Wk 31 - Insomnia in practice Flashcards
What is insomnia?
Unsatisfactory sleep:
- Sleep onset insomnia (youngers)
- Frequent nocturnal awakening (older)
- Early waking
- Poor daytime functioning w/ affected mood
What is chronic insomnia?
3 months of persistent sleep
What are detrimental effects of insomnia?
- Depression risk
- Dec QoL
- Dec productivity
- Impaired function
- Hypertension risk
- Diabetes risk
When should patients be referred?
- Obs sleep apnoea
- Restless leg syndrome
- Parasomnias
- Circadian rhythm sleep disorder
Outline the NICE guidelines of short-term insomnia (<3 months)
- Manage identifiable causes - sleep hygiene
- Hypnotic considered if daytime impairment severe
- Lowest dose for shortest duration (2wks)
- Symptoms persist refer to CBT
- Short acting benz or z-drugs
- Diazepam, nitrazepam + flurazepam not recommended: long HL = next day residual effect + repeated doses = cumulative
Outline the NICE guidelines of long-term insomnia (>3 months)
- Manage identifiable causes - sleep hygiene
- Refer to psychological services for CBT
- Pharmacological therapy = not recommended for LT management bc tolerance to hypnotics progressively red effectiveness
- Severe symptoms/acute exacerbation of persistent insomnia: short course (2 wks) for immediate relief
- Over 55 w/ persistent insomnia: modified release melatonin
- Sleep clinic if insomnia persists despite primary care
What is the first line of treatment regarding non-drug treatment?
- CBT
- Good sleep hygiene
- Establish fixed times for going to bed + waking
- Relax before bed
- Maintain comfortable sleeping environment
- Avoid napping
- Avoid caffeine, alcohol + nicotine w/in 6hrs of bed
- Avoid heavy meal late at night
- Avoid exercise w/in 4hrs of bedtime
What are important pharmacokinetic properties needed for a hypnotic drug?
- Faster drug enters brain the sooner sleep is induced
- Duration of action: Z-drugs shorter HL w/ minimal hangover effect, zolpidem = too short
- Sleep-onset insomnia: zolpidem + melatonin
- Waking through night: zopiclone
Which NT do benzodiazepines, zolpidem + eszopiclone act on?
- Benzo act on alpha 1, 2, 3 + 5
- Zolpidem acts on alpha-1
- Eszopiclone targets alpha-3
Which drugs decrease noradrenaline, serotonin, orexin + dopamine to promote sleep?
- Antihistamines cross BBB: diphenhydramine
- Orexin: antagonist of OR1 + OR2 promotes sleep
What are the NICE guidelines when choosing hypnotics?
- Prescribe cheapest drug, taking into account daily dose required
- Treatment changed if s/e occurs
- If treatment doesn’t work, doctors should not prescribe others
Give examples of short-acting benzodiazepines
- Temazepam
- Loprazolam
- Lormetazepam
- Lorazepam
Give examples of long-acting benzodiazepines
- Nitrazepam
- Flurazepam
- Diazepam
What are some adverse reactions of benzodiazepines?
- Tolerance + dependence
- Depression
- Emotional blunting
- Fall + fracture risk
- Aggression
What are the key interactions of benzodiazepines?
- Alcohol/opiates: lethal sedation
- Neuroleptics, antipsychotics + barbiturates: CNS depression
- Antihypertensives, vasodilators + diuretics: enhanced hypo effect
- CYP450 inhibitors: inc benso effect
- CYP450 inducer: dec benzo effect
- Phenytoin: altered phenytoin
