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How to address insomnia.

Of all the sleep disorders encountered by pharmacists, the most common is insomnia.

Insomnia is the inability to obtain sleep of sufficient quality or quantity to feel refreshed the next morning. Insomnia may be manifested as difficulty in initiating sleep or maintaining sleep--for example, awakening during the night or too early in the morning. Insomnia is usually classified as short-term, lasting for one to three weeks, or chronic, lasting longer than three weeks.

Up to 40% Americans rely on over-the-counter products or alcohol to help them sleep. Nearly $1 billion is spent annually on medications to improve sleep. Given that pharmacists are widely accessible health professionals and the high frequency of insomnia, it's not surprising that patients seek pharmacists' advice on the condition.

Whenever patients inquire about sleep aids, it is helpful for the pharmacist to conduct a brief medical and medication history to identify potential secondary causes of insomnia. These include depression, bipolar disorder, anxiety, undertreated pain, asthma, COPD, congestive heart failure, thyroid disease, gastroesophageal reflux disease, drug withdrawal, obstructive sleep apnea, neurological diseases and drug- or substance-induced causes.

If the pharmacist suspects that an underlying medical condition or medication is causing the insomnia, the patient should be referred back to his or her primary care provider or prescribing physician.

Critical to the evaluation of the patient with insomnia is the contribution of psychosocial factors, including marital, family or other relationship stress; job-related or financial stress; personal conflicts; and bereavement.

Pharmacists should also counsel patients on proper sleep hygiene. Patients should be advised to establish a routine time for bedtime and awakening; avoid daytime naps; avoid using alcohol, caffeine, nicotine and medications that disturb sleep, especially just before bedtime; keep ambient lighting at low levels at least one hour prior to bedtime; exercise regularly, but not prior to bedtime; mask noises with soft earplugs if necessary; use the bedroom only for sleeping, light reading or sexual activity; avoid engaging in stressful activities or unpleasant tasks near bedtime; and limit fluid and meal intake immediately before bedtime.

If those nonpharmacological measures have been implemented and the patient does not have underlying secondary causes for insomnia that can easily be addressed, then it may be appropriate for pharmacists to recommend an over-the-counter agent as an adjunct to good sleep hygiene.

Such antihistamines as diphenhydramine and doxylamine can be recommended for most patients for short-term use but should be used with caution in the elderly and avoided in patients with contraindications.

Such herbal preparations as valerian and chamomile and dietary supplements, including melatonin, are also marketed for insomnia. However, these products do not have large clinical trials to support claims of clinical efficacy in all patients with insomnia. Chamomile should be avoided in individuals with an allergy to ragweed, since cross-allergenicity has been reported.

As with most dietary supplements, patients should discuss these products with their primary medical provider and limit use to brief periods of time. Pharmacists should discourage the use of supplements that do not list the exact amount contained in each dosage unit.

Numerous prescription products are available to treat insomnia. Such benzodiazepines as temazepam have been widely used for years to treat insomnia. While this may be appropriate for short-term treatment, long-term administration can be complicated by adverse reactions, including euphoria, which can lead to abuse and longterm dependence. Benzodiazepines also may cause dizziness, confusion, tolerance and cognitive impairment, especially retrograde amnesia. Most authorities recommend that these drugs be used for no more than two to three weeks when treating insomnia.

Becaue of the abuse and addictive potential of benzodiazepines, nonbenzodiazepine sedative/hypnotic drugs (including zolpidem, eszopiclone and zaleplon) have been approved for the short-term treatment of insomnia. These drugs work through mechanisms similar to those of benzodiazepines and can be habit-forming. These drugs cause many of the same adverse effects as benzodiazepines, though the withdrawal syndrome may be less severe in cases of addiction.

Ramelteon is a melatonin receptor agonist approved for the treatment of insomnia characterized by difficulty initiating sleep onset. Clinical trials have demonstrated only modest benefits with this agent, though it is well tolerated, with few adverse effects.

Antidepressant drugs with sedating properties--including amitriptyline, doxepin and trazodone--are sometimes prescribed to treat insomnia. Data from clinical trials demonstrate efficacy when these drugs are used in the short term, but their effectiveness decreases over time.

As a general rule, pharmacists should discourage a pattern of chronic use of sleep aids, whether O-T-C or prescription. Otherwise, patients may become conditioned to associate a good night's sleep with use of that product. Instead, pharmacists should work to identify factors that cause or exacerbate insomnia and empower patients to address these, as well as work to establish good sleep hygiene.

Darrell Hulisz, R.Ph. and Pharm.D., is an associate professor at the Case Western Reserve University School of Medicine.
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Author:Hulisz, Darrell
Publication:Chain Drug Review
Geographic Code:1USA
Date:Apr 26, 2010
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