Insomnia Lecture 5 PDF

College of Pharmacy Fourth Year. Clinical Pharmacy Central nervous system conditions Insomnia Background: The length of sleep people need varies but typically people aged between 20 and 45 require 7 to 8 hours per day. Sleep requirements also decrease with in...

College of Pharmacy Fourth Year. Clinical Pharmacy Central nervous system conditions Insomnia Background: The length of sleep people need varies but typically people aged between 20 and 45 require 7 to 8 hours per day. Sleep requirements also decrease with increasing age and people over 70 commonly have 6 hours sleep per day (1). Insomnia has three features: 1-Difficulty in initiating sleep; 2-difficulty in maintaining sleep; or 3-waking up too early. In addition a fourth characteristic may be added: sleep that is perceived to be nonrestorative (i.e. not restore the body from the day‟s exertions) or of poor quality (2). Insomnia will affects the next day alertness and the tiredness can lead to poor performance at work (1). Insomnia is classified by its duration; transient (lasting less than 1 week) (3), short- term (up to 3 weeks) or chronic (greater than 3 weeks) (4). Transient insomnia is often caused by a change of routine, for example, time zone changes, excessive noise, sleeping in a new environment (e.g. hotel) or extremes of temperature. Short-term insomnia is usually related to acute stress such as sitting exams, bereavement, loss of job, forthcoming marriage or house move (1). The pharmacist can manage most patients with transient or short-term insomnia, however cases of chronic insomnia are best referred as there is usually an underlying cause (1). The key to restoring appropriate sleep pattern is the advice on sleep hygiene (see below).OTC product can help during transition period and can also be useful in periodic and transient sleep problems (4). Insomnia can arise from many different causes (Fig. 6-2) (4). Fig. 6-2: Causes of insomnia (1). 1 Patient assessment with insomnia: A-Age: In elderly people the total duration of sleep is shorter. Nocturnal waking is more likely because sleep is generally more shallow. However, people may still feel that they need more sleep and wish to take a medicine to help them sleep (4). Elderly people may nap during the day and this reduces their sleep need at night even further (1). Patient under the age of 16 years required referral (4). B-Duration: Chronic insomnia (longer than 3 weeks) required referral (4). C-Recent travel: Time zone changes will affect the person normal sleep pattern and can take a number of days to re- establish normality (1). D-Symptoms: It is important to differentiate between the different types of sleep problems: Difficulty in falling asleep. Waking during the night. Early morning waking. Poor sleep. Snoring. Depression is an important cause of insomnia. Early morning waking is a classic symptom of depression (Here the patient may describe no problems in getting to sleep but waking in the early hours and not being able to get back to sleep) (4). The pharmacist should look to other symptoms of depression (fatigue, loss of interest and appetite, feeling of guilt, difficulty in concentration and constipation) (1). Patient with suspected depression should be referred (4). Anxiety can also cause insomnia. This When to refer usually associated with difficulty in getting -Suspected depression (4). off to sleep because of an overactive mind. -Chronic problem (longer than 3 weeks‟ This is may be experienced by many duration) (4). people, particularly before an important -Children under 16 years (4). occasion, for example an exam. If, -Snoring, apnea, restless legs (4). however this occurs as a more regular -Associated physical conditions (4). pattern, referral is required (4). -Suspected alcohol dependency (4). -Insomnia for which no cause can be E-Contributing factors : (4) ascertained (1). 1-Shift work with changing shifts is a classic cause of sleep problems. Those who work away also may have insomnia. 2-life changes, for example (loss of job, moving house, loss or separation of wife (or husband) and menopause. 3-Heavy continuous alcohol consumption. 4-Other stressful events like exam, job interview, celebration... 2 5-Obesity can be associated with sleep apnea and snoring, both of which can interrupt sleeping. D-Medications and medical problems: 1-Some drug can cause or contribute to insomnia (table 6-4) (4). Table 6-4: Medication that may cause insomnia (1) Stimulants Caffeine, theophylline, sympathomimetics amines (e.g., pseudoephedrine), MAOIs –especially in early treatment) Antiepileptics Carbamazepine, phenytoin Alcohol Low to moderate amounts can promote sleep but when taken in excess or over a long period, it can disturb sleep Beta-blockers Can cause nightmares, especially propranolol. Limit by swapping to a beta-blocker that does not readily cross the blood-brain barrier SSRIs Especially fluoxetine Diuretics Ensure doses not taken after midday to stop the need to urinate at night Griseofulvin MAOIs, monoamine oxidase inhibitors; SSRIs, selective serotonin reuptake inhibitors. 2-Medical problems can be associated with insomnia e.g.: Through pain: Angina, arthritis, cancer and Gastro-esophageal reflux disease (GERD). Through breathing difficulties :(heart failure, COPD, and asthma). In addition other medical condition such hyperthyroidism (night sweats), menopausal symptoms (hot flushes) and Parkinson's disease (4). (In both cases the Dr. should be consulted and the treatment options discussed /suggested) (1). Treatment timescale: Improvement should be obtained within days: refer after week if the problem is not resolved (1). Management: A-non-pharmacological advices: 1-Sleep hygiene: See the above tables 6-5 (1, 4): 2-Bathing A warm bath 1–2 h (not immediately) before bedtime can help induce sleep (4). 3  Table 6-5: Key steps to good sleep hygiene 1-Establish a regular bedtime and waking time (4). 2-Consciously create a relaxation period before bedtime (4). 3-No meals just before bedtime (4). 4-No naps during the daytime (4). 5-No caffeine after early afternoon (4). 6-Reduce extraneous noise (use earplugs if necessary) (4). 7-Get up if you can‟t sleep – go back to bed when you feel „sleepy, tired‟ (4). 8-Avoid alcohol (1). 9-Restrict nicotine intake immediately before bedtime (4). 10-Avoid sleeping in very warm rooms (1). 11-No strenuous mental activity at bedtime (e.g., doing a crossword in bed) (1). 12-Associate bed with sleep – try not to watch TV (1). B-Pharmacological treatment: A-Antihistamine: Diphenhydramine and promethazine: can be recommended for adults and children over 16 years in UK (1) (older than 12 years of age in USA) (5). 1-They reduce sleep latency (time taken to fall asleep) and also reduce nocturnal waking (4). 2-Diphenhydramine should be taken 20-30 minutes before bedtime (1). The dose is 50 mg (1, 4, 5). 3-Promethazine: 20 or 25 mg taken an hour before bedtime (1). 4-Advise the patient to take the drug every night for 3 nights then skip 1 night and evaluate ability to sleep. If not improved, continue diphenhydramine for 3 more nights, and reevaluate ability to sleep without it. If symptoms persist for 10 days, the patient should seek medical evaluation.” (5) (tolerance to their effect can develop) (1, 4). 5-Diphenhydramine and promethazine should not be recommended for pregnant or breastfeeding women (4). 6-Summaries of practical points are listed in (tables 6-6) (4). Table 6-6: Practical prescribing: Summary of medicines for insomnia (4). Drug Likely side- Drug interactions of Patients in effects note whom care should be experienced Antihistamines Dry mouth, Increased sedation Glaucoma, (Diphenhydramine sedation with alcohol, opioid prostate and promethazine) analgesics, anxiolytics, hypertrophy. hypnotics and antidepressants B-Melatonin: Melatonin is an endogenous hormone produced by the body's pineal gland during darkness and is thought to regulate sleep (4). Melatonin tablets are available as an OTC product for insomnia in USA(4). Melatonin is advocated for sleep disturbance, particularly associated with jet lag. The timing of the 4 dose is critical. It has to be taken at bedtime (1) (1–2 hours before bedtime) (5) after darkness has fallen on the first day of travel then again in the same way on the second, and any subsequent day, of travel. Once at the final destination it should be taken for the following few days at the same time (1). References: 1-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4 th edition. 2017. 2-W. Steven Pray. Insomnia and Its Treatment With Nonprescription Products. US Pharm. 2009; 34(4)(OTC suppl):8-11. 3-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 4-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 5-BNF-74. 5-Snoring 1-Snoring is another sleep-related problem for which pharmacists can recommend a product. Snoring disrupts the patient‟s sleep, but is usually more troublesome for the spouse/bed partner, and for children whose bedrooms are in close proximity. Snoring is more common in males, perhaps because they have smaller caliber airways than females (1). 2-Most snoring is unrelated to any underlying medical condition and is known as primary snoring. Patients predisposed to snoring include those who are overweight (due to pressure on the airways from excessive neck tissue); females who are pregnant (especially in the last trimester); those with nasal congestion from the common cold or allergic rhinitis; those with inflammation of tonsils; and those with certain anatomical predispositions (e.g., abnormal facial bones, large tongue, ………………) (1). 3-Patients who are able to breathe normally through the nose do not snore, since the mouth is closed. However, nasal obstruction forces patients to mouth breathe. Thus, opening the nasal airways may eliminate some cases of snoring. The use of topical or oral nasal decongestants may accomplish this objective, although the accompanying CNS stimulation often interferes with sleep (1). 4-Another viable method to stop snoring is the use of FDA-approved, adhesive thin plastic nasal strips (1). These adhesive nasal strips work by opening the nostrils wider (2) ( When the strip is released, it gradually opens the nasal passages )(1) and enabling the breathing through the nose rather than through the mouth (2). (Further reading 1and 2) References: 1-W. Steven Pray.Insomnia and Snoring. US Pharm. 2012;37(1):12-15. 2-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. Motion sickness Background: Motion sickness is a travel (air, sea and land) sickness characterized by nausea (and sometimes vomiting), pallor, and cold sweats (1, 2 ). Patients may feel relief after a 5 single bout of vomiting, but in a few cases, the vomiting can be protracted and severe (3). Motion sickness is thought to be caused by a conflict of messages to the brain, where the vomiting center receives information from the eyes, the GI tract and the vestibular system in the ear (1). Pharmacists are often asked to recommend a travel-sickness remedy especially by parents for their children in whom the problem is most common (1). Effective prophylactic treatment is available OTC (1). Epidemiology 1-Motion sickness is more common in women than men (4). 2-It is uncommon in children under 2 years (4) (don’t usually required treatment ) (1) and most common in children between 2 and 12, reaching a peak at 12 years. Incidence reduces thereafter and after 21 declines significantly with age (4) (although some adults still experience the problem) (1). 3-Studies demonstrate that the person in control of a vehicle is less prone to become motion sick. Thus, the driver or pilot is protected, while the passengers are at higher risk (3). Patient assessment with motion sickness: A-Age: The minimum age at which products designed to prevent motion sickness can be given varies, so for a family with several children careful product selection can provide one medicine to treat all cases (1). (See treatment below) B-length of time of the travel: The duration of action of the available drugs varies, if it is a long travel , then it may be necessary to repeat the dose while traveling according to the dosing interval of each drug (1).(see treatment below). C-previous history: To know which member of the family have previous problem for whom treatment will be needed (1). D-Medication (1): To know: 1- Any treatment used in the past for motion sickness and their level of success or failure. 2-Other medication taken by the patient which may interact with selected OTC drugs. Treatment: 1-Non-Pharmacological therapy: A-General advice: 1-Children are less likely to feel or be sick if they can see out of the car, so appropriate seats can be used to elevate the seating position of small children so that they can lock outside and see still objects which may be helpful (1). 6 2-Keeping the line of vision fairly straight ahead (5). 3-For many patients, reading exacerbate the feeling of nausea (1). (Not reading during the travel) (5). 4-Avoiding excess of food before and during the extended travel (5). 5-Staying where motion is felt the least (e.g. front of the car) (5) (Planes - sit over the wing) (Ships - sit in the middle close to the water line) (6). 6-Avoiding strong odors particularly from food or tobacco smoke (5). 7- Ensure good ventilation, for example open a window (6). B-Acupressure wrist: It is elasticated wrist bands that apply pressure to a defined points on the inside of the wrists are available. Although there is no consistent evidence (till now) about their effectiveness, such wrist band may be worth trying for drivers or pregnant women (1). 2-Pharmacological therapy: It includes: Antihistamines: (meclozine, Cinnarizine, promethazine). Anticholinergics: Hyoscine hydrobromide : min. age 4 years for Kwells Kids, 3 years for Joy-Rides. It has anti-muscarininc adverse effects. CI – Prostatic enlargement, glaucoma, myasthenia gravis, paralytic ileus, pyloric stenosis - caution in patients taking interacting meds - short-acting (up to 4 hours) - taken 30mins before travel Summaries of medicines for travel sickness are listed in (tables 6-7 and 6-8). Hyoscine 3-Herbal remedy (Alternative or complementary medicine) Ginger (Zingiber officinale) powder: Ginger has been used for many years for travel sickness. Clinical trials have produced conflicting findings in travel sickness (1). Ginger would be worth trying for drivers who suffered from motion sickness and it may be worth considering for pregnant women for whom other antiemetics may not be used (1). - likely to act in GI tract - no dosage level established - non-drowsy - may be safe in pregnancy Table 6-7: Summary of medicines for travel sickness (part 1) Minimum Timing of 1st Dose Dose for prevention of Motion age for dose in relation interval sickness use (year) to journey (hour) Child 5–11 years: Initially 15 mg, then 7.5 mg. Child 12–17 years: Initially 30 Cinnarizine 5 2 h before 8 mg, then 15 mg. 7  Adult: Initially 30 mg, then 15 mg (7). Hyoscine 3 20 min before 6 Child 4–9 years: 75–150 mcg. hydrobromide Child 10–17 years: 150–300 mcg. Adult: 150–300 mcg (7). Meclozine 2 Previous 24 2–12 years: 12.5 mg. evening Adult: 25 mg (1). or 1 h before Promethazine 5 Previous 24 Child 5–9 years: 12.5 mg once teoclate evening daily. or 1 h before Child 10–17 years: 25 mg once daily. Adult: 25 mg once daily (7). Table 6-8: Summary of medicines for travel sickness (part 2) (6) Likely side Drug interactions Patients in which effects of note care is exercised Cinnarizine, Dry mouth, Increased sedation Angle-closure glaucoma, Meclozine, sedation with alcohol, opioid Prostate enlargement Promethazine analgesics, anxiolytics, teoclate hypnotics and antidepressants Hyoscine Dry mouth, Increased Angle-closure glaucoma, hydrobromide sedation anticholinergic side Prostate enlargement effects with Tricyclic antidepressants and neuroleptics Note :( Dry mouth): many people complain of the side effect of dry mouth. This is easily overcome by sucking a sweet, which will stimulate saliva production (6). References 1-Alison Blenkinsopp, Paul Paxton and John Blenkinsopp. Symptoms in the pharmacy. A guide to the managements of common illness. 7th edition. 2014. 2-Nathan A. Non-prescription medicines. 4th edition. London: Pharmaceutical Press. 2010. 3-W. Steven Pray.Understanding Motion Sickness. US Pharm. 2008;33(1):14. 4-Nathan A. fasttrack. Managing Symptoms in the Pharmacy. Pharmaceutical Press. 2008. 5-American pharmacists association. Handbook of Non-prescription drugs: An Interactive Approach to Self-Care. 18th edition. 2016. 6-Paul Rutter. Community Pharmacy. Symptoms, Diagnosis and Treatment. 4th edition. 2017. 7-BNF -74. Further reading 1-Nasal strips should not be used over any wound on the nose, or if the skin is irritated or sunburned. The maximum time of use is 12 hours daily, and those allergic to adhesives or tape should not use them. If strips cause skin irritation, they should not be used. Pharmacists should instruct patients that mouth breathing is often a long-standing 8 habit, and it may take 7 to 10 nights of strip use before the patient learns to breathe through the nose again (1). 2-Nasal strips are available in several options to fit patient preference. Most are sized for adults, but a “kids” strip is available. Another option is color. Since patients may object to having a visible tan strip placed over the nose, less noticeable transparent strips are available (1). 9