Modified Delphi Consensus on Optimal Pharmacological Management of Insomnia: Insights From a Malaysian Perspective

Abstract

Insomnia represents a significant risk factor for impaired daytime functioning and various chronic health conditions, emerging as a growing public health concern in Malaysia. The absence of standardized local guidelines complicates treatment decisions. This consensus aimed to develop pharmacological treatment recommendations for insomnia in Malaysia using a modified Delphi approach. An eight-member expert panel of sleep medicine, psychiatry, neurology, and pharmacology specialists reviewed high-level evidence on insomnia’s neurobiology, diagnosis, and treatment. A 31-item consensus statement survey addressing insomnia's definition, diagnosis, and pharmacological management was conducted, with agreement evaluated on a 5-point Likert scale. The consensus recommendations were finalized after two Delphi rounds and a final vote, with at least 75% agreement with each statement. Results underscored the need for tailored treatment strategies in Malaysia, combining nonpharmacological and pharmacological interventions. Insomnia was recognized as a chronic condition diagnosed primarily through subjective criteria, with sleep diaries and questionnaires recommended for assessment. Benzodiazepines, Z-class drugs, and dual orexin receptor agonists (DORAs) are effective, although concerns about long-term safety and dependency were noted. DORAs show promise in managing sleep onset and maintenance, highlighting lemborexant as a promising pharmacological option. The meeting emphasized the need for individualized treatment plans and careful risk assessment, especially for older adults, and provided practical recommendations for managing insomnia. Integration of Cognitive Behavioral Therapy for Insomnia (CBT-I) with pharmacotherapy was strongly advocated. These consensus statements provide a practical foundation for future national guidelines to improve insomnia care in Malaysia’s primary care settings.