My PPT_Drug treatment of Insomnia
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Similar a My PPT_Drug treatment of Insomnia
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My PPT_Drug treatment of Insomnia
- 1. Drug Treatment of Insomnia Dr Ranjita Santra (Dhali) Assistant Professor Dept. of Clinical & Experimental Pharmacolo School of Tropical Medicine Kolkata
- 2. What is Insomnia? The perception of inadequate or poor-quality sleep accompanied by significant distress or impaired function Chronic if it occurs on most nights and lasts a month or more You might suffer from insomnia if: ◦ It takes you more than 30 to 45 minutes to get to sleep ◦ You wake up during the night ◦ If you wake up early and cannot get back to sleep ◦ You wake up feeling un-refreshed in the morning A symptom, not a disease or sign, therefore difficult to measure Source: www.nih.gov.in.Accessed : 20.06.2015
- 3. Diagnosis Complaint that the sleep is: ◦ Brief or inadequate ◦ Light or easily disrupted ◦ Non-refreshing or non-restorative
- 4. Which patient populations have the highest prevalence of insomnia? Women Especially in 3rd trimester and after menopause Elderly Up to 65% ((Ohayon, 2002; Morphy, 2007; Foley, 1995) Those with various disorders Psychiatric disorders, including depression, anxiety, substance abuse, and posttraumatic stress disorder, are also strongly associated with insomnia (Spiegelhalder, 2013; Baglioni, 2011) Individuals with coexisting medical disorders (particularly pulmonary disease, heart failure, and conditions associated with pain such as cancer) are at increased risk for insomnia, as are patients with neurologic diseases (such as Alzheimer dementia and Parkinson disease) (Taylor, 2007)
- 5. Which patient populations have the highest prevalence of insomnia? An increased prevalence of insomnia is also associated with a variety of rheumatologic, endocrine, urologic, and dermatologic disorders (Dikeos, 2011). Population studies – unemployed, divorced, widowed, separated, or of lower socioeconomic status have a higher prevalence of insomnia (Gellis, 2005; Paine, 2004). Stimulants (e.g., caffeine, nicotine), antidepressants, β-antagonists, calcium channel blockers, and glucocorticoids. Additionally, individuals withdrawing from certain medications, such as alcohol or hypnotic medications, may have resulting insomnia.
- 6. Classification The 3rd edition of the International Congress of Sleep Disorders Classification (ICSD-3) was published in 2014 and includes 7 major categories of sleep disorders, one of which is insomnia Three major forms of insomnia are recognized: short term (< 3 months), chronic (symptoms occur at least 3 times / week for 3 months or more &
- 7. Classification Sleep initiating insomnia Sleep maintaining insomnia Early morning insomnia ◦ Short period of sleep Non-restorative sleep ◦ Multiple awakenings ◦ Combination of above patterns
- 8. Definitions Mild ◦ Almost nightly complaint of non-restorative sleep ◦ Associated with little or no impairment of social or occupational functioning Moderate ◦ Nightly complaints of disturbed sleep ◦ Mild to moderate impairment of social or occupational function Severe ◦ Nightly complaints of disturbed sleep ◦ Severe daytime dysfunction
- 9. Physical, Emotional, and Cognitive Effects of Insomnia Mood changes, irritability, poor concentration, memory defects, etc. Impairs creative thinking, verbal processing, problem solving Risk of errors, accidents due to excessive daytime sleepiness ◦ Markedly increases if awake more than 16-18 hours (micro-sleep attacks) Increased appetite, decreased body temperature Physiologic effects ◦ Rats die after 11-12 days of sleep deprivation ◦ Hippocampal atrophy in chronic jet lag or shift work
- 10. Sleep is an integral portion of human existence which is sensitive to most physiological or pathological changes (aging, stress, illness, etc.) Why do we sleep? ◦ Not clear, but has to do with regeneration (NREM) and brain development/memory (REM) – REM sleep is essential for the development of the mammalian brain ◦ Stages III & IV are involved in synaptic “pruning and tuning” Why do we get sleepy? ◦ Circadian factors ◦ Process S: linear increase in sleepiness ◦ Process C: rhythmic fluctuations of the circadian alert system
- 11. Normal Sleep Values Normal sleep per day is between 6-8 hours 4-6 NREM/REM cycles per night Wakefulness after sleep ◦ Less than 30 minutes Sleep Onset Latency (SOL) ◦ Less than 30 minutes REM Sleep Latency ◦ 70-120 minutes
- 13. Brain regions of current interest to the neurobiology of sleep. Subcortical regions (blue boxes), which control sleep–wake transitions and, within sleep, REM–NREM sleep alternation. The top tier includes areas that are key to the generation of the EEG rhythms of sleep, the subjective experience of sleep mentation or dreaming, and sleep's effects on cognition. Schematic representation of the regulatory circuits that control sleep–wake and REM–NREM transitions, as well as their key inputs and outputs. EEG, electroencephalogram; NREM, non-REM; REM, rapid eye
- 18. Historical Perspective Chloral hydrate and laudanum (opium and alcohol mixture) were first used for treating insomnia in the mid1800s The barbiturates and related medications dominated much of the 20th century The benzodiazepines first were used for sleep in the 1960s and 1970s, and the more selective nonbenzodiazepine analogues became available in the 1980s and 1990s The earlier compounds had the advantage of efficacy in promoting sleep, but had significant safety problems Newer FDA-approved insomnia medications have little or no abuse liability, much less likely to cause residual daytime sedation or impairment
- 20. Treatment Modalities Treatment of insomnia includes alleviating any physical and emotional problems that are contributing to the condition and exploring changes in lifestyle There are a myriad of treatments available for insomniacs, which fall into three major categories ◦ Drug Therapy ◦ Cognitive-Behavioral Therapy ◦ Alternative Treatments
- 21. When should clinicians consider prescription drug therapy for insomnia? When other approaches prove inadequate Considerations The nature of the sleep disturbance Whether insomnia is acute or chronic Presence of other medical or psychiatric conditions Side effects Cost
- 22. Drugs prescribed for Insomnia
- 23. Prescription & Non-prescription medications: Insomnia
- 24. FDA-approved prescription drug treatments for insomnia Benzodiazepines (flurazepam, temazepam, triazolam) Nonbenzodiazepine (zolpidem, eszopiclone, zaleplon) Orexin-receptor antagonist (suvorexant) Melatonin Receptor Agonists (ramelteon) Antidepressants (doxepin) Others options Barbituates Antipsychotics Anticonvulsants
- 26. Sedative-hypnotic drugs. In: Basic and clinical pharmacology, 8th edition. Katzung BG. USA: The McGraw Hill Companies, Inc, 2001:364–381.
- 33. Suvorexant is a potent dual orexin receptor antagonist approved by the US-FDA march 2014 that blocks both OX1R and OX2R Roughly 70,000 orexin neurons are in the human brain, located in the perifornical lateral hypothalamus, which send signals throughout the brain and spinal cord. Promotes the natural transition from wakefulness to sleep by inhibiting the binding of orexin A and B, neuropeptides that promote wakefulness Also improves sleep onset and sleep maintenance Suvorexant
- 34. Table: 1 PK determinants for Suvorexant
- 35. Should clinicians screen for insomnia, and if so, how? Consider screening as part of regular patient care Ask patients if they have Difficulty initiating or maintaining sleep Early morning waking Nonrestorative sleep Insomnia screening instruments Sleep Condition Index questionnaire (2 questions) Epworth Sleepiness Scale Insomnia Questionnaire
- 36. Sleep Condition Index questionnaire “Thinking about a typical night in the last month, how many nights do you have a problem with sleep?” (with ≥3 representing a positive response), and “Thinking about the past month, to what extent has poor sleep troubled you in general?” (with “somewhat” to “very much” being a positive response) Positive responses to these 2 questions correlate with other more extensive assessments and may be effective for clinicians as a screening tool to detect insomnia (Espie, 2014).
- 38. Insomnia questionnaire I have real difficulty falling asleep. Thoughts race through my mind and this prevents me from sleeping. I wake during the night and can’t go back to sleep. I wake up earlier in the morning than I would like to. I’ll lie awake for half an hour or more before I fall asleep. I anticipate a problem with sleep almost every night If you checked three or more boxes, you show symptoms of insomnia, a persistent inability to fall asleep or stay asleep. (Insomnia questionnaire : American College of Sleep Medicine)
- 39. When do activities occur Going to bed, waking up, getting out of bed What are the components of a comprehensive sleep history? How much sleep Sleep latency, frequency of awakening, duration awake after awakening, total sleep time Quality of sleep How well rested do you feel after awakening? Environmental factors Light, sound, temperature, telephone, TV Behaviors that might affect sleep Sleep habits, daytime napping, exercise, stimulant use
- 40. What are the components of a comprehensive sleep history? A sleep diary may be more accurate than general questioning alone in characterizing sleep issues by formally documenting these factors and minimizing recall bias. Several instruments are available for patient use, and should be used daily for at least 1 to 2 weeks (National Sleep Foundation Diary; Carney, 2012).
- 41. Things to Ask about When Taking a Comprehensive Sleep History Problems of sleep initiation, sleep maintenance, early morning waking, or nonrestorative sleep Ascertain if the patient has acute, short-term, or chronic insomnia Stability or progression of symptoms—that is, if the insomnia is stable, worsening, or improving Precipitating causes of insomnia Bedtime, wake time, length of sleep time Caffeine and alcohol use Any current or previous behavioral therapies used to treat insomnia Previous over-the-counter or prescription sedative-hypnotic use Shifting work and irregular sleep schedule Potential acute stressors, such as: Medical or psychiatric illness Medication use, both prescribed and illicit Acute stress at home or work Circadian rhythm stressors, such as jet lag
- 42. Sleep Disorder Differential Diagnosis of Insomnia Sleep-related breathing disorders ◦ The obstructive sleep apnea syndrome ◦ The central sleep apnea syndrome Sleep-related movement disorders ◦ The restless legs syndrome ◦ Periodic limb movement disorder ◦ Nocturnal leg cramps Circadian rhythm sleep–wake disorders ◦ Time zone change syndrome (jet lag) ◦ Shiftwork sleep disorder ◦ The delayed sleep-phase syndrome ◦ The advanced sleep-phase syndrome Parasomnias related to non–rapid eye movement
- 43. When a possible underlying sleep disorder is suspected When insomnia may be linked to concomitant disease Laboratory testing in the evaluation of insomnia Possible tests Polysomnography Multiple Sleep Latency Test Sleep Actigraphy Tests for disorders contributing to insomnia Urine drug screening (to check for substance use)
- 44. What is sleep hygiene, and what is its role in the treatment of patients with insomnia? Sleep hygiene refers to the optimization of the environmental and behavioral factors associated with sleep (Stepanski, 2003). Poor sleep hygiene can contribute to sleep fragmentation, disturbance of normal circadian rhythms, and overstimulation. Good sleep hygiene behaviors Maintain constant bed times and rising times Allow adequate time for sleep (7 h to 8 h for adults) Do not force sleep, and avoid clock watching Maintain a quiet, dark bedroom Remove potential disruptors of sleep (tv, phone) Avoid sleep-fragmenting substances near bedtime Exercise regularly but avoid exercise just before bedtime Resolve stressful situations and relax before bedtime Avoid daytime naps
- 45. Things to consider when prescribing drugs to treat insomnia Use the minimal effective dose Avoid medications with a long half-life Be aware of potential drug-drug interactions Caution patients about interaction with alcohol Review potential side effects, especially daytime sleepiness Agree on an appropriate duration of use Start with a GABA agonist for acute or short-term insomnia Look for rebound insomnia after discontinuation Consider intermittent use of hypnotic medications when long-term therapy is required Consider consultation with a sleep specialist before starting continuous, long-term therapy with hypnotic medication
- 46. What is the appropriate duration of prescription drug therapy for insomnia? Avoid prolonged or excessive therapy Discuss risks and benefits of drug therapy Continuous therapy Limit to 1 month Conduct periodic tapering and discontinuation trials to determine when continuous therapy can be stopped As-needed therapy Limit to 6 months Reserve for patients who can assess when drug treatment will be helpful
- 47. What are contraindications to drug therapy? Sedating antihistamines ◦ Cardiopulmonary disease, glaucoma, problems w/ urination Sedative-hypnotics If pregnant or breastfeeding Underlying medical disorders in which sedation detrimental Any sedating mediation Alcohol or another sedating medication Driving or using hazardous equipment All medications History of alcohol or drug abuse Use more cautiously in elderly Beware potential interaction with complementary and alternative medications
- 48. When should clinicians consider speciality referral for patients with insomnia? Suspicion of an underlying sleep disorder Poor response to behavioral interventions / drug therapy Psychiatrist: possible psychiatric disorder Pulmonologist: suspected sleep disordered Otolaryngologist, oral surgeon, or dentist: excessive snoring or other oropharyngeal or airway issues Neurologist: possible Parkinson disease, cerebrovascular disease, or dementia
- 49. Treatment: Alternative Therapies Valerian extracts cause both CNS depression and muscle relaxation. Ginseng has an inhibitory effect on the CNS and may modulate neurotransmission. Kava Kava possibly acts on GABA and benzodiazepine binding sites in the brain. Passion flower is associated with significantly prolonged sleeping time in rats, and may be applicable to humans. Hops, when infused in tea, are reported to have a calming effect within 20-40 minutes of ingestion
- 50. Treatment: Alternative Therapies Physiological Agents ◦ Melatonin increases sleep quality when compared with baseline and placebo in night-shift workers ◦ Tryptophans reduce sleep latency by increasing subjective “sleepiness” and also decreasing waking time Other Approaches ◦ Acupuncture therapy can affect the regulation of sleep-wake cycles and possibly reharmonize a disturbed sleep-wake cycle. ◦ Low energy emission therapy, in healthy volunteers, 15 minutes of LEET treatment induced EEG changes, and was associated with objective and subjective feelings of relaxation
- 51. Resources for Insomnia patients
- 52. Conclusion Insomnia can be problematic if not dealt with Although many treatments are available, few people seek treatment Proper sleep hygiene is integral to daily life
Notas del editor
- When should clinicians consider prescription drug therapy for patients with insomnia? When other approaches prove inadequate, prescription drug therapy may be warranted. Pharmacologic therapy appears to have similar short-term effectiveness as CBT for insomnia, but there is limited evidence that initial combination therapy with medication and CBT is superior to CBT alone for insomnia. The choice of medication for insomnia is typically individualized based on a number of factors. A primary consideration is the nature of the sleep disturbance. For example, for individuals with problems of sleep onset (difficulty falling asleep), use of a rapid-onset, short-acting agent may be appropriate, whereas patients with issues of sleep maintenance (staying asleep), a drug with slower-onset but longer half-life may be preferable. Additional considerations include whether the patient has acute or chronic symptoms, the presence of other medical or psychiatric conditions, potential side effects, or cost issues that might influence medication choice. Several classes of drugs are used for insomnia, including those with a specific indication for treatment of sleep disturbances and those approved for another indication but used for this purpose. Medications with an FDA indication for use in treating insomnia are listed in Table 3. Benzodiazepines Benzodiazepines exert their effect primarily through the nonspecific enhancement of the gamma-aminobutyric acid (GABA) type A receptor complex. GABA is an inhibitory neurotransmitter that reduces neuronal firing, thereby decreasing arousal and facilitating sleep. Benzodiazepines decrease sleep latency and prolong total sleep time. Although specific benzodiazepines differ somewhat in their receptor affinity and may carry different indications, all have a hypnotic (sleep promoting) effect, and a major consideration in prescribing them for insomnia is their time of onset, elimination half-life, and route of metabolism. Because of the nonspecific activation of GABA receptors, benzodiazepines have additional effects beyond promoting sleep. In addition to possible daytime sedation, benzodiazepines may also cause cognitive impairment, dizziness, lightheadedness, motor incoordination, and anterograde amnesia. Respiratory depression is a concern in patients with ventilatory issues, such as OSAS or obesity-hypoventilation syndrome. Benzodiazepines also have potential for dependence and abuse. Nonbenzodiazepine GABA Agonists Nonbenzodiazepines GABA agonists are chemically unrelated to the benzodiazepines but bind more specifically to certain subunits of the GABA type A receptor complex; this tends to result in fewer side effects than benzodiazepines and other sedative-hypnotics. Their effect on sleep appears similar to that of benzodiazepines, with decreased sleep latency and extended total sleep time. Nonbenzodiazepines tend to have a more rapid onset and shorter half-lives than most benzodiazepines. Adverse reactions associated with nonbenzodizepine agents may include residual sedation, disorientation, nightmares, amnesia, mood changes, nausea, vertigo, headache, and visual distortion. Nonbenzodiazepine abuse can occur, especially among patients with comorbid substance abuse and psychiatric illness. However, these agents are generally preferred over other hypnotic agents because of their effectiveness and safety profile. Orexin-Receptor Antagonists Orexins are excitatory neurotransmitters secreted by the hypothalamus that act on various brain nuclei to stimulate arousal. These drugs work by inactivating the stimulation of wakefulness instead of actively promoting sleep, as occurs with benzodiazepine and nonbenzodiazepine GABA stimulants. It is believed that this mechanism of action may cause fewer side effects than those commonly associated with GABA-stimulants, although next-day drowsiness impairing activities requiring alertness may occur. Data that directly compare these drugs with other insomnia medications are limited. Suvorexant is the first orexin antagonist approved for insomnia. Melatonin Receptor Agonists The prescription form of melatonin, ramelteon, has increased affinity for the MT1 melatonin receptor with a primary effect of decreasing sleep latency; it is indicated only for treatment of sleep-onset insomnia. The most common side effects are nausea, headache, dizziness, and fatigue, but it is not associated with daytime somnolence or other cognitive changes. It is also not considered to be habit forming and is not classified as a controlled substance. It may also cause elevated prolactin levels; however, routine monitoring of prolactin levels is not indicated. Antidepressants Antidepressants, particularly older agents, have a sedating effect and are sometimes used as therapy for insomnia, often in lower doses than those used for treatment of depression. Only one antidepressant, doxepin, has an FDA-approved indication for treatment of insomnia. Although doxepin is a tricyclic, its approved dose for insomnia is very low compared to those used for treatment of depression, and the pharmacologic effect at that level is primarily antihistaminic. This tends to avoid the antiserotonergic and anti-adrenergic effects and their associated potential complications seen with tricyclic antidepressants at higher dosing levels. Other tricyclic antidepressants are frequently also used off-label for treatment of insomnia although there is very limited evidence of effectiveness of these drugs for treating sleep disorders not associated with depression. Trazodone, a novel antidepressant, is commonly prescribed for insomnia although evidence for its effectiveness is also extremely limited. Other later generation antidepressants, such as mirtazapine, are also sometimes prescribed for insomnia. However, there have been no studies of this agent used for treatment of non-depression-related sleep disturbances. Because of the lack of demonstrated effectiveness and the potential for significant adverse effects, treatment with antidepressants other than doxepin for insomnia in the absence of depression is not recommended (Minkel, 2013). Other Drugs Barbituates were historically used to treat insomnia, but their use has been supplanted by newer agents with decreased adverse effects and dependency issues, and they are not currently recommended. Antipsychotic agents (such as quetiapine and olanzapine) are helpful in treating sleep disturbances in patients with associated psychiatric disorders; however, their effectiveness in treating insomnia in patients with only insomnia disorder has not been established. Anticonvulsants (such as gabapentin and pregabalin) may be useful in treating underlying conditions associated with disturbed sleep (such as chronic pain or fibromyalgia), but do not appear to be effective as therapy for insomnia. Drug Therapy for Insomnia Secondary to Restless Leg Syndrome or Periodic Limb Movement Disorder In addition to exclusion of iron deficiency and the avoidance of caffeine, nicotine, and alcohol, patients with restless legs syndrome (RLS) that is disruptive of sleep may also benefit from pharmacologic therapy. A low bedtime dose of a dopaminergic agonist agent, such as pramipexole or ropinirole, is the usual first line therapy. If dopaminergic agents are ineffective, poorly tolerated, or contraindicated, other treatment options include levodopa, benzodiazepines, or opioids (such as tramadol, codeine, hydrocodone, or oxycodone). The pharmacologic treatment for periodic limb movement disorder is similar.
- See Table 3. U.S. Food and Drug Administration–Approved Prescription Drug Treatments for Insomnia
- What are the components of a comprehensive sleep history? In patients with insomnia, a comprehensive sleep assessment enables clinicians to diagnose insomnia, establish factors that may be disrupting sleep, and to plan effective treatment (Schutte-Rodin, 2008). Sleep and wakefulness should be assessed across the entire day to characterize sleep issues and their impact on daytime function. The temporal aspects of sleep should be elicited, including when the patient goes to bed, attempts to go to sleep (“lights out time”), wakes up, and gets out of bed. Evaluating quantitative sleep is important, including how long it takes to fall asleep (sleep latency), how often the person awakens and stays awake before falling back to sleep, and the total time the person sleeps. The quality of a patient’s sleep should be elicited, including the perceived causes of sleep difficulty and how well rested they feel upon wakening. Careful documentation of environmental factors affecting sleep is important, including the sleep environment (light, sound, temperature) and other stimuli present (television, telephone, computer). Behaviors potentially affecting sleep are also important, such as sleep habits, the amount of time allotted for sleep, daytime napping, exercise, stimulant use, and psychosocial stressors. A sleep diary may be more accurate than general questioning alone in characterizing sleep issues by formally documenting these factors and minimizing recall bias. Several instruments are available for patient use, and should be used daily for at least 1 to 2 weeks (National Sleep Foundation Diary; Carney, 2012). BOX: Things to Ask about When Taking a Comprehensive Sleep History Problems of sleep initiation, sleep maintenance, early morning waking, or nonrestorative sleep Ascertain if the patient has acute, short-term, or chronic insomnia Stability or progression of symptoms—that is, if the insomnia is stable, worsening, or improving Precipitating causes of insomnia Bedtime, wake time, length of sleep time Caffeine and alcohol use Any current or previous behavioral therapies used to treat insomnia Previous over-the-counter or prescription sedative-hypnotic use Shifting work and irregular sleep schedule Potential acute stressors, such as: Medical or psychiatric illness Medication use, both prescribed and illicit Acute stress at home or work Circadian rhythm stressors, such as jet lag
- When should clinicians consider laboratory testing in the evaluation of patients with insomnia? Insomnia is a clinical diagnosis; therefore, the sleep and medical history, in conjunction with the physical examination, are the primary diagnostic tools. Additional testing is not routinely required, but may be appropriate in patients when a possible underlying sleep disorder is suspected or there is clinical evidence of concomitant disease that may be associated with insomnia. Polysomnography An overnight sleep study, or polysomnography, is not routinely indicated for evaluation of insomnia but may be indicated in patients with suspected sleep-related breathing issues (such as OSAS or central sleep apnea), other sleep disorders (including narcolepsy and periodic limb movement disorder), or for characterizing poorly-defined sleep disturbances. Multiple Sleep Latency Test (MLST) The MSLT is a test that objectively measures an individual’s tendency to fall asleep involving a series of monitored naps in a sleep laboratory that measure the time to onset of REM sleep. Its primary use is to diagnose narcolepsy; it is therefore not a routine study for evaluation of insomnia, but may be useful in patients suspected of having this disorder. Sleep Actigraphy Actigraphy uses a small, watch-like electronic device worn around the wrist of the nondominant arm that detects motion, with periods of inactivity suggesting periods of sleep. It is also not used routinely to evaluate insomnia, but may be useful in assessing or confirming sleep patterns and circadian rhythms in selected patients and in those with difficulty in recalling their sleep pattern. Other Tests to Evaluate for Underlying Comorbidity Other studies may be needed to evaluate for underlying cardiac, pulmonary, gastrointestinal, or neurologic disorders contributing to insomnia. Restless legs syndrome is associated with diabetes mellitus, kidney disease, and iron deficiency; exclusion of these disorders and measurement of iron stores are indicated when this disorder is suspected. Both hyper- and hypothyroidism are associated with sleep disturbances and should be evaluated through thyroid function testing. Urine drug screening may also be useful in some patients because of the association of stimulant and other substances with altered sleep. Directed testing is indicated for other conditions possibly underlying a complaint of insomnia as suggested by the clinical history and physical examination. Examples include evaluation for congestive heart failure, chronic obstructive pulmonary disease, and gastroesophageal reflux disease in patients considered at risk for these conditions (see Table 2).
- What is sleep hygiene and what is its role in the treatment of patients with insomnia? Sleep hygiene refers to the optimization of the environmental and behavioral factors associated with sleep (Stepanski, 2003). Poor sleep hygiene can contribute to sleep fragmentation, disturbance of normal circadian rhythms, and overstimulation. Clinicians should review and advise correction of poor sleep hygiene in all patients complaining of insomnia (see Box) to promote sound sleep and daytime wakefulness. BOX: Good sleep hygiene behaviors Maintain stable bed times and rising times Allow adequate time for sleep (7 h to 8 h for adults) Try not to force sleep and avoid clock watching Maintain a quiet, dark bedroom Remove potential disruptors of sleep (tv, phone) Avoid sleep-fragmenting substances near bedtime (caffeine, nicotine, alcohol) Maintain regular exercise but avoid heavy exercise within several hours of bedtime Attempt to resolve stressful situations and maintain a 30-minute relaxation period before bedtime Avoid daytime naps
- Things to Consider when Prescribing Drugs to Treat Insomnia Use the minimal effective dose. Avoid long half-life medications, including long half-life metabolites. Be aware of potential interactions between drugs, including over-the-counter drugs. Caution patients on these medications about interaction with alcohol. Review potential side effects—in particular, daytime sleepiness. Confer with the patient to determine an appropriate period of use. Use a GABA agonist over other sedative-hypnotics for treatment of acute or short-term insomnia. Look for rebound insomnia after discontinuation. Consider intermittent or long-term use of hypnotic medications, depending on the clinical situation. Consider consultation with a sleep specialist before starting long-term therapy with hypnotic medication.
- What is the appropriate duration of prescription drug therapy for insomnia? There is limited data regarding long-term use of prescription drug therapy for insomnia, with most studies evaluating the effectiveness of treatment for less than 12 weeks (Krystal, 2009). Therefore, it has been generally recommended to limit continuous drug therapy to 1 month to avoid the risk of tolerance (defined as the loss of effectiveness over time), dependence, or withdrawl upon discontinuation. This recommendation has been tempered by more recent evidence from longer term studies using nonbenzodiazepine medications that did not show evidence of tolerance or withdrawal when used continuously for up to 1 year (Roth, 2005; Walsh, 2007). Additionally, many individuals take medication for insomnia on an as-needed basis instead of continuously, and studies of this dosing pattern extending to 6 months have shown symptomatic benefit without apparent adverse effects (Perlis, 2004; Krystal, 2008). Without available evidence to guide the optimal use of medications for insomnia, a prudent approach is to establish an effective medication regimen for a specific patient, and then tailor the dosing pattern and duration of treatment to that person’s needs while attempting to avoid prolonged or excessive therapy. This should include discussion of risks and benefits of drug therapy with the patient and an individual determination of whether they would benefit from as-needed or continuous dosing. Candidates for as-needed use may be those with only intermittent insomnia who are able to assess when drug treatment would be helpful. In those initially treated with continuous therapy, periodic tapering and discontinuation trials are useful in determining whether longer term therapy is needed.
- What are the contraindications to drug therapy in the treatment of patients with insomnia? Patients with insomnia considering over-the-counter medications should be cautioned regarding side effects and potential interactions with other drugs. Because of the anticholinergic effects associated with sedating antihistamines, they are generally not recommended for patients with cardiopulmonary disease, glaucoma, or problems with urination. Patients considering use of complementary and alternative medications should be advised to discuss their intended use with their physician before doing so to assess for possible interactions with other medications. Caution should be exercised and possible harms weighed against potential benefits when considering pharmacologic treatment in older patients as most of these centrally-acting agents have been shown to significantly increase the risk of cognitive and psychomotor adverse events in this population. Some sedative-hypnotic medications have been associated with anterograde amnesia, complex sleep-related behaviors (such as somnambulation and performing other activities such as driving) while not fully awake, and aggressive behavior. There is also some risk for rebound insomnia, particularly when using short-acting agents or treating continuously for longer periods of time. All patients taking sedating antihistamines or any sedative-hypnotic agents should restrict alcohol intake, or avoid alcohol all together. These agents should also be avoided or used with caution in patients taking other sedating medications. Additionally, all patients taking these drugs should be advised to use particular care when driving or using hazardous equipment. Patients who are pregnant or breastfeeding should avoid sedative-hypnotics. These medications should also not be used in patients with specific underlying medical disorders (such as OSAS) in which sedation might be detrimental. Benzodiazepines, and likely to a lesser extent nonbenzodiazepine medications, have potential for abuse and should not be used by patients with a current alcohol or drug abuse problem or by patients in recovery. Although intentional or accidental overdose of benzodiazepines or nonbenzodiazepine agents alone rarely results in death or serious illness, they are frequently taken with either alcohol or other medications, which can be dangerous.
- When should clinicians consider specialty referral for patients with insomnia? Clinicians should consider referring patients with insomnia to a sleep specialist if there is suspicion of an underlying sleep disorder, such as OSAS, RLS, periodic limb movement disorder, narcolepsy, or circadian rhythm disturbance. Referral is also appropriate for patients with insomnia who fail to respond to available behavioral interventions or drug therapy. Referral to a sleep specialist offers an opportunity for reassessment of insomnia symptoms, possible additional testing to better characterize the sleep disturbance, and implementation of more comprehensive CBT interventions for insomnia. Referral to a psychiatrist for diagnostic evaluation can be helpful when it is unclear whether a concurrent psychiatric disorder, such as depression, is present. Referral to other specialists may be helpful depending on the nature of associated comorbidities. A pulmonologist consultation is appropriate for patients with suspected sleep disordered breathing in whom polysomography and other testing may be appropriate. An otolaryngologist, oral surgeon, or dentist may help in evaluating patients with excessive snoring or other oropharyngeal or airway issues that might disturb sleep. A neurologist may be considered for management of sleep disorders associated with neurologic diseases, such as Parkinson disease, cerebrovascular disease, or dementia.