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From the Clinical Inquiries Family Physicians Inquiries Network

Cindy W. Su, MD and What’s the best diagnostic Sean Gaskie, MD Sutter Santa Rosa Family evaluation of night sweats? Medicine Residency Program, Santa Rose, Calif Kristin Hitchcock, MSI Department of Preventive Evidence-based answer Medicine, Northwestern There is no single best evidence-based Among menopausal women with hot University, Chicago, Ill approach to the diagnostic evaluation of flashes associated with night sweats, night sweats, given the limited number of oral hormone therapy is highly effective studies on the subject. A detailed history, in reducing their frequency (SOR: A, however, does appear to be the most based on a Cochrane review with a clear important initial diagnostic tool (strength of recommendation). Antireflux therapy may recommendation [SOR]: C, based on usual also be effective (SOR: B, based on a ® practice and clinical opinion). Dowdencohort study). Therapy Health aimed Mediaat decreasing No clinical trials have directly studied has also been suggested symptomatic relief of nightCopyright sweats alone.For personal(SOR: C, based useon clinical only opinion.) Clinical commentary Night sweats are an increasingly strategy for -related night common complaint sweats. Gabapentin may hold promise for fast track Complaints of night sweats among my hormonal symptoms if reflux is not the issue. If history menopausal patients have become very Other sinister causes of night sweats are common with the declining use of hormone uncommon, but are always in the back of and exam replacement therapy. Both women and my mind when the issue is raised, so the are unrevealing, their bed partners are affected, and history and help focus the a trial of antireflux deprivation is a significant side effect, so work-up. The pretest probability of unusual medication the problem must be taken seriously. diagnoses guides specific laboratory testing. Though venlafaxine can cause night Lisa Johnson, MD is recommended Providence Health Care Systems, sweats, it is also a reasonable treatment University of Washington, Seattle z Evidence summary that menopausal hot flashes were a con- Night sweats are a common complaint founding factor, at least for women. In a in the ambulatory primary care setting: subsequent study of 795 patients older Of 2267 patients in 1 cross-sectional than 64 years, 10% still reported being study, 41% reported night sweats, de- bothered by night sweats.2 fined as “sweating at night even when it isn’t excessively hot in your bed- The more common causes room” within the previous month.1 are not widely studied Because the peak prevalence in both Few studies look at the causes of night men and women occurred in the group sweats. Although they have been associ- ages 41 to 55 years, there was concern ated with , , and

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n table 1 I Medications that may cause sweating or flushing al

c Antidepressants Hypoglycemic agents

Bupropion (Wellbutrin) Insulin

Clini SSRIs Sulfonylureas

Tricyclic antidepressants Sympathomimetic agents Venlafaxine (Effexor) Beta-agonists Antimigraine Phenylephrine (Sudafed)

Naratriptan (Amerge) other agents Rizatriptan (Maxalt) Alcohol Sumatriptan (Imitrex) Beta-blockers Zolmitriptan (Zomig) Bromocriptine (Parodel) Antipyretics Calcium channel blockers Acetaminophen Clozapine (Clozaril) Aspirin Cyclosporine Nonsteroidal anti-inflammatory drugs (NSAIDs) Hydralazine (Hydra-Zide)

Cholinergic agonists Niacin Nitroglycerin Bethanechol (Urecholine) Omeprazole (Prilosec) Pilocarpine GnRH agonists Sildenafil (Viagra) Gonadorelin Tamoxifen (Nolvadex) Goserelin (Zoladex) Theophylline Histrelin (Vantas) Tramadol (Ultram, Ultracet) Leuprolide (Lupron) Nafarelin (Synarel)

4 fast track Source: UpToDate. For menopausal HIV , these are not common Finding the right diagnosis women, oral causes of night sweats in outpatient requires thorough history & exam hormone therapy care. With such a long differential diagnosis effectively reduces In the only study that specifically ad- (Table 2),4–6 night sweats should initial- night sweats dressed the causes of night sweats in an ly be evaluated with a thorough history ambulatory population, Reynolds3 inter- and physical examination (according to a viewed 200 consecutive patients, 70% consensus opinion of various authors). If from a primary care practice and 30% these don’t elicit possible causes, the ap- from a gastroenterology practice. Of the propriate next step in the work-up can 81 patients who reported having an epi- vary. Some authors recommend multiple sode of night sweats at least once a week, laboratory and imaging studies, while esophageal reflux and menopause were others advise against any routine tests. the most frequent causes. None of these approaches is evidence- Several authors agree that certain based. medications are frequently associated One reasonable algorithm recom- with night sweats, although the exact mends an initial work-up including a incidence is unknown due to a lack of complete blood count, thyroid-stimu- published epidemiologic data.4–6 Anti- lating hormone (TSH) and erythrocyte depressants and antipyretics are among sedimentation rate (ESR) level, a purified the more commonly cited offenders protein derivative (PPD) and HIV test, (Table 1).4 and a chest x-ray.5 If the results are un-

494 vol 56, No 6 / June 2007 The Journal of Family Practice Evaluation of night sweats

revealing, a trial of antireflux medication table 2 is recommended. If the patient does not Differential diagnosis for night sweats improve, consider a diary of nocturnal temperatures to help discern the pres- Endocrine Neurologic disorders ence or absence of febrile pulses and fur- syndrome Autonomic dysreflexia ther evaluate for suspected endocarditis insipidus Autonomic neuropathy or lymphoma. Stroke Substance withdrawal Evidence is scant Post-orchiectomy Alcohol for symptom relief Cocaine Very few clinical trials have directly Opioids studied symptomatic relief of night Miscellaneous sweats. A large Cochrane meta-analysis Endocarditis Chronic syndrome found that oral hormone therapy—es- Human immunodeficiency virus Gastroesophageal reflux trogens alone or estrogens with pro- Menopause gesterone—reduced the frequency of Obstructive sleep disorder night sweats associated with hot flashes Mycobacterium avium complex Panic disorder among menopausal women by 75% Osteomyelitis when compared with placebo alone.7 Tuberculosis Prinzmetal’s angina Takayasu’s arteritis Neither primrose oil nor foot reflexol- Malignancy Temporal arteritis 8 ogy proved effective. A cohort study found that 80% of Lymphoma the patients with frequent night sweats Prostate responded to antireflux therapy.3 One Renal cell carcinoma author suggests using therapies aimed at Other neoplasms 6 relieving hyperhydrosis. These include Source: UpToDate;4 Viera et al, Am Fam Physician 2003;5 Chambliss, Arch Fam Med 1999.6 local treatment with aluminum chloride hexahydrate (Drysol), antiperspirants, scopolamine, or phenoxybenzamine hy- 2. Mold jW, roberts M, Aboshady HM. Prevalence fast track and predictors of night sweats, day sweats, and drochloride (Dibenzyline). hot flashes in older primary care patients: an OK- Local PRN study. Ann Fam Med 2004; 2:391–397. Recommendations from others 3. Reynolds WA. Are night sweats a sign of esopha- treatments— geal reflux? J Clin Gastroenenterol 1989; 11:590– A thorough literature search through 591. such as anti- Cochrane Database Systematic Reviews, 4. Smetana GW. Approach to the patient with night perspirants and AHRQ, National Guideline Clearing- sweats. UpToDate [database online]. Updated Oc- tober 3, 2006. Available at: www.uptodate.com. scopolamine— house, and Medline did not yield any 5. Viera AJ, Bond MM, Yates sW. Diagnosing night have limited guidelines or consensus statements from sweats. Am Fam Physician 2003; 67:1019–1024. other organizations or specialty groups 6. Chambliss ML. What is the appropriate diagnos- evidence on the evaluation or treatment of night tic approach for patients who complain of night sweats? Arch Fam Med 1999; 8:168–169. sweats. n 7. MacLennan AH, Broadbent jl, lester s, Moore V. oral oestrogen and combined oestrogen/pro- References gestogen therapy versus placebo for hot flushes. Cochrane Datab Syst Rev 2004; CD002978. 1. Mold jW, Mathew MK, Belgore s, Dehaven M. Prevalence of night sweats in primary care pa- 8. Williamson J, White A, Hart A, Ernst E. Randomised tients: an oKPRN and TAFP-Net collaborative controlled trial of reflexology for menopausal symp- study. J Fam Pract 2002; 51:452–456. toms. BJOG 2002; 109:1050–1055.

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