Insomnia

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Medication should be used to treat insomnia only when it is severe, disabling, or causing the patient extreme distress. Benzodiazepines and the Z–drugs should be avoided in the elderly, because the elderly are at greater risk of becoming ataxic and confused, leading to falls and injury. However, if prescribing in elderly, they have reduced clearance of medicines and are likely to require a lower dose to minimise adverse effects. 

Discontinuing the use of zopiclone or a benzodiazepine may reverse some of these effects, e.g. improving motor performance, cognition and reducing the risk of dementia.

Concomitant use of benzodiazepines or zopiclone with opioids or alcohol increases many risks, such as lack of judgement, sexual disinhibition, criminal activity and fatal overdose.

Z-drugs

  • zaleplon, zolpidem and zopiclone
  • nonbenzodiazepine hypnotics
  • although structurally from the benzodiazepines, they are also agonists of the GABA receptor complex and therefore enhance GABA-mediated neuronal inhibition
  • developed with the aim of overcoming some of the disadvantages of benzodiazepines – for example, next day sedation, dependence and withdrawaliIn common with the benzodiazepines, the sedative effects of the Z-drugs may persist into the next day
  • all three Z-drugs carry warnings about their potential to cause tolerance, dependence and withdrawal symptoms
  • in certain cases an extension beyond the maximum treatment period may be necessary; if so it should take place after re-evaluation of the patient's status
  • long term side effects of Z-drugs involve muscle weakness, vertigo, effects on cognition including an increased risk of dementia; these effects can lead to adverse clinical outcomes, such as an increased risk of falls and increased risk of motor vehicle accidents.

Zaleplon

  • pyrazolopyrimidine
  • elimination half-life of 1 hour
  • licensed for "the treatment of patients with insomnia who have difficulty falling asleep"
  • indicated only when the disorder is severe, disabling or subjecting the patient to extreme distress
  • treatment should be as short as possible with a maximum duration of 2 weeks

Zolpidem

  • imidazopyridine
  • elimination half-life of 2.5 hours
  • licensed for "the short-term treatment of insomnia in situations where the insomnia is debilitating or is causing severe distress for the patient"
  • duration of treatment should usually vary from a few days to 2 weeks with a maximum of 4 weeks, including tapering off where appropriate
  • recommended dose for adults is 10 mg to be taken immediately at bedtime and 5mg for elderly

Zopiclone

  • cyclopyrrolone
  • elimination half-life of 3.5–6.5 hours
  • licensed for "the short-term treatment of insomnia (including difficulties in falling asleep, nocturnal awakening and early awakening, transient, situational or chronic insomnia, and insomnia secondary to psychiatric disturbances) in situations where the insomnia is debilitating or is causing severe distress for the patient"
  • duration of treatment should be 2–5 days for transient insomnia and 2–3 weeks for short-term insomnia. The recommended dose for adults is 7.5mg to be taken immediately at bedtime (start with 3.75mg for elderly and increase to 7.5mg if needed).

Benzodiazepines

  • indicated for the short-term relief (two to four weeks only) of anxiety that is severe, disabling, or causing the patient unacceptable distress, occurring alone or in association with insomnia or short-term psychosomatic, organic, or psychotic illness. Loprazolam, lormetazepam, and temazepam act for a shorter time and they have little or no hangover effect although withdrawal phenomena are more common with the short-acting benzodiazepines
  • if insomnia is associated with daytime anxiety then the use of a long-acting benzodiazepine anxiolytic such as diazepam given as a single dose at night may effectively treat both symptoms

Temazepam

Diazepam

Other prescribable medications

Clomethiazole

  • may be a useful hypnotic for elderly patients because of its freedom from hangover but, as with all hypnotics, routine administration is undesirable and dependence occurs

Promethazine

  • sedative antihistamine, no tolerance or dependency however prolonged duration of action can often cause drowsiness the following day
  • sedative effect of antihistamines may diminish after a few days of continued treatment
  • antihistamines are associated with headache, psychomotor impairment and antimuscarinic effects

Melatonin

  • a pineal hormone
  • licensed for the short-term treatment of insomnia in adults over 55 years

Mirtazipine

Quetiapine

  • not recommended for the treatment of insomnia in the absence of psychiatric disorder, e.g. schizophrenia
  • may increase total sleep time and sleep efficiency
  • adverse effects such as leg movements and akathisia (restlessness) limit its effectiveness

OTC

Valerian

Melatonin

Lavender

 

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