When patients can’t sleep
Updated guide to workup and hypnotic therapy
Sleep hygiene. Many individuals unknowingly engage in habits that impair sleep. Those with insomnia, for example, often try to compensate for lost sleep by staying in bed later in the morning or by napping, which further fragment nocturnal sleep. Advise these patients to adhere to a regular awakening time—regardless of how long they slept the night before—and to avoid naps. Other tips for getting a good night’s sleep are outlined in Table 2.14
Caffeine has a plasma half-life of 3 to 7 hours, although individual sensitivity varies widely and caffeine’s erratic absorption can prolong its effects. Advise patients with insomnia to avoid caffeine-containing beverages—including coffee, tea, and soft drinks—after noon.
Relaxation training. Muscle tension can be reduced through techniques such as electromyography (EMG) biofeedback, abdominal breathing exercises, or progressive muscle relaxation. Relaxation training is usually effective within a few weeks.
Psychological counseling. Counseling can help identify and dispel tension-producing thoughts that may be disrupting sleep, such as preoccupation with unpleasant work experiences or school examinations. Reassurance may help patients overcome fears about sleeplessness; suggest that they deal with anxiety-producing thoughts during counseling sessions and at times other than bedtime.
Table 2
How to get a good night’s sleep
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Prescribing Hypnotics
Sedative-hypnotics are indicated primarily for short-term insomnia management. Most are used at bedtime until insomnia dissipates or the physician advises the patient to take a break.
Treatment principles. Because many insomnias are recurrent, prolonged hypnotic treatment given in short bouts is often optimal. Longer treatment—months to years—is clearly needed by a few patients with chronic insomnia. In these cases, carefully monitor for tolerance, as manifested by dosage escalation. Hypnotic treatment is generally not suitable for patients with drug abuse or dependence histories.
Although chloral hydrate and barbiturates are effective hypnotics, adverse effects limit their safety and usefulness. Benzodiazepines and more recently introduced agents have milder side-effect profiles (Table 3). Choose agents based on the patient’s situation, preferences, and effects of prior trials with similar agents. Guidelines for hypnotics discourage chronic use to minimize abuse, misuse, and habituation (Table 4).
Elimination half-life is one of the most important pharmacological properties that differentiates the hypnotics from each other:15
- longer half-life: flurazepam, quazepam
- intermediate half-life: estazolam, temazepam, eszopiclone
- short half-life: triazolam, zolpidem, zolpidem ER, zaleplon, ramelteon.
Benzodiazepine receptor agonists. Of the all the drugs in class, zalepon—because of its ultra-short half-life—is least likely to cause residual daytime effects when administered at bedtime. At 10-mg doses, its side effects seem to last no more than 4 hours after administration. Zaleplon can be safely taken after nocturnal awakenings if the patient remains in bed 4 hours or longer after taking it.17
An ultra-short half life is less desirable for patients with difficulty with sleep initiation and discontinuous sleep throughout the night. For them, longer elimination half-life agents—such as zolpidem, zolpidem extended release (ER), and eszopiclone—may be more predictably effective for the entire night.18
Short half-life hypnotics do not offer anxiolysis for patients with daytime anxiety, as the longer half-life agents do.
Zolpidem ER and eszopiclone do not have a limitation imposed on duration of use. Although zolpidem ER has not been investigated in controlled trials greater than 3 weeks, eszopiclone was evaluated during a 6-month study that demonstrated lack of tolerance during the entire period, and lack of rebound after rapid discontinuation.19 Eszopiclone is the only hypnotic indicated for long-term (lasting > 3 weeks) insomnia.
Melatonin receptor agonists. Ramelteon’s activity at MT1 and MT2 receptors is believed to contribute to its sleep-promoting properties. This agent has been found to reduce sleep latency,20,21 and it is indicated to treat insomnia characterized by sleep-onset delays. Although controlled, longterm studies are lacking, ramelteon does not have a limit on duration of use. It demonstrated a lack of abuse liability when compared with triazolam and placebo in subjects with a history of sedative/hypnotic or anxiolytic drug abuse.22
Tolerance and rebound. Tolerance can develop after repeated dosing with benzodiazepines—primarily triazolam—and rebound insomnia can follow abrupt discontinuation. Both can be minimized by using benzodiazepines at the lowest effective dosages and for brief periods. Gradual tapering when discontinuing the drug can help control rebound.
