Insomnia management

Krystal AD The changing perspective of chronic insomnia management. J Clin Psychiatry 2004 65(Suppl 8) 20. 

Benzodiazepines also are used for purposes other than anxiety and insomnia management. For example, benzodiazepines have muscle-relaxant and anticonvulsant actions and arc often used as a treatment for muscle spasms and seizures. Short-acting benzodiazepines such as midazolam (trade name Versed) arc used as anesthetics in some surgical procedures. 

Benzodiazepines and other anxiolytics. Although benzodiazepines are widely used in the treatment of acute alcohol withdrawal, most nonmedical personnel involved in the treatment of alcoholism are opposed to the use of medications that can induce any variety of dependence to treat the anxiety, depression, and sleep disturbances that can persist for months following withdrawal. Researchers have debated the pros and cons of the use of benzodiazepines for the management of anxiety or insomnia in alcoholic patients and other substance abuse patients during the postwithdrawal period (Ciraulo and Nace 2000 Posternak and Mueller 2001). 

Phentermine is available as an immediate-release and a sustained-release product. In conjunction with a healthy lifestyle, 30 to 37.5 mg of phentermine is administered once daily, typically before breakfast or 1 to 2 hours following the morning meal. The dosage should be individualized some patients maybe managed adequately at 15 to 18.75 mg daily, whereas a dose of 18.75 mg twice daily may be used to minimize side effects, excluding insomnia. To lessen the risk of insomnia, dosing phentermine in the evening should be avoided. Timed-release preparations of phentermine are not recommended because phentermine s half-life is approximately 20 hours.39... 

BZD effects on human sleep are well characterized (Mendelson 2001) (a) decreased sleep latency (b) decreased awakenings (c) increased stage II sleep (d) suppressed stage III and IV sleep (e) increased REM sleep latency (f) initial reduction and fragmentation of REM sleep. Discontinuation of BZD treatment after three to four weeks produces a rebound of REM sleep as well as slow-wave sleep (SWS). BZD and non-BZD compounds are pharmacological agents indicated in the management of anxiety, insomnia, and other conditions in which anxiety is the main symptom, and should be considered as symptomatic medications (Nishino et al. 2004). 

Management includes identifying the cause of insomnia, education on sleep hygiene, stress management, monitoring for mood symptoms, and elimination of unnecessary pharmacotherapy. 

NIH State-of-the Science Conference Statement on Manifestations and Management of Chronic Insomnia in Adults (ed. NIH, National Heart, Lung and Blood Institute, National Center on Sleep Disorders Research), 2005. 

Walsh JK. Pharmacologic management of insomnia. J Clin Psychiatry 2004 65(Supplement 16) 41-45. 

Circadin is the proprietary preparation of melatonin, which is used for the short-term management of insomnia. 

Diazepam is used for the control of anxiety and tension, the relief of muscle spasms, and the management of acute agitation during alcohol withdrawal, but it itself may be habit-forming. Chlordiazepoxide has similar uses and its synthesis is somewhat analogous to diazepam. Flurazepam is a hypnotic, useful for insomnia treatment. It is reported to provide 7-8 hr of restful sleep. 

The adverse effects of caffeine are a common experience to most caffeine consumers. Too much caffeine results in uncomfortable to adverse central nervous system effects, or neurotoxicity. The effects include restlessness, tension, and mild tremor or the jitters and may progress to feelings of anxiety and even fear. Regular caffeine users soon learn how to manage their caffeine consumption to maintain blood caffeine at a desirable level that produces mild stimulation without the uncomfortable neurotoxic effects. Fortunately, the half-life of caffeine is short, so that any undesirable effects soon decline. Many people also experience insomnia from caffeine consumption. Caffeine s effect on sleep varies from individual to individual. Some people can consume caffeine late in the evening and sleep well, but for other people consumption of caffeine late in the day affects sleep. It is important to understand your own individual response to caffeine. 

Estazolam (Prosom) [C-IV] [Hypnotic/Benzodiazepine] Uses Short-term management of insomnia Action Benzodiazepine Dose 1-2 mg PO qhs PRN -1- in hqjatic impair/elderly/debilitated Caution [X, -] t Effects w/ CNS d ressants Contra PRG Disp Tabs SE Somnolence, weakness, palpitations, anaphylaxis, angioedema, amnesia Interactions t Effects W7 amoxicillin, clarithromycin T effects OF diaz am, phen5rtoin, warfarin X effects W7 food X effects OF azole antifungals, digoxin EMS Use caution w/ other benzodiazepines, may need a reduced dose concurrent EtOH and caffeine use can t CNS effects OD May cause alt ed reflexes, drowsiness, CNS depression, slurred speech, and Szs flumazenU can be used as an antidote... 

Unlabeled Uses Management of agitation and insomnia in dementia patients... 

McCall WV. Diagnosis and management of insomnia in older people. 1 Am Geriatr Soc 2005 53 S272-S277... 

American Psychiatric Association Benzodiazepine Dependence, Toxicity, and Abuse A Task Force Report of the American Psychiatric Association. Washington, DC, American Psychiatric Association, 1990 Cohn JB, Wilcox CS Low-sedation potential of buspirone compared with alprazolam and lorazepam in the treatment of anxious patients a double-blind study. J Clin Psychiatry 47 409 12, 1986 Dolovich LR, Addis A, Vaillancourt JM, et al Benzodiazepine use in pregnancy and major malformations or oral cleft meta-analysis of cohort and case-control studies. BMJ 317 839-843, 1998 Goldberg HL, Finnerty RJ The comparative efficacy of buspirone and diazepam in the treatment of anxiety. Am J Psychiatry 136 1184—1187, 1979 Kupfer DJ, Reynolds CF 111 Management of insomnia. N Engl J Med 336 341-346, 1997... 

Like almost all relevant authors, Lader and Petursson (1983) also advise against the long-term use of anxiolytics and they emphasize that most anxiety states and phases of insomnia generally last for only a limited period of time either the acute stress fades or the patient becomes used to the situation (or copes with it successfully), or a spontaneous remission occurs. In many cases the patient can be managed with advice and reassurance, and thus without medicaments. 

The major benefit of BZDs may be in diminishing some of the secondary symptoms of an acute exacerbation (e.g., insomnia, agitation, panic, and other general anxiety symptoms) that are not necessarily rapidly and specifically affected by lithium or antipsychotics. With this approach, exposure to antipsychotics may be precluded in some situations and kept to a minimum in others, thus avoiding the potential for more serious antipsychotic-induced adverse effects. Additionally, given the high comorbidity with alcohol abuse/dependence, concurrent withdrawal symptoms may also be managed with BZDs. 

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