Medications for Insomnia Risks and Benefits

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steve on Oct 13, 2011 Says :

nice presentation which covers all the aspects of insomnia

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Show Notes

Slide 1 :

Medications for Insomnia: A Story of Risks and Benefits Sarah M. Richey, MD September 3rd, 2008

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Objectives Be able to define insomnia Describe why a doctor would recommend treatment for insomnia Identify the two types of treatment for insomnia Understand what a risk/benefit analysis is and how physicians use it when prescribing meds for insomnia

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What is insomnia? Persistent difficulty initiating or maintaining sleep Do not wake feeling refreshed Decline in social or occupational functioning

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Prevalence 10-20% of the general population 50% of those seen in primary care clinics Most common sleep disorder

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Insomnia’s Effects Daytime sleepiness Fatigue Cognitive impairment Decline in work performance Work days missed Depression and Anxiety

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The Risk/Benefit Analysis Doctors make most of their medical treatment decisions based on this principle Risks of not treating the patient are weighed against the expected benefits and risks of each treatment

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The Balancing Act It is only because there is some loss of function or quality of life that there is something to be gained by starting therapy that will have costs and risks. Those with greater impairment will stand to gain greater benefit from treatment.

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What does the evidence say? The choice of treatment is guided by which treatment is associated with the greatest ratio of benefits to cost/risks. Doctors get this information from well-designed research studies that included subjects similar to their patient

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Insomnia Therapies Pharmacologic Non-pharmacologic Both have strong evidence to support their use

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The Non-pharmacologic Approach Cognitive Behavioral Therapy for Insomnia (CBTi) Stimulus control therapy Sleep restriction therapy Relaxation training Cognitive therapy Sleep hygiene education

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The Pluses of CBTi Benefits are long-lasting, even after therapy is over Relatively free of medical risks No significant interactions with other medical treatments

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And the minuses… Monetary cost (repeated visits to a provider) Improvement may not occur for several weeks Requires time and motivation Daytime sleepiness during sleep restriction Lack of access to a trained therapist Lack of therapist expertise

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Combined Treatment CBTi can be used along with medications. For example, medications can provide rapid relief and CBTi can lead to long-lasting results.

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Pharmacologic Therapies Benzodiazepines Non-benzodiazepine hypnotics Melatonin receptor agonists Antidepressants Antipsychotics Antihistamines

Slide 17 :

Benzodiazepines Many end in “pam” or “lam” clonazepam (Klonopin) lorazepam (Ativan) diazepam (Valium) alprazolam (Xanax) temazepam (Restoril) triazolam (Halcion)

Slide 18 :

GABA receptor

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The Good Side of Benzos Enhance sleep Decrease anxiety Muscle relaxant

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The Bad Side of Benzos Daytime sedation Decreased reaction time Unsteadiness of gait—can lead to falls Cognitive impairment & memory problems Risk of tolerance Risk of withdrawal (and rebound insomnia) Risk of abuse

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Non-benzodiazepine hypnotics Examples: zolpidem (Ambien) zolpidem ER (Ambien CR) zaleplon (Sonata) eszopiclone (Lunesta)

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The Pluses Bind to sub-types of GABA receptors that specifically modulate sleep and therefore are thought to have less unwanted side effects Tolerance and abuse have not been shown to be a major problem in the general population In general have shorter duration of action than most benzos and therefore are less likely to cause next day sedation

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The Minuses But drowsiness, dizziness, unsteadiness of gait, rebound insomnia and memory impairment have been reported.

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FDA Indications Sleep onset only: zolpidem and zaleplon Sleep onset and sleep maintenance: zolpidem ER and eszopiclone

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Ramelteon Brand name is Rozerem Selective agonist at MT1 and MT2 melatonin receptors FDA approved for sleep-onset insomnia Only medication FDA approved for insomnia that is not a controlled substance because it does not seem to lead to abuse or withdrawal Associated with headache, dizziness, drowsiness, fatigue and nausea

Slide 26 :

Antidepressants Commonly used for insomnia but are not FDA approved trazodone doxepin amitriptyline mirtazapine

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Trazodone Used at much lower doses for insomnia than depression The most commonly prescribed agent for treating insomnia across all classes of medications No good research to support its use Major side effects: sedation, dizziness, dry mouth, orthostatic hypotension, priapism (rare)

Slide 28 :

The Tricyclics amitriptyline (Elavil) doxepin (Sinequan) Side effects: dry mouth, urinary retention, dizziness, daytime sedation Used at much lower doses for insomnia than depression

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Mirtazapine Brand name: Remeron Associated with weight gain, increased appetite, daytime sedation and dizziness

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Antipsychotics Called the “atypical antipsychotics” Block dopamine from binding to receptors in the brain Examples: risperidone (Risperdal) olanzapine (Zyprexa) quetiapine (Seroquel) ziprasidone (Geodon)

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Antipsychotics Not FDA approved for insomnia Typically used at doses much lower than those for treating psychosis Quite sedating but also associated with weight gain, increased risk for diabetes, high blood pressure, restless leg syndrome, muscle spasm or parkinson-like symptoms Quetiapine and ziprasidone have been shown to increase total sleep time as well as sleep efficiency

Slide 32 :

Antihistamines Diphenhydramine (Benadryl, Tylenol PM) and Doxylamine (Unisom), hydroxyzine (Vistaril) Little evidence to support their use Side effects: dry mouth, urinary retention, blurred vision, dizziness, sedation

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Caution with the “PM” meds! They all have more than one medication in them. Taking too much Tylenol is dangerous! May interact with other medications patients are taking, and doctors may not think to ask if their patients are taking them. Patients should always tell their doctors they are taking these meds.

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Another Caution: Mixing Pills Heath Ledger had insomnia and passed away from an accidental overdose of the following medications: oxycodone hydrocodone diazepam temazepam alprazolam doxylamine

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Take Home Points Insomnia is defined by having daytime symptoms. There are two pathways for treating insomnia: medications and CBTi. They can be used at the same time. All treatments have their pluses and their minuses. Doctors look at the patient’s impairment and weigh that against the risk of treatment.

Slide 36 :

Take Home Points Many of the most common drugs for insomnia are not FDA approved for that purpose. No drug for insomnia is completely safe or free of the risk of side effects. Be sure to inform your doctor of all medications you are taking, including over-the-counter and herbal ones.

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References Cohrs S, Rodenbeck A, Guan Z et al. Sleep promoting properties of quetiapine in healthy subjects. Psychopharmacology 2004; 174(3):421-9. DeMartinis NA, Winokur A. Effects of psychiatric medications on sleep and sleep disorders. CNS Neurol Disord Drug Targets 2007;6(1): 17-29. Edinger JD, Bonnet MH, Bootzin RR et al. Derivation of research diagnostic criteria for insomnia: report of an American Academy of Sleep Medicine Work Group. Sleep 2004; 27(8): 1567-96. Markowitz JS, Brown CS, Moore TR. Atypical antipsychotics. Part I: Pharmacology, pharmacokinetics, and efficacy. Ann Pharmacother 1999;33(1):73-85. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep-onset and sleep-maintenance insomnia. Pharmacotherapy 2007;27(1):89-110. Morin CM, Culbert JP, Schwartz SM. Nonpharmacological interventions for insomnia: a meta-analysis of treatment efficacy. Am J Pyschiatry 1994; 151:1172-80. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep 2005; 28(9): 1049-57. Ohayon MM, Roth T. What are the contributing factors for insomnia in the general population? J Psychosom Res 2001; 51:745-55. Rickels K, Morris RJ, Newman H et al. Diphenhydramine in insomniac family practice patients: a double-blind study. J Clin Pharmacother 1983; 23(5-6):234-42. Simon GE, VonKorff M. Prevalence, burden, and treatment of insomnia in primary care. Am J Psychiatry 1997;154:1417-23.

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