Insomnia: Assessment and Treatment in Primary Care (Part Two of Two)

When efforts to change sleep hygiene profiles prove unsuccessful and other contributing conditions have been examined and ruled out, use of a medication may be appropriate. Both prescribed and over-the-counter options are available and choice can be based on patient preference, clinical symptoms and need for short-term versus long-term treatment.

Prescription Meds: In general the most studied and effective medications for short term and/or intermittent treatment of insomnia are the benzodiazepines and the hypnotic “Z” drugs (zolpidem, zaleplon, eszopiclone). Risks include dependency, excessive sedation, cognitive impairment and complex sleep related behaviors. Sleep onset insomnia will typically benefit more from short acting medications such as zolpidem, zaleplon, or triazolam. If there are issues with maintenance of sleep a longer acting choice such as eszopiclone, zolpidem ER, lorazepam, or temazepam may be more beneficial, but these may carry an additional risk of morning sedation.

Other options that could be used when there are concerns about abuse of these medications or addictive risk, include low doses of sedating antidepressants such as trazodone, mirtazapine, amitriptyline and doxepin. These agents are not infrequently used as long-term agents, when effective. Use of quetiapine (Seroquel) or clonidine may also be an option.

OTC: Over the counter options for insomnia typically have antihistamines as their active ingredient. Generally these are fairly safe and a viable option though the research has not supported their use for treatment of primary insomnia. Nonetheless, these agents are popular and readily accessible.

Herbals: Herbal products are also frequently used even though studies of effectiveness are limited or inconclusive. It is important to inform patients of possible negative effects of these substances along with information about their potential benefits. The most common alternative remedies used for insomnia include melatonin, valerian, kava, chamomile, St. John’s wort, and 5-Hydroxytryptophan (5-HTP).

Melatonin has some of the best research supporting its use in sleep disorders, mainly for disorders of the circadian rhythm. There are few side effects associated with melatonin and it may help with both sleep onset and maintenance. Research only supports the use of doses between 0.3-0.6 mg, higher doses will raise blood levels of melatonin throughout the day with risk of daytime sedation as well the potential of hyperprolactinemia. A melatonin agonist (ramelteon) is also now available.

St. John’s wort has been used for depression, anxiety and sleep. It is believed to work on the GABA and serotonin systems. In general it is probably safe to use for insomnia but the patients should be warned about various interactions with other medications as St. John’s wort affects the p450 system and thus can increase the risk of serotonin syndrome if taken along with an SSRI medication.

Other Herbals: Valerian appears to work on the GABA system through benzodiazepine-like activity. It should not be used by pregnant or breast feeding women and there has been some reports of possible liver failure. Three or more weeks of daily use may be required for efficacy to become apparent. Kava has also been frequently used for insomnia and it too appears to work through the GABA system. There have also been some reports of liver failure with its use. Chamomile is generally used in a tea for insomnia. It has very little research supporting its use in insomnia but has very few potential adverse effects so there is no reason to discourage its use if the patient desires. Finally 5-HTP is a serotonin precursor that may have some benefit for insomnia, though the evidence is weak. It may take 6-12 weeks of use to see any benefit and because it raises serotonin levels use with other serotonergic medications may increase the risk of serotonin syndrome.

In summary behavioral treatments for insomnia should always be used first but if ineffective then use of a medication or herbal supplement could be tried. First line treatment for short term use should probably be a benzodiazepine or a “Z” drug. Use of herbal supplements while lacking rigorous studies, do seem to have some benefit and in general low side effects profiles so they could be recommended as possible treatment options. Patients should be advised that these substance are not intrinsically safe because they are “natural” and that they can have side effects and drug interactions. Additionally, they are unregulated and can be subject to contaminates that may be harmful. Patients should try to obtain these substances from reputable sources. If the patient does not respond to sleep aid options or they are unable to be tapered off the prescription meds after 1-2 months, then it would be recommended refer to a sleep clinic for further evaluation and treatment.

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