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G. C. Carlson et al.
The choice of pharmacotherapy agent should be made using a shared decision­making approach. Factors to consider include type of insomnia (sleep onset, main­tenance, or early awakening), consideration of the patients’ age, comorbidities inclusive of renal and hepatic dysfunction, additional medications including poly­pharmacy, response to prior therapy, cost and availability of medications, prior his­tory of dependence on controlled substances, and patient and clinician preferences. Medication alone rarely results in a full remission of insomnia disorder, and over time increased dosage is needed to obtain the same efcacy. In addition, unlike CBT-I, where the effects of treatment are long lasting, discontinuation of pharmaco­therapy for insomnia results in return of the insomnia symptoms.
Several randomized controlled studies comparing pharmacotherapy vs. CBT-I have been performed with consistent ndings that behavioral therapies are superior in treating insomnia when compared to medication and that the effects achieved with behavioral therapy are long lasting. Morin etal. compared CBT-I with temaze­pam for an 8-week treatment period and then a 2-year follow-up [88]. In this study, CBT-I was superior to temazepam in improving sleep time after sleep onset imme­diately post-treatment, and at 24months follow-up, CBT-I gains in sleep time were sustained while the temazepam group was similar to the placebo group. Similar results were noted by Jacobs etal. using CBT-I compared to zolpidem when using sleep latency as a primary outcome [89]. CBT-I resulted in more sustained benets than medications in both studies.
Non-Benzodiazepine receptor agonists (non-BZRAs) Non-BZRAs are com­monly used to treat insomnia and include eszopiclone, zaleplon, and zolpidem. Middle of the night formulations (dissolving tablets or spray) of zolpidem are avail­able. The mechanism of action is enhancement of the neurotransmitter gamma­aminobutyric acid (GABA) function at the GABA-A receptor within the central nervous system (CNS). These medications are FDA approved for sleep onset and sleep maintenance insomnia and, due to their shorter half-life (1–6hours), are con­sidered to have a better safety prole and less daytime impairment when compared with benzodiazepines. They are all Schedule IV controlled substances although appear to have less potential for abuse when compared with traditional benzodiaz­epines. All the non-BZRAs are metabolized by CYP enzymes resulting in potential drug interactions and in reduced recommended dosages in older patients. For mid­dle of the night awakenings, zolpidem spray and sublingual dissolving tablets offer a faster onset of action. Zaleplon can also be considered due to its very short half­life (1hour). For middle of night awakening, these medications can be used if there is remaining 4hours of sleep after the awakening. Zolpidem extended release has the longest half-life and can be considered in patients where the other non-BZRAs wane in efcacy over the course of the night. In addition to the usual central nervous system impairment noted with all insomnia medication, the non-BZRAs carry an FDA box warning for sleep behaviors such as sleepwalking, sleep driving, sexsom­nia, and sleep eating among others. They should not be prescribed in patient with preexisting parasomnias. According to a meta-analytic review, these medications
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decrease sleep latency by 10–20minutes and increase sleep time by 10–30min­utes [90].
Benzodiazepine receptor agonists (BZRAs) BZRAs with FDA approval for insomnia include estazolam, urazepam, quazepam, temazepam, and triazolam. All are Schedule IV controlled substances and tend to be avoided for treatment of insomnia due to their longer half-life when compared with non-BZRAs, increased potential for dependence, and increased risk for side effects with abrupt discontinu­ation. Benzodiazepines also function by enhancing GABA at the GABA receptor within the CNS but have less afnity for the GABA-A receptor, and thus tend to cause more sedation than their non-BZRA counterparts. They are metabolized by CYP-34A, and like the non-BZRA medications, adjustments must be made for age and polypharmacy. Due to the long half-life of these sedatives, the FDA has placed a box warning to avoid with use of narcotics due to the concern for respiratory sup­pression. Studies on the efcacy of BZRAs use both self-reported and polysomnog­raphy data, and the results vary. On average this class of medication reduces sleep latency by 10–20minutes and increases nighttime sleep by 30–60minutes [90].
Melatonin receptor agonists Ramelteon is a MT1 and MT2 melatonin receptor agonist which is FDA approved for the treatment of sleep onset insomnia. Ramelteon is cleared by CYP1A2 and CYP2C9 and should be avoided in individuals with severe liver disease and those on medications inhibiting these enzymes (i.e., uvox­amine). Effect size of ramelteon is small, but a meta-analysis showed a reduction in sleep latency of approximately 5 minutes and increase in overall sleep time of 7minutes [91].
Orexin receptor antagonists Lemborexant and suvorexant are dual orexin recep­tor antagonists (DORAs) which function at the OX1R and OX2R receptors. Both are FDA approved for sleep onset and sleep maintenance insomnia. The orexin/ hypocretin system initiates at the hypothalamus and communicates with multiple wake-promoting regions of the brain responsible for secreting acetylcholine, dopa­mine, histamine, norepinephrine, and serotonin. As with other insomnia medica­tions, DORAs cause somnolence. This class should specically be avoided in individuals with narcolepsy and individuals on medications which inhibit CYP3A and those with hepatic impairment. Both medications improve sleep onset latency and increase sleep time [92].
Antidepressants
Trazadone is one of the most commonly prescribed antidepres-
sants for insomnia, and it improves some sleep parameters over the short-term [93]. Its mechanism of action is via antagonism of 5-HT2A, 5-HT2B, alpha-1A, and 2C receptors, agonism of 5-HT1, and inhibition of serotonin reuptake. The AASM clinical practice guidelines recommend against use of trazadone for insomnia as there is minimal data regarding its efcacy and a very small size effect which was
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not sustained over time noted in the one randomized trial available for inclusion in the guidelines [87]. There are many potential side effects of trazadone including QT prolongation, orthostatic hypotension, priapism, increased suicidal ideation, mania and hypomania, closed-angle glaucoma, and serotonin syndrome, among others. Due to the potential side effects at higher doses, it is not recommended to increase doses over 150mg nightly for the treatment of insomnia. Trazadone also has a long half-life (10–12 hours) leading to the risk of increased daytime sleepiness in patients [94].
Low-dose doxepin (3 or 6mg tablets) is FDA approved for the treatment of sleep maintenance insomnia. Doxepin is a tricyclic antidepressant with primarily antihis­tamine antagonist (H1 receptor) features at a low dose. As with all other tricyclic antidepressants, MAOI inhibitors need to be avoided, and it should not be used in patients with urinary retention or those with untreated closed-angle glaucoma. Due to the cost of the low-dose tablets, providers may sometimes prescribe the liquid formulation or the 10 mg tablets, which are signicantly lower priced in the USA.On average doxepin increases sleep time by 25–40minutes.
Antipsychotics Quetiapine is a commonly prescribed anti-psychotic medication
for insomnia although there is minimal data on its effect on sleep in patients without psychiatric disease, and it poses signicant side effect risks [87]. Its mechanism of action is not wholly understood but is known to be a D2 and 5-HT2 antagonist, and it is metabolized by CYP3A4. It has a high side effect prole including orthostatic hypotension, dizziness, suicidality in younger patients, and extrapyramidal symp­toms, among others. Due to its high side effect prole and the paucity of data on sleep, it is not recommended for the treatment of insomnia, especially in individuals without mood disorders or schizophrenia [95].
G. C. Carlson et al.
Nutritional Supplements
Several dietary supplements are marketed for insomnia. Dietary supplements are not FDA regulated, resulting in variability of concentration and purity of active ingredients [96]. Although there is scant evidence for the efcacy of supplements for the treatment of insomnia, overall, the risk for adverse effects is low. Hepatic failure, however, has been reported with valerian root and kava root.
Melatonin Melatonin is a commonly used dietary supplement for the treatment of
insomnia. It is a melatonin receptor agonist acting at the suprachiasmatic nucleus, among other areas. As with endogenous melatonin, exogenous melatonin assists with sleep onset by reducing arousal caused by the suprachiasmatic nucleus. It is typically dosed between 1 and 5mg for insomnia. Studies of efcacy of melatonin for the treatment of insomnia show a minimal effect on sleep onset and total sleep time, which may not be clinically meaningful [97]. Potential side effects include
13 Management ofInsomnia Disorder
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headache, nightmares, dizziness, and daytime sleepiness. Exogenous melatonin is not recommended for use by AASM clinical practice guidelines due to the lack of efcacy data [87].
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Medication Treatments forInsomnia: Safety Considerations
All medications for treatment of insomnia can result in depression of the central nervous system and motor impairment leading to increased risk of falls, motor vehi­cle accidents, and occupational accidents. This is confounded in individuals with polypharmacy inclusive of other sedating medications, individuals with cognitive impairment, individuals with obstructive sleep apnea, and in those who drink alco­hol. The benzodiazepines can also suppress respiratory drive. This is enhanced by addition of opiates and other sedating medications leading to a potential deadly combination.
Special consideration in the pharmacologic treatment of insomnia needs to occur in individuals where side effects are particularly problematic or may increase risk for adverse outcomes. This includes:
• Advanced age
• Cognitive impairment
• Fall risk
• Obstructive sleep apnea or hypoventilation
• Hepatic and renal impairment
• Concomitant medications which induce or inhibit CYP P450 3
• Polypharmacy inclusive of opiates or other sedating medications
• History of dependence on controlled or illicit substances
• History of signicant depression, especially in those with active or historical
suicidal ideation or attempts
• Abnormal sleep behaviors
There is also extensive epidemiological data indicating increased mortality with hypnotic use. Kripke etal. [98] reviewed 10,529 patients who received hypnotic prescriptions in the USA (mean age 54) and 23,676 matched controls between 2002 and 2007. After controlling for other co-factors associated with increased mortality the group prescribed hypnotics had a mortality hazard ratio (HR) from 3.6 to 5.32 compared to controls, with increasing HR in individuals with higher number of prescriptions for hypnotics. Similar ndings were reported in a later study by Linnet et al. in multi-morbid and non-multi-morbid patients with increasing mortality noted in individuals with high numbers of hypnotic prescriptions [99]. Although the specic cause of death is not delineated in these cohort studies, there is ample evi­dence to suggest increased mortality with increasing number of prescriptions for hypnotics.
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G. C. Carlson et al.
Summary of Key Points
Insomnia is highly prevalent with the population [100]. CBT-I is the rst line
treatment for insomnia disorder, and a large body of research shows that
CBT-I is highly effective for the treatment of insomnia in patients with mul-
tiple medical and psychiatric comorbidities [8, 32]. The strongest research is
for the delivery of CBT-I in an individual treatment format, but there is also
research demonstrating the helpfulness of group-based CBT-I, self-guided
CBT-I, and apps as a supplement to traditional CBT-I treatment [45, 47].
There is also research support for BBT-I and mindfulness-based intervention
for insomnia [51, 62]. The risks associated with behavioral treatments for
insomnia are minimal, though there are circumstances in which some inter-
vention components (e.g., sleep restriction) may be contraindicated [72, 73].
It is important to thoroughly assess daytime activities, comorbid sleep disor-
ders, medical conditions, and mental health conditions, as well as potential
safety concerns prior to initiating behavioral treatments with patients endors-
ing insomnia symptoms. CBT-I has been shown to be superior for the treat-
ment of insomnia when compared with pharmacologic treatment in terms of
immediate effect on sleep and longevity of treatment. Ideally, pharmacother-
apy should not be used without a behavioral component to address factors that
contribute to insomnia maintenance over time; however, pharmacotherapy
can be used in specic situations with emphasis on a time-limited treatment
plan and monitoring of side effects.
Patient preferences are important considerations when providers collabo­rate with patients to develop a treatment plan. The shared decision-making model of clinical practice involves presenting evidence-based treatment options to the patient [101]. In the case of insomnia, this would involve edu­cating patient about the strong recommendation for the use of CBT-I to treat insomnia disorder and conditional recommendations for behavioral compo­nents of CBT-I to treat insomnia disorder. Providers should also describe the risks associated with CBT-I relative to medication treatments for insomnia and the impact of CBT-I and/or medications on any comorbid conditions (e.g., sleep apnea) and their corresponding treatments (e.g., CPAP). This informa­tion will allow patients to make informed choices about their treatment. While each patient is unique, research suggests that patients prefer non-medication treatment for insomnia over medication treatment [102]. Additionally, when patients with comorbid insomnia, depression, and PTSD are presented with evidence-based treatments for each condition, a study found that patients report preference for CBT-I [103]. Figure13.1 includes a decision-making framework for providers to follow after they have educated patients about evidence-based treatments for insomnia. Through a collaborative and trans­parent process, providers can connect patients with insomnia symptoms to the most effective interventions available.
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13
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