemborexant, and survorexant are approved alternatives to benzodiazepines that target orexin, D’Ambrosio said. “Orexin is a chemical made in the brain that promotes wakefulness,” she said. “This works because we are blocking the chemical that makes the person stay awake,” she said.
Other options for medication to help keep patients asleep include ramelteon, a melatonin receptor agonist; and doxepin, a histamine receptor antagonist, she said.
Some patients may ask about brain stimulation for insomnia, but well-controlled studies show no difference between a brain stimulation device and a sham device for insomnia, D’Ambrosio noted.
Options for Obstructive Sleep Apnea
Home sleep tests, which have become common, only identify sleep apnea, D’Ambrosio emphasized. “If you are worried enough about sleep apnea to order a home test, you should do a sleep study in a laboratory if the home sleep test is negative,” she said in her presentation.
For patients whose insomnia stems from obstructive sleep apnea (OSA), identifying the cause is essential to find the most effective treatment, D’Ambrosio said. Overall, data suggest that 44% of patients with OSA have anatomical issues as the primary cause, usually collapsibility of the upper airway, she said. Approximately 56% have a nonanatomical basis for OSA, including loop gain (a measure of respiratory stability), arousal threshold, and poor muscle response, she said.
Positive airway pressure (PAP) remains an effective sleep apnea treatment when used correctly, but it doesn’t work for everyone and many patients may be candidates for other options, including hypoglossal nerve stimulation, said D’Ambrosio in her presentation.
In general, patients aged 18 years or older with less severe OSA, body mass index < 40, and < 25% central and mixed apneas are most likely to benefit from hypoglossal nerve stimulation, D’Ambrosio noted. However, this option is mainly for people who cannot tolerate any other treatments and she rarely recommends it, D’Ambrosio told Medscape Medical News in an interview.
Other alternatives to PAP include weight loss for patients with overweight or obesity; D’Ambrosio recommends glucagon-like peptide 1 (GLP-1) receptor agonists. In particular, the US Food and Drug Administration has approved tirzepatide for moderate to severe OSA, she said. Looking ahead, “there are medications in the pipeline to help stabilize the upper airway and affect the arousal response as a way to treat sleep apnea in some patients,” D’Ambrosio told Medscape Medical News.
Artificial Intelligence (AI) Takes Aim at Sleep Problems
The use of AI in sleep medicine continues to evolve, said D’Ambrosio. She cited a recent review in the Journal of Clinical Sleep Medicine in which experts identified the potential of AI in three areas of sleep medicine: Clinical care, lifestyle management, and population health management.
For example, public-facing interface apps can be used for sleep surveillance, D’Ambrosio said. Also, AI can increase access to sleep medicine care by facilitating remote home monitoring and connections between providers and patients, she said. Clinicians can be alerted sooner to changes in patients’ conditions, she added.
Ultimately, AI applications in sleep medicine may include detecting sleep microstructure events and mining biometric and polysomnographic data to diagnose sleep disorders, D’Ambrosio added.
Staying Aware in Primary Care
A basic understanding of sleep medicine is important for primary care providers because of the high prevalence of sleep disorders such as insomnia and OSA, said Arianne K. Baldomero, MD, a pulmonologist and assistant professor of medicine at the University of Minnesota, Minneapolis, in an interview. “Early recognition and treatment, as well as the ability to identify which patients require referral to a sleep medicine specialist, are crucial for improving patient outcomes,” she said.
While drugs may provide some relief for patients, “first-line treatments such as cognitive behavioral therapy for insomnia and continuous PAP remain essential for long-term management,” said Baldomero.
If non-PAP options for OSA are needed, they should be tailored to a patient’s specific OSA phenotype and tolerance for therapies, said Baldomero. Such options may also include positional therapy, oral appliances, and lifestyle modifications in addition to GLP-1s and hypoglossal nerve stimulation, she said.
“Referral to a sleep medicine specialist is warranted for patients with severe OSA unresponsive to standard treatments, central or mixed apneas, unexplained excessive daytime sleepiness despite adequate therapy, or complex cases requiring advanced diagnostic tools like polysomnography,” Baldomero told Medscape Medical News. “Additionally, patients with comorbidities such as heart failure or neurological disorders may benefit from specialist evaluation,” she said.
D’Ambrosio disclosed consulting work for Dynamed Inc. Baldomero had no financial conflicts to disclose.
