insomnia in practice Flashcards
what is incomnia?
nsomnia is typically characterised by
unsatisfactory sleep
how is insomnia characterised?
•Sleep-onset insomnia (more common in younger pts) •Frequent nocturnal awakening (more common in older pts) •Early waking And poor daytime functioning with affected mood.
what are some of the detrimental effects of insomnia?
decrease in QOL depression risk diabetes risk HPT risk impaired function dec in productivity absenteeism accidents
how would you assess insomnia?
Patient questioning –Sleep habits? –Sleep scheduling? –Intake of substances that can disturb sleep?
how would you manage short-term insomnia? ie less than 3 months
•Manage any identifiable causes where possible, sleep
hygiene
•Hypnotic considered if daytime impairment severe
•Lowest dose for shortest duration (not more than 2
weeks)
•If symptoms persist, refer for CBT
•Short acting benzodiazepine or Z drug
why are diazepam, nitrazepam and flurazepam not recommended for short term treatment of insomnia?
because their long half-life commonly gives
rise to next-day residual effects, and repeated doses tend
to be cumulative.
how do you treat long-term insomnia?
•Manage any underlying cause where possible; sleep hygiene
•Refer to psychological services (IAPT) for a cognitive or
behavioural treatment
when is pharmacological treatment recommended for long term patients with insomnia?
–For people with severe symptoms or an acute exacerbation of persistent insomnia a short course (2 weeks, occasionally 4) of a hypnotic drug may be considered for immediate relief of
symptoms
–For people over 55years of age with persistent insomnia, consider treatment with a modified-release melatonin.
–Sleep clinics if insomnia persists despite primary care management
what would be non-drug treatment for insomnia?
Cognitive Behavioural Therapy (CBT) – BAP 1st line
Good “sleep hygiene”
why is pharmacokinetics important in insomnia?
•The faster a drug enters the brain the sooner sleep is induced –Risk if too quickly? •Duration of action? –Linked to ease of waking –Hangover effects
what is the rationale for the use of z drugs?
shorter half life with minimal hangover effect
how would bioavailability influence the choice of drug?
–Formulation e.g. temazepam tablets have a poorer
bioavailability and slower absorption and a longer
presence in the body than previous gel formulations.
what are the individual factors to consider when treating insomnia?
–Hangover effects vary significantly between patients
–Sleep onset insomnia shorter acting drug may be best
e.g. zolpidem, melatonin
–Waking through the night- slightly longer duration of
action e.g. zopiclone
what do the traditional benzodiazepine drugs for insomnia act on?
he alpha-1, 2,3 and 5 subtypes •Zolpidem targets alpha-1 subtype preferentially •Eszopiclone targets alpha-3 subtype preferentially
what do benzos and z drugs enhance the effects of?
enhance the effects of
GABA at the GABAA receptor.
what antihistamine that crosses the BBB is used to promote sleep OTC?
diphenhydramine
what do orexins do?
antagonists of OR1 and OR2
(Newer agents) promote sleep e.g.
Suvorexant (not available in Europe)
when is hypotnotics most beneficial?
High quality evidence for efficacy of hypnotics in
short-term insomnia (≤4 wks) - but consider
adverse effects
why is long term pharmacological treatment not recommened?
–Side effects/risks
–Conflicting evidence of effectiveness
–Intermittent dosing?
how do NICE recommend that hypnotics should be prescribed?
prescribe the cheapest drug, taking into
account the daily dose required and the cost for
each dose.
when should hypnotics be changed?
–Treatment should only be changed from one of these
hypnotics to another if side effects occur that are
directly related to the medicine.
what if treatment of hypnotics does not work?
If treatment with one of these hypnotic medicines
does not work, the doctor should not prescribe one
of the others.
when should benzodiazepines be given?
consider a short course of a hypnotic drug only if daytime
impairment is severe.
•If no response to a hypnotic do not prescribe another.
what is a short-/long acting benzo?
Short-acting
•Temazepam, loprazolam, lormetazepam, lorazepam
Long acting
•Nitrazepam, flurazepam, diazepam
what are some of the ADRs with benzos?
tolerance and dependence, cognitive and psychomotor impairment, depression, emotional blunting, paradoxical anxiety, aggression, hyperactivity, fall risk, inc risk of road accidents
what are the key interactions that benzodiazepines have?
alcohol/opiates- lethal sedation centrally acting drugs- cns depression antihpt, vasodilatiors and diuretics- hypotensive effect CYP450 inhibitors- inc benzo effects CYP450 inducers- decrease benzo effects phenytoin- alt phenytoin levels
what do the different z drugs treat?
Zaleplon 1 hour Difficulty getting to sleep. Max 2 weeks
Zolpidem 2.5 hours Debilitating or causing distress. Max. 4
weeks
Zopiclone 3.5-6.5 hours Debilitating or causing distress. Max. 2-3
weeks
what are the ADRs of z-zdrugs?
GI disturbances, paradoxical effects, dizziness, drowsiness, dry mouth, confusion, hallucinations, nightmares, perceptual disturbances
what are the key interactions with Z drugs?
alcohol and opioids- can induce lethal sedation
Centrally acting drugs- CNS depression
CYP450 inhibitors- enhance z drugs effects
inducers- can accelerate hepatic elimiation of Z drugs
phenytoin- alt levels of phenytoin
what is melatonin?
•Pineal hormone involved in the regulation of circadian rhythm. •Production of melatonin declines with age; levels lower in middle-aged/elderly people who have insomnia.
what has prolonged release melatonin shown to improve?
shown to improve sleep onset
latency and quality in patients over 55 yrs.
who is melatonin licensed for? what is the dose?
Licensed for short-term treatment of insomnia in adults over 55
years.
•Dose: 2mg once daily, taken 1-2 hours before bedtime for up to
13 weeks (recommended initial duration is 3 wks).
what are the adverse effects of melatonin?
headache, dizziness, nausea, drowsiness,
falls risk.
what should you avoid on melatonin?
Avoid alcohol- less effective, plus additional CNS depressant
effects
what are some other drugs used for insomnia?
edating antidepressants (not generally recommended):
–If co-existent mood disorder, might consider use of
antidepressants
–Not generally recommended but low doses (sub-therapeutic
for depression) of sedating tricyclics, particularly amitriptyline
(10-25mg at night) are commonly used in UK for long periods
how should you discontinue treatment?
Discontinuation of hypnotics should be based on slowly
tapering down medication.
•CBT during taper can improve outcome
what are the usual effects during the withdrawl periods ?
Temporary worsening of sleep, usually taking longer to fall
asleep is reported during the withdrawal period for most
GABAergic agents
what are the symptoms of withdrawl?
•Anxiety/agitation (most common) •Insomnia •Dizziness •Headache •Abnormalities of perception •Tremor, sweating, tinnitus, nausea, vomiting •Occasionally, psychosis or convulsions
how long does it take to withdraw?
Gradually withdraw over 4-8 weeks after long term use, can take up to 1 year
how should you taper the dose?
–such as 5–10% reduction every 1–2 weeks, or an eighth of the dose fortnightly, with a slower reduction at lower doses, and titrated according to the severity of withdrawal
symptoms.
who is switchig to diazepam recommended for?
•Short-acting potent benzodiazepines (alprazolam and lorazepam).
•Preparations that do not easily allow for small reductions in dose (alprazolam, flurazepam, loprazolam and lormetazepam).
•Temazepam or nitrazepam who choose to withdraw from diazepam after discussing the advantages and disadvantages.
•Difficulty withdrawing directly from temazepam, nitrazepam, or z-drugs, due to a high degree of dependency (associated with long
duration of treatment, high doses, and a history of anxiety
problems).
is exact sub dose possible for diazepam?
Exact dose substitution is not possible
Switching to diazepam is best carried out gradually, usually in a stepwise fashion.
–Consider making the first switch in the night-time dose to avoid daytime sedation.
what is some additional patient advice to give to the patient?
•Sleep hygiene
•Hypnotics: Advise the person not to drive if they
feel sleepy (although it is not necessary to inform
the Driver and Vehicle Licensing Agency [DVLA]
unless a primary sleep disorder is confirmed).
•Driving on Benzodiazepines and UK Law
•Duration of treatment! Tolerance and
dependence
•Alcohol and illicit drugs
