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The Pharmacoeconomic Burden of Insomnia

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The Pharmacoeconomic Burden of Insomnia The Pharmacoeconomic Burden of Insomnia: Current Treatment Challenges and an Update on Safe and Efficacious Options © 2020. All rights reserved. No part of this report may be reproduced or distributed without the expressed written permission of PTCE. Faculty Information Julie A. Dopheide, PharmD, BCPP, FASHP Douglas S. Burgoyne, PharmD, FAMCP Professor of Clinical Pharmacy, Adjunct Associate Professor Psychiatry and the Behavioral Sciences Department of Pharmacotherapy University of Southern California School University of Utah College of Pharmacy of Pharmacy and Keck School of Medicine Salt Lake City, Utah Los Angeles, California This activity is supported by an educational grant from Eisai. Educational Objectives After completion of this activity, participants will be able to: • Characterize the pathophysiology, epidemiology, and disease burden of insomnia including the impact on quality of life in vulnerable patient groups • Identify appropriate pharmacotherapy for insomnia based on guideline recommendations, drug efficacy and safety profiles, and patient factors • Examine the economic burden of insomnia and impact of available treatment options, including effects on vulnerable patient groups Insomnia Overview Julie Dopheide, PharmD, BCPP, FASHP Emily Morris, 16 years old Emily Morris, 16 years old 2020 National Sleep Foundation Poll Shows High Levels of Daytime Sleepiness and Negative Health Impact #1 Cause of Daytime Sleepiness: Insomnia Health Impacts of Feeling Sleepy Feeling Sleepy How Many Days Per Week? 5-7 days 28% 28% 2-4 days 44% 0-1 days 0 20 40 60 1-2 days 2-4 days 5-7 days Feeling Unwell Headache Irritability Sleep in America Poll 2020. National Sleep Foundation. Published March 2020. Accessed October 8, 2020. sleepfoundation.org/professionals/sleep-america-polls/2020- sleepiness-and-low-action. What Are the Different Types of Insomnia? • Difficulty falling asleep (DFA) How Is It Categorized? • Difficulty maintaining sleep (DMS); frequent awakenings • Situational • Waking up too early in the morning (EMA) • Short-term: less than 3 months • • Poor quality or nonrestorative sleep 30%-50% of population • Chronic: insomnia at least 3 times per week for 3 months or more • 10% of population Dopheide JA. Am J Manag Care. 2020;26(4):S76-S84; Sateia M, et al. Chest. 2014;146(5);1387-1394. Insomnia Impacts Everyone 1 of 3 adults get less sleep Shift workers have high rates than needed. of insomnia due to erratic schedules. Women are twice as likely to experience insomnia; Up to Two-Thirds of Iraq/Afghanistan menopause increases risk. veterans experience chronic insomnia. Hughes JM, et al. Clin Psychol Rev. 2018;59:118-125; Dopheide JA. Am J Managed Care. 2020;26. Sleep and sleep disorders. Centers for Disease Control and Prevention (CDC). Updated April 15, 2020. Accessed October 8, 2020. cdc.gov/sleep/index.html; https://www.cdc.gov/nchs/products/databriefs/db286.htm. Short-Sleepers (<6 Hours per Night) Are at Greater Risk for Disease and Early Death • Increased risk of ischemic stroke • Increased risk of myocardial infarction • Increased obesity • Impaired glucose tolerance and increased risk of type 2 diabetes • Increased cancer risk: breast, prostate, endometrial, colorectal • 2-3x greater risk for depression, anxiety, alcohol use disorder Dopheide JA. Am J Manag Care. 2020;26(4):S76-S84; Luyster FS, et al. Sleep. 2012;35(6):727-734. COVID-19 Increases Risk for Insomnia • Home confinement disrupts routine • Worries contribute to inability to sleep • Increased screen time prevents release of melatonin and sleep-promoting neuropeptides • Reestablish routine/minimize news time • Intentional relaxation: yoga, exercise Voulgaris A, et al. Sleep Med. 2020;73:170-176; Altena E, et al. J Sleep Res. 2020;29:e13052; COVID-19 and sleep. American Sleep Association. Accessed October 8, 2020. sleepassociation.org/about-sleep/covid-19-and-sleep/ COVID-19 Increases Risk for Insomnia • Home confinement disrupts routine • Worries contribute to inability to sleep • Increased screen time prevents release of melatonin and sleep-promoting neuropeptides • Reestablish routine/minimize news time • Intentional relaxation: yoga, exercise Voulgaris A, et al. Sleep Med. 2020;73:170-176; Altena E, et al. J Sleep Res. 2020;29:e13052; COVID-19 and sleep. American Sleep Association. Accessed October 8, 2020. sleepassociation.org/about-sleep/covid-19-and-sleep/ Bidirectional Connection Between Medical/Psychiatric Conditions and Chronic Insomnia Chronic Insomnia Co-occurring Chronic Insomnia • Depression/anxiety: >5 times more likely to experience chronic insomnia • Hypertension, gastrointestinal disorders, cancer, pain syndromes: 2-3x more likely to experience chronic insomnia • Need to treat all conditions concurrently Medical/Psychiatric Condition Morin C, Benca R. Lancet. 2012;379(9821):1129-1141; Dopheide JA. Am J Manag Care. 2020;26(4):S73-S83. Neurochemistry of the Sleep-Wake Cycle • Wakefulness and sleep: antagonistic states competing for control of brain activity • Wakefulness promoting: norepinephrine (NE), dopamine (DA), histamine, acetylcholine, hypocretin/orexin • Sleep promoting: γ-aminobutyric acid (GABA), opioids, enkephalins, endorphins, serotonin (5HT) • Environment, stress, genetics, medications, exercise, and medical/psychiatric illnesses all influence the sleep/wake cycle Dopheide J, Stimmel G. Sleep disorders. In: Alldredge BK, et al, eds. Koda-Kimble & Young’s Applied Therapeutics, 10th ed. Lippincott Williams & Wilkins; 2013:1900-1920. Polysomnography (EEG/EOG/EMG) and Sleep Stage Significance (Sleep Architecture) • Non-Rapid Eye Movement (NREM) - 75% of total sleep time • Stage 1 - relaxed wakefulness Hypnotics increase • Stage 2 - rest for brain and muscles time in NREM Stage 2 • Stage 3 - feeling of rejuvenation DORAs increase time in REM • Stage 4 - immune enhancement, growth hormone • Rapid Eye Movement (REM) - 25% of total sleep time • Higher cortical areas and neurotransmitters active while body resting, cholinergic tone • Autonomic instability (pulse, BP), temperature drops BP, blood pressure; NREM, non-rapid eye movement sleep; REM, rapid eye movement sleep. Dopheide J, Stimmel G. Sleep disorders. In: Alldredge BK, et al, eds. Koda-Kimble & Young’s Applied Therapeutics, 10th ed. Lippincott Williams & Wilkins; 2013:1900-1920 Herring WJ, Roth T, Krystal AD et al. J Sleep Research 2019. Electroencephalogram (EEG); Electrooculogram (EOG), Electromyogram (EMG). The Clinician’s Role in Insomnia ✓ Recommend optimal assessment for patients with sleep complaints ✓ Educate providers and patients on appropriate non- drug and drug treatment ✓ Given a medication regimen, screen for causes of insomnia and drug interactions ✓ Counsel patients with hypnotic prescriptions on how to safely and effectively use their medication Patient Assessment • Type of insomnia: DFA or DMS, EMA • Duration of insomnia? • Resulting daytime impairment? • Difficulty falling asleep? maintaining sleep? • What has the patient tried? • Consider drug and alcohol use • Engage patient to set goals of treatment • Determine if medical or neuropsychiatric comorbidities need to be addressed along with sleep hygiene, CBT-I, or medication CBT-I, cognitive behavioral therapy for insomnia. Dopheide J, Stimmel G. Sleep disorders. In: Alldredge BK, et al, eds. Koda-Kimble & Young’s Applied Therapeutics, 10th ed. Lippincott Williams & Wilkins; 2013:1900-1920; Buysse DJ. JAMA. 2013;309(7):706-716. Treatment of Insomnia Clinical Guidelines for Management of Insomnia All Guidelines Recommend CBT-I First-Line for Chronic Insomnia • American Academy of Sleep Medicine (AASM) (2017) • American College of Physicians (ACP) (2016) • Agency for Healthcare Research and Quality (AHRQ) (2017) • British Association for Psychopharmacology (2019) Wilson S, et al. J Psychopharmacol. 2019;33(8):923-947; ACP recommends cognitive behavioral therapy as initial treatment for chronic insomnia. News release. ACP; May 3, 2016. Accessed October 8, 2020. acponline.org/acp-newsroom/acp-recommends-cognitive-behavioral-therapy-as-initial-treatment-for-chronic-insomnia; Management of insomnia disorder in adults: current state of the evidence. AHRQ. Published August 1, 2017. Accessed October 8, 2020. effectivehealthcare.ahrq.gov/products/insomnia/clinician; Sateia MJ, et al. J Clin Sleep Med. 2017;13(2):307-349. Cognitive Behavioral Therapy-Insomnia (CBT-I) Can take 3-6 weeks for significant improvement. 40%-45% of patients achieve remission. CBT approach Comments Sleep hygiene education (SHE) Teaches healthy lifestyles for sleep; not effective as sole treatment for chronic insomnia Stimulus control Restrict bedroom activities to sleep only, creating a positive association between the bed and sleep (no television or computer work in bed) Sleep restriction Limits time in bed to sleeping Cognitive therapy Cognitive therapy (goal to change the patient’s unrealistic expectations of sleep) Relaxation training Lowers somatic and cognitive arousal states (eg, progressive muscle relaxation guided imagery, meditation) Morin CM, Benca R. Lancet. 2012;379(9821):1129-1141; Dopheide J. Am J Manag Care. 2020;26(4):S76-S84. Digital Cognitive Behavioral Therapy-Insomnia (dCBT-I) • Metered, interactive, tailored approach meant to simulate face-to-face CBT-I • SHUTi/Somryst – Sleep Healthy Using the Internet, originated by US researchers • Sleepio – US/UK application • Controlled trials show long-term benefit • Patients must be motivated to participate • Not found superior to face-to-face CBT-I Ritterband LM, et
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