Condition/Case



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Condition/Case


Insomnia

Goals of Therapy

1. Promote sound and restorative sleep



2 Minimize external (stress, noise, environment) and internal (anxiety mood, pain) factors

3 Reduce daytime impairment (fatigue, poor conc.) and complications of lack of sleep

4 Improve effectiveness of behavioral interventions in managing patients with 1o chronic insomnia

5 Minimize side effects of treatment

Tx Options (drug classes)

- consider effectiveness, toxicity, S/E, convenience



Rx

Pro

Con

Choose 1 agent: indications, S/E, CI

1Zopiclone

Works at GABA receptor as well as benzo but less rebound insomnia, less tolerance and less amnesic effects.




Does not treat anxiety
Bitter taste/ dry mouth, headache.



s/e: bitter taste, (30-40% of people), dry mouth, headache, sleepiness.
Drug interaction: CNS depressants, CYP2C9 and CYP3A4 drugs (inducers and inhibitors).
Hepatic impairment: t1/2 11.9 hrs. (Too long).

Short half life - less/no morning hang-over.



assoc. with suicidal ideation, aggression and worsening depression

2Antihistamine

trazodone

Improved sleep latency and duration




Limited data in primary insomnia (only 2 studies)

s/e: sedation, dizziness, orthostasis, psychomotor impairment, priapism, etc.

has some impact on anxiety as well with seratinergic properties.



Consider side effects.

3Benzodiazepines
temazepam

Options:“LOT”

Lorazepam

oxazepam


temazepam

Effective in promoting sleep onset.

Does not accumulate.



Increased risk of higher cortical impairment (confusion and falls)

(Carry over effect)



May cause more rebound insomnia on withdrawal than temazepam or oxazepam, may cause amnesia with higher doses.

Short duration of action limits morning sedation.




Tolerance develops with repeated admin. (must increase dose)

4L-Tryptophan

more natural alternative for patients looking for non-BZD



erratic response, more expensive therapy


combined therapy with seratonergic drugs increases risk of seratonin syndrome. (triptans, SSRIs, SNRIs, MAOIs)

Has added benefits in depression, anxiety, bruxism.



May cause seratonin syndrome (shivering, diaphoresis, hypomanic behaviour and ataxia) alone (rare), or when combined with other serotonergic drugs.

5 Zolpidem

Rapid onset of action- good for sleep onset. t1.2 2.5-3 hrs.



Nausea, dizziness, drowsiness, rebound insomnia.

Costs TWICE Zopiclone.



CI: severe hepatic impairment, respiratory insufficiency.
NOT for frequent awakenings or wake too early (short half life).

No bitter taste (vs. Zopiclone)




Similar to Zopiclone: suicidal ideation, worsening depression, aggressive behaviour.

What I would Rx (including d/c of Rx)

Date, Name, address of patient.

Rx: Zopiclone 3.75mg

Sig:


Mitte:

No Refills.

Name, Sign, Reg #.
Pro: does not accumulate, free of cognitive effects, minimal additive effects with low dose alcohol. Less addictive than BZD.

Con: bitter/metallic taste, may cause rebound insomnia and daytime anxiety on withdrawal. Habit forming in some- does have street value.


Lowest effective dose, ideal prn (<4X/week), Ideal short term treatment (2-4 weeks) depending on presentation. Need for tapering if longer term dosing (cut dose 25% per week), Consider WHEN to dose based on patient presentation (wakes late in the night, early in the night, etc.) mixed with ONSET of medication. Such as, for slower onset: take dose 1 hour before bed time, crawl into bed 30 min before “sleep” time. Patient plays active role in treatment.

Monitoring Parameters

EFFICACY

&

TOXICITY

(10 marks- add more that are case specific in exam)

What to monitor?

When?

Who is monitoring?

Daytime functioning/ level of daytime impairment


Ongoing with journal, and at follow-ups

Patient.

Adverse effects: s/e: bitter taste, (30-40% of people), dry mouth, headache, sleepiness.

Ongoing at follow ups

Patient. Doctor assess for impact and compliance issues with these side effects.

Sleep Journal



at follow up visits- patient keeps it

Patient- Doctor provides log with many factors like napping, sleep hours, wake rested, time to sleep...

Potential underlying causes


at initial and follow up visits

Doctor questions re: meds that can cause insomnia (see below), lights, sleep hygiene, stress, pain, etc.


Emergance of a mood disorder

All follow-up visits, even into the following year

Protracted insomnia can be prodrome for mood disorder. Doctor monitors.

Misc



Rx Changes

After 2 weeks if no improvement, re-evaluate compliance with sleep hygiene and psychological and medical status, then another 2 week course of hypnotic. If poor response then, refer for 2nd opinion from sleep specialist, neurologist, psychologist, etc. Withdraw at low stress time and shorten sleep by 20 min 2 nights before.


Other Tx

Non-pharm options: proper sleep hygiene (same wake/sleep time, calm down time before bed, no lights, etc.), relaxation/breathing exercises and tapes, stimulus control, sleep restriction, sleep diary, exercise earlier in the day (45 min with sweating), CBT for insomnia.


Misc

Warn patients about combined effects with CNS depressants like ALCOHOL.


Red Flags

Question patients bed partner as well - Beware signs of sleep apnea which would CI above meds. (snoring, gasping, etc.- ask bed partner)


Meds that can CAUSE/WORSEN Insomnia: Antidepressants (buproprion, fluoxetine, SNRIs, MAOIs, TCAs), Antihypertensives (B-blockers, methyldopa), Nicotine, Sympathomimetic Amines (amphetamines, methylphenidate, caffeine, cocaine, decongestants, appetite suppressants, bronchodilators s/a salbutamol), corticosteroids, anticonvulsants (phenytoin, valproic acid), levodopa, quinidine, thyroid supplements, estrogen,





Pharm Insmonia AK 1013


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