2.5 2.5 ANCC PHARM CONTACT CONTACT HOURS HOURS 38 l Nursing2015 l March www.Nursing2015.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. Pharmacology for insomnia: Consider the options By Jamie M. Rosini, PharmD, BCPS, and Pooja Dogra, PharmD, BCACP, CDE INSOMNIA IS POOR SLEEP quality, defined as difficulty initiating and/ or maintaining sleep or waking up too early despite adequate sleep op- portunity, which then interferes with daytime functioning.1,2 Consid- ered the most common sleep disorder, insomnia affects approximately 60 million Americans annually.3 To care for patients suffering from insomnia, clinicians must first thoroughly assess their sleep habits, identifying and addressing under- lying conditions that may contribute to insomnia such as depression, emotional stress, sleep apnea, or substance abuse. Patients should also be counseled about sleep hygiene, stimulus control, and behavioral approaches to improving the quality of sleep. (See Helping improve a patient’s sleep hygiene.) If indicated, the healthcare provider may then add a medication to the treatment regimen for a limited period. The choice of medication is based on many factors, including the type of insomnia (difficulty falling asleep, staying asleep, or both).3,4 (See Classifying insomnia types.) This article provides an overview of agents commonly used to treat insomnia, including prescription drugs, over-the-counter (OTC) medi- cations, and herbal or dietary products. By understanding how and why certain medications help treat insomnia, nurses can help patients use them safely to get a good night’s sleep. Unless otherwise specified, the following information applies to adults, not children. Consult a pharmacist, comprehensive and current drug reference, or the product labeling for more details about potential ENDRON G adverse reactions, drug interactions, and precautions, including infor- ATHY mation on medication safety during pregnancy and breastfeeding. C www.Nursing2015.com March l Nursing2015 l 39 Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. PRESCRIPTION Helping improve a patient’s sleep hygiene4,27 SEDATIVE-HYPNOTICS Medication selection depends on Many patients with insomnia respond well to changes in lifestyle and behavior the type of insomnia being treated, that facilitate good sleep habits, known as “sleep hygiene.” Helpful habits to the drug’s onset of action and dura- cultivate include the following: tion of action, potential adverse • Avoid stimulants such as caffeine and tobacco, which can continue to exert reactions, and patient response. effects for up to 8 hours. Remind patients that many OTC products contain Educate patients about the proper caffeine. use, risks, and precautions associ- • Avoid alcohol, which interferes with normal sleep patterns. ated with these drugs and review • Don’t eat a heavy meal or exercise vigorously within 5 to 6 hours before with them the FDA-approved med- bedtime. ication guide dispensed with the • Establish a relaxing bedtime routine. Try to go to bed and get up at about the medications.5 Emphasize that the same time each day. medication should be taken exactly • Make your bedtime cool, dark, and quiet. Avoid distractions such as watching as prescribed. Warn them that television or using social media at bedtime. because sedative-hypnotics can • Don’t nap during the day. cause daytime drowsiness, they For more lifestyle and behavioral changes that may help, refer patients to the should avoid driving and other ac- National Institutes of Health/National Heart, Lung, and Blood Institute website: tivities requiring alertness until http://www.nhlbi.nih.gov/health/health-topics/topics/inso. The agency offers a they determine how the medication free booklet for patients entitled Your Guide to Healthy Sleep. affects them. Instruct them to avoid drinking alcohol or using (The benzodiazepine lorazepam isn’t benzodiazepine class, but its pro- other substances that may have approved for insomnia but it may be longed onset makes it less than ideal additive central nervous system prescribed off-label for this indica- for facilitating sleep onset, and its (CNS) effects. To avoid potential- tion.) Although these drugs are intermediate duration of action often ly dangerous drug interactions, widely used for short-term treatment leads to daytime drowsiness.8 Its teach patients to inform their of insomnia, their nonselective bind- quick onset of action and short dura- healthcare provider and pharmacist ing to the GABA receptor results in tion of action make triazolam a good about any other medications they’re many adverse reactions, including agent for sleep-onset insomnia with taking. alteration of sleep cycles, daytime minimal potential for morning hang- drowsiness, cognitive and psycho- over. Because flurazepam and quaz- Benzodiazepine receptor motor impairment, anterograde epam have long durations of action, agonists amnesia, rebound insomnia, and they’re the most likely to be associ- Benzodiazepine receptor agonist withdrawal symptoms on discon- ated with daytime drowsiness. medications enhance the activity of tinuation.4,6 Daytime drowsiness is Caution must be used in pa- the inhibitory neurotransmitter specifically associated with benzodi- tients with a history of drug or al- gamma-aminobutyric acid (GABA). azepines with longer durations of cohol use because of the potential This drug class includes both benzo- action. of these medications to cause de- diazepines such as temazepam and Older adults are more sensitive pendency. Caution should also be the newer nonbenzodiazepines such to the effects of benzodiazepines and exercised in patients with respira- as zolpidem. The newer agents are the slow metabolism of long-acting tory disorders, including chron- preferred in many patients because agents. The Beers criteria list medi- ic obstructive pulmonary disease they have a more selective binding cations that are potentially inappro- (COPD) and sleep apnea, because activity and shorter half-lives, result- priate for older adults due to the benzodiazepines may cause signifi- ing in fewer adverse reactions. All of high risk for adverse reactions. The cant respiratory depression.9 these medications are federally con- Beers criteria recommend avoiding Abrupt discontinuation or large trolled or “scheduled” substances all benzodiazepines in older pa- dosage decreases may result in re- because they can be abused or cause tients due to the increased risk of bound insomnia or withdrawal dependence. cognitive impairment, delirium, symptoms, such as tremors, abdomi- Estazolam, flurazepam, temaze- falls, fractures, and motor vehicle nal or muscle cramps, diaphoresis, pam, quazepam, and triazolam are crashes.7 seizures, and vomiting. If a patient benzodiazepines that are FDA- Temazepam is the most common- has been using any of these drugs approved to treat chronic insomnia. ly prescribed medication in the for an extended time, the medication 40 l Nursing2015 l March www.Nursing2015.com Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved. dosage should be slowly tapered to and engage in activities they’re not discontinue therapy. aware of and may not remember the next day. Reported activities include Nonbenzodiazepines “sleep driving,” preparing and eating These medications are more specific food, making phone calls, having for sedation with less potential for sex, and sleepwalking.13 Special care adverse reactions compared with ben- should be taken to prescribe zolpi- zodiazepines due to their selective dem at the lowest effective dose for binding of the GABA receptor. In old- all patients. Instruct patients not to er adults, however, these drugs cause exceed the prescribed dosage, edu- adverse reactions similar to those of cate them about risks and adverse benzodiazepines and, according to the reactions, and give them the medi- Beers criteria, provide only minimal cation guide provided with the improvement in sleep latency (the medication. length of time needed to fall asleep) An ultrashort elimination half-life of and duration.7 Chronic use of these less than 1 hour distinguishes zaleplon medications (more than 90 days) from zolpidem. Its rapid onset of ac- should be avoided in all patients. tion and short duration make it ideal Zolpidem has been shown to for patients who have trouble falling decrease sleep latency and improve asleep without the concerns for sleep maintenance due to its quick morning drowsiness. It hasn’t been onset of action and intermediate shown to increase total sleep time or duration of action. It’s available in Short-term insomnia decrease the number of awakenings.14 various formulations, including an generally lasts less than Dosage reductions should be consid- immediate release (IR) tablet, oral 3 months and may ered in older adults and in patients spray, controlled release (CR) tablet, be linked to a specific with mild-to-moderate hepatic im- and sublingual (SL) tablet. The CR pairment. Its use isn’t recommended formulation helps patients fall stressor, such as grief. in patients with severe renal or he- asleep and stay asleep. The SL for- patic impairment. Zaleplon is fairly mulation is approved for insomnia slowly than men, the recommended well tolerated, causing adverse reac- characterized by problems with starting dose was lowered for wom- tions similar to placebo. sleep initiation.10 en, but the FDA encourages provid- Similar to zolpidem, eszopiclone Zolpidem should be administered ers to consider prescribing a lower is effective in decreasing