Drugs To Treat Insomnia Flashcards
Before prescribing sleeping pills…
1) Cognitive behavioral therapy and sleep hygiene
2) Work-up for underlying cause
3) Sedative-Hypnotic options
Potential underlying causes of insomnia:
Substance use disorder
Psychiatric illness (mood or anxiety disorders)
Medial illness
Restless leg syndrome
Sedative-Hypnotic Options
Benzodiazepines Non-benzodiazepine agonists Melatonin receptor agonists Anti-histamines Herbal preparations that affect GABA transmission
Will sleeping pills cure insomnia?
Can behavioral/psychological technqiues cure insomnia?
NO!
Sometimes
FDA approved benzodiazepines for insomnia Rx
Estazolam Temazepam Quazepam Flurazepam Triazelam Lorazepam
Which FDA approved benzo is used most often to treat insomnia?
Temazepam
How long can benzos be used to treat insomnia?
How many days in a week can a pt use sleeping pills for insomnia?
Short term (1-3 months) No more than 3 days/week
Which drugs should be used to treat insomnia in elderly pt?
LOT!
Lorazepam
Oxazepam
Temazepam
Problems with benzos
Rebound insombia Psychological dependence Tolerance Physiological dependence Risk of withdrawal Substance abuse disorder
Which patients are at the high risk of substance abuse with benzos?
Pts with other substance issues
Signs of substance abuse:
Running out of meds early, wanting a higher dose, losing meds, going to multiple doctors for prescriptions (IL PMP)
Non-benzodiazepines agonists approved for sleep disorders
Imidazopyridine: Zolpidem, Zaleplon Pyrrolopyrazine: Eszopiclone "Z meds to get more zzz's"
Side effects of Non-benzo agonists
sleep walking, sleep driving, sleep eating
Relative costs of the non-benzo agonists vs. benzos
Benzos are the LEAST expensive
Zolpidem and Zaleplon are more expensive but no unreasonable
Eszopiclone is expensive
Ramelteon
M1 & M2 melatonin receptor agonist
Down side of Ramelteon
COST- typically requires prior approval by insurance company, or trying less expensive drugs first
Sedating drugs with anti-histamineric actions: Tricyclic antidepressants
Amitriptyline
Doxepin
Imipramine
Sedating drugs with anti-histamineric actions: Mixed action antidepressants
Mirtazapine
Trazadone
Benefit of using antidepressants to treat insomnia
Also treat depression and anxiety, which may be the underlying cause of patient’s insomnia
Sedating drugs with anti-histamineric actions: H1 histamine receptor antagonists
Cyclobenzapine
Dihenhydramine
Hydroxyzine
Of the antihistamines, which is preferred for use in the elderly?
Hydroxyzine (NOT muscarinic)
Herbal Insomnia Rx: Valeriana officinalis
sesquiterpene: mediate GABA release and inhibit GABA breakdown No morning after hangover No aversive effects No serious drug interactions Useful for 4 weeks
Herbal Insomnia Rx: Chamomile
Apigenin: benzo agonist
relaxing
Herbal Insomnia Rx: Kava
Contains compounds that facilitate binding of GABA
Reported calming effects
Herbal Insomnia Rx: Passion Flower
Chrysin: a benzo partial agonist
Reported to be safe and effective (unsubstantiated)
Over the counter meds (no longer available)
Compoz (pyrilamine +methapyrilene)
Nytol (methapyrilene + salicylamide)
Sominex (methapyrilene + salicylamide + scopalamine)
Sleep-Eze (methapyrilene + scopalamine)
Produce tolerance and rebound insomnia, NOT more effective than placebo
Currently available OTC sleep aids
Unisom (doxylamine)
ZzzQuil (diphenhydramine)
*both antihistamines
Buspirone site of action
5HT-1A partial agonist
Buspirone t1/2
short (2.5 hours)
Buspirone Side Effects
Headaches, dizziness, nervousness, sedation, nausea
Buspirone DDI
DO NOT use with MAOI
Buspirone Clinical Consideration
Generalized Anxiety Disorder
C antidepressants for major depression
C antidepressants for anxiety disorders
Advantage of Buspirone vs. benzos
No risk of dependence, no withdrawal, no GABA cross tolerance
Advantage of Buspirone vs. anti-depressants
Low/no sexual side effects, weight neutral, no withdrawal
Disadvantages of Buspirone
Effectiveness?
