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
When should zaleplon be used?
Difficulty sleeping, max 2 weeks
When should zolpidem be used?
Debilitating/causing distress, max 4 weeks
When should zopiclone be used?
Debilitating/causing distress, max 2-3 weeks
What are some adverse reactions of Z-drugs?
- GI disturbances
- Risk fall
- Dry mouth
- Confusion, hallucination
What are the key interactions of Z-drugs?
- Alcohol/opiates: lethal sedation
- Neuroleptics, antipsychotics + barbiturates: CNS depression
- CYP450 inhibitors: enhance Z-drug effect
- CYP450 inducer: accelerate hepatic elimination of Z-drugs
- Phenytoin: altered phenytoin
What is melatonin?
- Pineal hormone which regulate circadian rhythm
- Dec w/ age
- For ST treatment in over 55
- Dose: 2mg OD, 1-2 hrs before bed upto 13 wks (initial = 3wks)
What are the adverse effects of melatonin?
- Headache, nausea, fall risk
- Avoid alcohol: CNS depressant + less effective
- Affect ability to drive
What are the off-license uses for melatonin?
- Sleep disruption in children
- Other disorders associated w/ sleep disruption
What should be used if co-existent mood disorder occurs alongside insomnia?
Sedating antidepressants
- Amitriptyline (10-25mg at night)
- Acts on: histamine H1 receptor antagonist, 5-HT2 + cholinergic muscarinic antagonism
Outline the symptoms of withdrawal
- Anxiety
- Insomnia
- Dizziness
- Abnormal perceptions
- Tremor
- Sweats
Outline the dose tapering of benzodiazepines
- 5-10% red every 1-2 wks, or 8th of dose fortnightly, w/ slower red at lower dose
- Sub w/ diazepam or lorazepam w/drawals
When is switching to diazepam recomended?
- Short acting potent benz (alprazolam + lorazepam)
- Prep that don’t allow for small red in dose (alprazolam, lorazepam + flurazepam)
- Difficulty w/drawing from temazepam, nitrazepam or Z drugs due to high dependency
Give examples of advice you can give patients with insomnia
- Sleep hygiene
- Do not drive if sleepy
- Duration of treatment
- Alcohol + illicit drugs
Temazepam 10mg to diazepam 5mg
Wk 1: tem 10mg -> diaz 5mg
Temazepam 20mg to diazepam 10mg
- Wk 1: tem 20mg -> 10mg + diaz 5mg
- Wk 2: tem 10 -> diaz 5mg
Nitrazepam 5mg to diazepam 5mg
Wk 1: nit 5mg -> diaz 5mg
Nitrazepam 10mg to diazepam 10mg
- Wk 1: nit 10 -> 5mg + diaz 5mg
- Wk 2: nit 5mg -> diaz 5mg
Zopiclone 7.5mg to diazepam 5mg
Wk 1: zop 7.5mg -> diaz 5mg
Zopiclone 15mg to diazepam 10mg
- Wk 1: zop 15 -> 7.5mg + diaz 5mg
- Wk 2: zop 7.5mg -> diaz 5mg
