Insomnia & Drowsiness: Drugs Only

Question 1

Insomnia: Exclusions for Self-Treatment

Answer 1

• <12 years of age
• ≥65 years of age
• Pregnancy or breastfeeding
• Frequent nocturnal awakenings or early morning awakenings
• Chronic insomnia (>3 months)
• Sleep disturbance secondary to psychiatric or medical disorders

Question 2

Non-pharmacologic Therapy

Answer 2

• Cognitive behavioral therapy for insomnia (CBTI)
- Addresses dysfunctional behaviors and beliefs that
contribute to insomnia
- 1st line therapy for ALL patients
• Good sleep hygiene - for ALL patients

Question 3

Pharmacologic Therapy

Answer 3

• Antihistamines (block H1 and muscarinic receptors)
- Diphenhydramine - only recommend this for sleep
- Doxylamine - value not established for sleep
• Ethanol

Question 4

Diphenhydramine: Onset, Max

Answer 4

• Rapid onset (1-4 hrs); T1/2: 2.4-9.3 hrs (max sedation after 3-6 hrs)
• Metabolized in liver (delayed half-life in liver dysfunction)
• For transient and short-term use, particularly with occasional problems falling asleep
• Combo products w/ APAP, aspirin, or ibuprofen but no evidence that helps insomnia d/t pain

Question 5

Diphenhydramine: Dosing

Answer 5

• Capsules, gelcaps, tablets, chewable tablets, solutions, and elixirs
• Dose: 25-50 mg HS
• Pregnancy → refer to provider
• Nursing moms: not recommended (may slow milk production and harm baby)

Question 6

Diphenhydramine: Adverse Effects

Answer 6

• Sedation/hangover effect
• Anticholinergic symptoms/toxicity
• Dry mouth, constipation, blurred vision, urinary retention, tinnitus
• Inability to concentrate, cognitive impairment
• Tachycardia/QT prolongation
• Paradoxical CNS stimulation (excitation in children and elderly)

Question 7

Diphenhydramine: Contraindications

Answer 7

• Men with BPH and difficulty urinating
• Angle-closure glaucoma
• Angina or arrhythmias
• Dementia
• Children <6 years old OR with family hx of SIDS or sleep apnea

Question 8

Diphenhydramine: Interactions

Answer 8

• ↓ clearance of metoprolol especially in women
• May enhance CNS depression of alcohol and opioids
• May enhance adverse effects of glucagon
• Avoid with solid potassium supplements (may cause ulceration)
• Avoid driving, cooking, and operating machinery until response is known

Question 9

Patient Education for Diphenhydramine

Answer 9

• Take diphenhydramine 30-60 min before sleep
• Do not take more than 50 mg/night
• After 3 consecutive nights, skip for 1 night to see if relieved
• Don’t use longer than 10 days
• Do not take with alcohol
• Do not take with prescription sleep aids
• Caution with children/teens in home

Question 10

Drowsiness & Hyperinsomnia: Exclusions for Self-Treatment

Answer 10

• <12 years of age
• Pregnancy and breast-feeding
• Heart disease
• Anxiety disorders
• Medication-induced drowsiness (refer to provider to adjust medication dose)
• Chronic fatigue (refer to provider to rule out hypothyroidism, sleep apnea, other medical conditions)

Question 11

Caffeine

Answer 11

• FDA-approved non-rx stimulant
• For occasional use for mental alertness or wakefulness
• Dose: 100-200 mg PO q3-4h PRN
• Peak concentration within 30-75 min, half-life of 3-6 hours
• Primary metabolite can accumulate causing decreased clearance
• Rapid tolerance is common
• Withdrawal with abrupt discontinuation of as little as 1-2 cups of coffee on routine basis
• HA, fatigue, decreased concentration, irritability within 12-24 hours after cessation persisting for 1-5 days

Question 12

Caffeine-containing Products

Answer 12

• Nonprescription caffeine-only

• NoDoz Maximum Strength® (200 mg)
• Vivarin® (200 mg)

• Nonprescription combination

• Excedrin Migraine® caplets (65 mg)
• Midol Complete® caplets (60 mg)

Caffeine powder NOT recommended

Question 13

Caffeine: Adverse Effects

Answer 13

• CNS stimulation
- Insomnia, nervousness, restlessness, tinnitus, tremor, headache, irritability, anxiety, depression (more pronounced in children/elderly)
• GI irritation (N/V/D, stomach pain)
• Cardiovascular (tachycardia, arrhythmias, increases in BP/HR)
• Renal (diuresis)
• Increased effects in caffeine-naive, elderly, females, non-smokers, anxiety/panic attack)

Question 14

Caffeine: Drug Interactions

Answer 14

• Exaggerated effect with other caffeine-containing meds
• Increases absorption of aspirin
• May reduce clearance of theophylline (increased HR)
• Blocks clozapine at high caffeine doses
• Cigarette smoking increases caffeine clearance
• If trying to quit smoking, decrease caffeine 50%
• Hormonal contraceptives and ciprofloxacin inhibit caffeine absorption
• If on MAO-Is or with existing heart disease, uncontrolled HTN, or pre-existing arrhythmias
- Avoid nonrx caffeine preparations and moderate intake of dietary caffeine (increases BP)