sleeping pills

Insomnia Medications – A review of popular sleeping pills

There are many insomnia medications available to people who are having difficulty falling asleep. Prescription and over-the-counter options have been around for decades.Each has its own advantages and disadvantages.

It is reported that nearly 60 million Americans are affected by a sleep disturbance or disorder each year and to date there still continues to be research into the best method for treating these conditions that have the potential to impact an individual’s quality of life. One of the most notable sleep disturbances that can be faced by many Americans is insomnia. Insomnia is defined as the inability to initiate or maintain sleep when there is no known physical or mental condition that is preventing the individual from sleeping s which has the potential to cause significant distress and impairments .   It  is recognized as one of the most commonly identified sleep related issues with  about 10-15% of the American population experiencing  sleep relate impairment. There are about 100 identifiable causes of sleepiness or sleep disturbances but the act of simply recommending a sedative to a patient who has daytime sleepiness could have serious consequences if the person’s daytime sleepiness is caused by sleep apnea.

Contributing factors to Insomnia

The presence of primary insomnia can result from the combination of psychological, environmental, biological, or physical factors and has the potential to develop in any individual.  Acute insomnia can progress to chronic insomnia which only tends to develop in a smaller percentage of patients who may possess preexisting factors.

Review of Sleep Pattern

By taking a detailed sleep history this can help to determine why the patient is sleepy or having difficulty with initiating and/or maintain sleep . With this detailed sleep history in a person can be referred to their physician where pharmacotherapy or not non-pharmacological interventions can be initiated. Ultimately the best approach is to treat the underlying cause of the sleep problems to target the sleep issue. In order to effectively track an individual’s sleep issue the presence of a sleep history can increase the likelihood of the identification and resolution of the sleep issue

A regular circadian rhythm is shifted with DSPS & DSPD
A regular circadian rhythm is shifted with DSPS & DSPD

Pharmacological and Nonpharmacological Interventions

For many years the benzodiazepine hypnotics (eg., temazepam, estazolam) were considered the  hypnotics of choice due to their relative safety in comparison to bariburates but there has been a growth in the use of nonbenzodiazepine hypnotics.  The benefits of short-term and intermediate-term benzodiazepines are recommended for the treatment of insomnia but as a downside the class can be associated with addictive qualities and withdrawal symptoms.

The use of the benzodiazepine receptor agonists (eg., zolpidem, zaleplon, eszopiclone) are considered to be one of the first-line therapies given their effectiveness with helping to improve sleep latency and quality.

Zolpidem is a sedative hypnotic of the imidazopyridine class that is generally regarded as a good first choice for sleep-onset insomnia.

Zalpelon is a nonbenzodiazepone hypnotic from the pyrazolopyrimidine class that is also indicated for sleep-onset insomnia with a quick onset of action.

Eszopiclone is a nonbenzodiazpeine hypnotic of the cyclopyrrolone class whose mechanism of action is not quite knowne but is generally use to lower sleep latency and improve sleep maintenance. As a class the benzodiazepine receptor agonists are known to help individuals to fall asleep, aid with difficulty falling asleep, and the maintenance of sleep.  However, these nonbenzodiazepines can contribute to next day drowsiness or impair performance, or decision-making process. Antidepressants (e.g,m amitripyline,mirtazapine)  are also utilized for insomnia in the treatment of sleep maintenance or insomnia that is associated with depression.The benefits that can be associated with antidepressants include the management of concurrent issues related to sleepiness and anxiety but can contribute to transient gastrointestinal effects, weight gain, constipation, dizziness, or sexual dysfunction.

Ramelteon (Rozerem®), a melatonin receptor agonist, is also approved for the treatment of insomnia in the United States. It is noted to work by being specific to the MT1 and MT2 receptors that are located in the areas of the hypothalamus that controls the circadian rhythm, wakefulness, and alertness and is not associated with any nonspecific central nervous system sedation. Unless other agents that may not be used long-term, it can be used long-term and not associated with abuse or dependence.

On the other hand, there are non-drug treatments for sleep disturbances such as cognitive behavioral therapy (CBT) which is shown to be effective in up to 80% of patients with persistent insomnia. The purpose of using CBT is to focus on changing or modifying the beliefs and attitudes about sleep, providing stimulus control, and sleep restriction. In order to achieve optimal benefit non-drug approaches should be initiated concurrently with drug therapy for sleep disturbances.

Ongoing Management of Insomnia

For all patients that present with insomnia, whether acute or chronic, education should also be provided about nonmedicine interventions to achieve good sleep hygiene and pattern. Prior to the initiation of any pharmacological intervention, it is important for sleep hygiene to be assessed. Good sleep hygiene techniques can include establishing a regular sleep habit, creating a routine to unwind prior to bedtime

When it comes to addressing sleep disturbances it is best to attempt to treat the underlying cause through non-pharmacological intervention or sleep hygiene techniques as first line. If after an optimal duration and these interventions prove to not be successful, consideration can be given for pharmacological interventions with the goal of helping to improve sleep latency and quality. The initiation of a therapeutic intervention should be carefully evaluated  on a case by case basis and assessment as to which medication would be most appropriate for a given patient.

 

Author: Abimbola Farinde, PharmD

Dr. Farinde is a clinical pharmacist specialist and professor. Her areas of experience are in psychopharmacology and geriatrics with research endeavors focused on cognitive decline, behavioral and neuropsychiatric disturbances in the elderly population.

References:

  1. Hersen, M., Turner, S. & Beidel, D. (Eds.). (2007). Adult psychopathology and diagnosis. (5th ed.) Hoboken, NJ: John Wiley & Sons.
  1. Hahn, R.K, Albers, L.J., & Reist, C. (2008).Psychiatry.Blue Jay, California: Current Clinical Strategies Publishing.
  2. Dopp, J.M. & Bradley, B.G. (n.d.). Sleep Disorders. Pharmacotherapy Self-Assessment, 6th edition.
  1. Kelso,M. (2014). Primary insomnia. Medscape. Retrieved from http://emedicine.medscape.com/article/291573-overview
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