Rebound insomnia

Sedation, anterograde amnesia in severe OD (or IV use), reverse with flumazenil Rebound insomnia, rebound anxiety... 

A rebound sleep disturbance has been found after only 7—10 days of treatment with therapeutic doses of triazolam (Greenblatt et al. 1987). Others have described a withdrawal syndrome after substitution of a short-acting benzodiazepine for a long-acting benzodiazepine (Conell and Berhn 1983). Rebound insomnia may occur with zolpidem. 

On discontinuation of hypnotic BZDRAs, patients can experience rebound effects, specifically rebound insomnia that may last for one to two nights. Rebound insomnia occurs more frequently after discontinuation of shorter-duration BZDRAs compared with long-duration BZDRAs. Intermittent hypnotic therapy with the lowest dose possible reduces the likelihood of tolerance, dependence, and withdrawal when therapy is stopped. Patients should be counseled that rebound insomnia is not necessarily a return of their original symptoms, and it may take a few nights for rebound symptoms to subside. 

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). 

Abrupt withdrawal of TCAs (especially high doses) may result in symptoms of cholinergic rebound (e.g., dizziness, nausea, diarrhea, insomnia,... 

Zaleplon also binds to the GABAa receptor. It has a rapid onset, a half-life of about 1 hour, and no active metabolites. It does not reduce nighttime awakenings or increase the total sleep time. It may be best used for middle-of-the-night awakenings. It does not appear to cause significant rebound insomnia or next-day psychomotor impairment. The most common side effects are dizziness, headache, and somnolence. The recommended dose is 10 mg (5 mg in the elderly). 

Rebound insomnia occurs frequently with high doses of triazolam, even when used intermittently. 

Rebound insomnia can be minimized by utilizing the lowest effective dose and tapering the dose upon discontinuation. 

Insomnia can be a common problem for people when first changing a drug problem. Sleeping problems can be related to the rebound effects of the drugs, or may be related to rumination and regret. Since insomnia is common, therapists and counselors will likely want to teach their clients how they can reduce the duration of this potentially uncomfortable problem. To orient the client, the counselor or therapist will want to emphasize to the client that insomnia is not life threatening, and that eventually he or she will sleep. This orientation is meant to put the client at ease... 

The most common side effect of clonidine is drowsiness. This can begin with the very hrst dose and usually goes away after a few weeks. Clonidine s sedating effects can actually be useful when it s taken at bedtime. Insomnia is a common problem for patients with ADHD either as a side effect of stimulants or as a consequence of rebound hyperactivity at night when the daytime dose of stimulant has worn off. Clonidine can help the ADHD patient with insomnia to go to sleep. Other side effects of clonidine include low blood pressure, dizziness, depression, dry mouth, nausea, and slowed heart rate. One important point to remember is that not only does clonidine not cause tics, it can, in fact, relieve tics when they appear in patients with ADHD. 

Stimnlants can also canse insomnia. However, insomnia can also result from rebound hyperactivity when the daytime dose of stimulant has worn off In either case, before stopping the stimnlant, it is prudent to consider a bedtime dose of cloni-dine. Clonidine may relieve not only nighttime hyperactivity bnt insomnia as well. 

What to do with the patient who is a long-time user of sedative-hypnotics is often a difficult clinical decision. The most successful treatment approaches seem to be those that are gradual and address the insomnia from a multimodal perspective. Many of the sedative-hypnotics with moderate or longer half-lives will display rebound insomnia on discontinuation and this only complicates the treatment picture. At some point, one has to ask if discontinuing the chronic use of a sedative-hypnotic, in the absence of any harmful effects, is treating the patient or the prescriber. 

Triazolam (ti/2 of elimination -1.5-5.5 h) is especially likely to impair memory (anterograde amnesia) and to cause rebound anxiety or insomnia and daytime confusion. The severity of these and other adverse reactions (e.g., rage, violent hostility, hallucinations), and their increased frequency in the elderly, has led to curtailed or suspended use of triazolam in some countries (UK). 

Sleep disorder Rebound sleep disorder, which is characterized by recurrence of insomnia to levels worse than before treatment began, may occur following abrupt withdrawal of triazolam, usually during the first 1 to 3 nights. Gradual rather than abrupt discontinuation of the drug may help avoid this syndrome. 

Eszopiclone has been approved for the treatment of patients who experience difficulty falling asleep, poor sleep maintenance, and for long-term treatment of insomnia. Clinical trials have shown that eszopiclone improved sleep onset, sleep maintenance, total sleep time, sleep quality, and daytime functioning compared with placebo. Improved wake time alertness, concentration, and sense of well-being were reported. Eszopiclone was well tolerated, with only mild adverse events reported. There was no evidence of dmg-drug interactions, tolerance, residual drowsiness or treatment-related rebound insomnia. The recommended dose to improve sleep onset and maintenance is generally between 1 and 3 mg. 

Abrupt withdrawal may result in rebound hypertension associated with nervousness, agitation, anxiety, insomnia, hand tingling, tremor, flushing, and diaphoresis. 

Drowsiness, sedation, rebound insomnia (may occur for 1-2 nights after drug is discontinued), dizziness, confusion, euphoria Occasional... 

CNS Bowel Dysfunction Bladder Dysfunction Falls Other Withdrawal symptoms after long-term use, rebound insomnia... 

Somnolence, sedation, mild rebound insomnia (on first night after drug is discontinued)... 

Insomnia, decreased appetite, weight loss, dysphoria Possible reduction In growth velocity during long-term use Withdrawal and rebound hyperactivity Unmasking or induction of tics... 

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