combined therapy with seratonergic drugs increases risk of seratonin syndrome. (triptans, SSRIs, SNRIs, MAOIs)
Has added benefits in depression, anxiety, bruxism.
May cause seratonin syndrome (shivering, diaphoresis, hypomanic behaviour and ataxia) alone (rare), or when combined with other serotonergic drugs.
5 Zolpidem
Rapid onset of action- good for sleep onset. t1.2 2.5-3 hrs.
Nausea, dizziness, drowsiness, rebound insomnia.
Costs TWICE Zopiclone.
CI: severe hepatic impairment, respiratory insufficiency.
NOT for frequent awakenings or wake too early (short half life).
No bitter taste (vs. Zopiclone)
Similar to Zopiclone: suicidal ideation, worsening depression, aggressive behaviour.
What I would Rx (including d/c of Rx)
Date, Name, address of patient.
Rx: Zopiclone 3.75mg
Sig:
Mitte:
No Refills.
Name, Sign, Reg #.
Pro: does not accumulate, free of cognitive effects, minimal additive effects with low dose alcohol. Less addictive than BZD.
Con: bitter/metallic taste, may cause rebound insomnia and daytime anxiety on withdrawal. Habit forming in some- does have street value.
Lowest effective dose, ideal prn (<4X/week), Ideal short term treatment (2-4 weeks) depending on presentation. Need for tapering if longer term dosing (cut dose 25% per week), Consider WHEN to dose based on patient presentation (wakes late in the night, early in the night, etc.) mixed with ONSET of medication. Such as, for slower onset: take dose 1 hour before bed time, crawl into bed 30 min before “sleep” time. Patient plays active role in treatment.
Monitoring Parameters
EFFICACY
&
TOXICITY
(10 marks- add more that are case specific in exam)
Doctor questions re: meds that can cause insomnia (see below), lights, sleep hygiene, stress, pain, etc.
Emergance of a mood disorder
All follow-up visits, even into the following year
Protracted insomnia can be prodrome for mood disorder. Doctor monitors.
Misc
Rx Changes
After 2 weeks if no improvement, re-evaluate compliance with sleep hygiene and psychological and medical status, then another 2 week course of hypnotic. If poor response then, refer for 2nd opinion from sleep specialist, neurologist, psychologist, etc. Withdraw at low stress time and shorten sleep by 20 min 2 nights before.
Other Tx
Non-pharm options: proper sleep hygiene (same wake/sleep time, calm down time before bed, no lights, etc.), relaxation/breathing exercises and tapes, stimulus control, sleep restriction, sleep diary, exercise earlier in the day (45 min with sweating), CBT for insomnia.
