doxepin PRN

[Dogdaysofsummer]

Anyone ever rx Doxepin PRN for sleep? I haven't but have a pt who states she had that before and it worked well for her.

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[michaelrack]

Anyone ever rx Doxepin PRN for sleep? I haven't but have a pt who states she had that before and it worked well for her.

Doxepin10 mg or the brand Silenor 3-6 mg are ok for sleep

 

[TexasPhysician]

Silenor is expensive because lower dosages have been found to be more effective for sleep. To get below 10mg, there is a liquid form that is cheaper. Otherwise it is only capsules.

 

[billypilgrim37]

I've had folks open up the 10mg capsule, dump about half out, and stick the capsule back together, with good results.

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[michaelrack]

I've had folks open up the 10mg capsule, dump about half out, and stick the capsule back together, with good results.

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You got to be careful about telling pts things like that. If something goes wrong, the state medical board and the malpractice attorney suing you aren't going to care that you were trying to save the patient $.

 

[PikminOC]

Any major SE with such a small dose of doxepin other than sedation? I would like to use it on my ambien patients. Im going to the look at the product insert for silenor now.

 

[Dogdaysofsummer]

Thanks for the feedback.
So this pt states she was on 200mg for sleep. I'm hesitant to go that high because titration would be tricky using this as a PRN medication and she doesn't want to take it daily...

 

[MedSchoolFool]

I've used Doxepin 10mg several times for insomnia and patients always seem to feel it worked great. Plus it isn't associated with rebound insomnia. However, not every attending is willing to let me use it so I don't get to rx it as much as I would like.

 

[PikminOC]

I've used Doxepin 10mg several times for insomnia and patients always seem to feel it worked great. Plus it isn't associated with rebound insomnia. However, not every attending is willing to let me use it so I don't get to rx it as much as I would like.

Why don't the attendings let you use it more often?

 

[SpiritiualDuck]

Studies for folks with sleep maintenace difficulties, in the range of 1mg, 3mg, and 6 mg the s/es were comparable to placebo with no reported anticholinergic effects. I've used 10mg for folks with some success, but the higher doses seem to pick up s/es. Liquid formulation would be a good choice so you could titrate about 5mg. If folks have trouble staying asleep then this is a good option.

I found an interersting article regarding doxepin for sleep compared to Silenor. I'm not sure if I believe that 10mg generic is greatly different than the lower doses like this article suggests.

http://stevebmd.files.wordpress.com/2011/03/silenorvsdoxepin10.pdf

 

[MedSchoolFool]

Why don't the attendings let you use it more often?

You know...TCA's are poison and such. Especially in residents hands.

 

[vistaril]

Anyone ever rx Doxepin PRN for sleep?QUOTE]

of course....this is standard practice.

 

[PistolPete]

Hey all!

Wanted to revive this old thread and ask about doxepin. Haven't used it all that much.

Is the sedative effect dose dependent? Thinking about using it as monotherapy for a depressed patient with sleep-maintenance insomnia, but it seems like the sedating effect may wear off over time, which would be a negative for her. In your experiences, what's the level of sedation at anti-depressant dose levels vs your standard 3 or 6mg used for insomnia only. Thoughts?

 

[thoffen]

Why does anyone think that a medication treatment of insomnia ever has anything beyond short-term, PRN, or placebo efficacy?

 

[st2205]

Why does anyone think that a medication treatment of insomnia ever has anything beyond short-term, PRN, or placebo efficacy?

Because "I've been on it for years and it's the only thing that works." These comments typically come on the heels of talking about how poor their sleep is.

 

[milesed]

Why does anyone think that a medication treatment of insomnia ever has anything beyond short-term, PRN, or placebo efficacy?

Some people have chronic sleep problems that are not solved by other means.
We use doxepin and trazodone back and forth a lot as they may lose effect at some point.

 

[thoffen]

yes it is more sedating but plateaus at some point. the sedative effects will wear off eventually. if you are going to use a sedating TCA why no go for good old fashioned amitriptyline which might be statistically speaking the most effective antidepressant. just bear in mind some pts can't cope with TCAs but I have found my pts who can't tolerate SRIs fare well with TCAs

If all you want from the med is sedation from H1 antagonism, low-dose doxepin is the way to go.

Rotating sedating medications with different mechanisms of action to ward off tolerance is intriguing.

Otherwise, some patients may hate me for it, but I try not to be complicit in reinforcing maladaptive sleep patterns in my prescribing practices. Usually the ones who get pissed off really are only looking to use mental health care as an object in their disavowal defenses anyway. Good to start setting and enforcing necessary therapeutic boundaries from the start. If they're not ready to actually get better, they'll look for someone else.

 

[Blitz2006]

Any major SE with such a small dose of doxepin other than sedation? I would like to use it on my ambien patients. Im going to the look at the product insert for silenor now.

Yeah, I'm interested in adverse effects with 10 mg doxepin?

As a PGY3, I've been drilled into my head that TCAs are evil. Here we only use Trazodone/Remeron/Vistaril for sleep.

Nobody speaks of this Doxepin in the clinical world...I wonder why?

It seems like a safe drug:

http://formularyjournal.modernmedic...oxepin-silenor-histamine-h1-receptor-antagoni

 

[PistolPete]

Thanks for the replies. In your guys' experience, how long do you have before the sedating aspect of a moderate to high dose TCA such as doxepin wears off? A month? Two?

 

[WisNeuro]

Yeah, I'm interested in adverse effects with 10 mg doxepin?

As a PGY3, I've been drilled into my head that TCAs are evil. Here we only use Trazodone/Remeron/Vistaril for sleep.

Nobody speaks of this Doxepin in the clinical world...I wonder why?

It seems like a safe drug:

http://formularyjournal.modernmedic...oxepin-silenor-histamine-h1-receptor-antagoni

Probably partially depends on your usual patient population. We don't see it much because 1) I don't believe it's in the VA formulary, and 2) it has a fairly significant anticholinergic burden, which is generally no bueno for my older patients with cognitive problems.

 

[Jules A]

Probably partially depends on your usual patient population. We don't see it much because 1) I don't believe it's in the VA formulary, and 2) it has a fairly significant anticholinergic burden, which is generally no bueno for my older patients with cognitive problems.

I don't use them very often because of my population of substance abusers who seem to love them as well as the fact that a majority of my patients who complain of chronic insomnia have at some point either accidentally or intentionally OD'd.

 

[WisNeuro]

. imho TCAs are underutilized in geriatric patients the pendulum has swung too far away from thier use in the elderly

Anticholinergic burden is understated in the elderly. Far too often I get pts on several heavy anticholinergics, cognitive problems abound, iADL's in the ****ter. We work with their PCP's and psychiatrists to clean up that mess, and voila, somehow their cognitive issues drastically improve! When there aren't many meds on board, maybe. But, these are never the patients I see. The patients I see probably average 10-12 different meds.

 

[vistaril]

The question is ridiculous...of course many of us try doxepin for sleep sometimes. Along with the other usual sleep meds. Along with the usual sleep hygiene tips and pt education that pts ignore. My 7 yo nephew can do the same thing.....give him a 3 day course in psychopharmacology and he would be just fine in terms of prescribing doxepin, trazodone, melatonin, restoril, and whatever else new garbage is out for what pts describe as imsonmnia.

 

[Blitz2006]

Anticholinergic burden is understated in the elderly. Far too often I get pts on several heavy anticholinergics, cognitive problems abound, iADL's in the ****ter. We work with their PCP's and psychiatrists to clean up that mess, and voila, somehow their cognitive issues drastically improve! When there aren't many meds on board, maybe. But, these are never the patients I see. The patients I see probably average 10-12 different meds.

I agree, but will 6 mg of Doxepin cause this "anticholinegric burden"?

 

[PistolPete]

I agree, but will 6 mg of Doxepin cause this "anticholinegric burden"?

The reason why Silenor is approved at 3 and 6mg dosages is allegedly for this reason: selective H1 activity for sedation and little to no anticholinergic activity. Apparently you don't start affecting m1 and other receptors until above 10mg.

 

[Blitz2006]

The reason why Silenor is approved at 3 and 6mg dosages is allegedly for this reason: selective H1 activity for sedation and little to no anticholinergic activity. Apparently you don't start affecting m1 and other receptors until above 10mg.

Well then I'm gonna start precribing it. I waste so much time on Trazodone/Remeron.

 

[Jules A]

Well then I'm gonna start precribing it. I waste so much time on Trazodone/Remeron.

I wonder how many of the self-reported chronic insomniacs truly don't sleep overnight without napping during the day. To hear my outpatients some of them haven't slept in years which I just don't buy especially compared to the large numbers of flawed perception/reports of not sleeping on the inpatient unit when they absolutely slept through round checks all night.

 

[st2205]

I wonder how many of the self-reported chronic insomniacs truly don't sleep overnight without napping during the day. To hear my outpatients some of them haven't slept in years which I just don't buy especially compared to the large numbers of flawed perception/reports of not sleeping on the inpatient unit when they absolutely slept through round checks all night.

Among those who complain of insomnia, it's not often that I feel there isn't a concurrent personality pathology, whether specific or non-specific. This is just my bias.

 

[splik]

Among those who complain of insomnia, it's not often that I feel there isn't a concurrent personality pathology, whether specific or non-specific. This is just my bias.

half the population complains of insomnia. you are dealing with psychiatric patients so of course you have a limited view

 

[st2205]

half the population complains of insomnia. you are dealing with psychiatric patients so of course you have a limited view

Half the population may have insomnia but those who complain and insist you do something about the insomnia introduce a rather significant selection bias skewing to personality pathology, for a multitude of reasons.

 

[WisNeuro]

I agree, but will 6 mg of Doxepin cause this "anticholinegric burden"?

By itself, unlikely, in conjunction with several others, which is usually the case, yes. Is there a reason that anticholinergic burden is in quotes? This isn't a controversial concept, this is a well known phenomenon.

Also, in the elderly, the low dosages seem to help with reduction in waking after sleep, but doesn't really do anything to reduce latency to fall asleep initially. So, in most of my patients, not addressing their primary sleep problem.

 

[Blitz2006]

By itself, unlikely, in conjunction with several others, which is usually the case, yes. Is there a reason that anticholinergic burden is in quotes? This isn't a controversial concept, this is a well known phenomenon.

Also, in the elderly, the low dosages seem to help with reduction in waking after sleep, but doesn't really do anything to reduce latency to fall asleep initially. So, in most of my patients, not addressing their primary sleep problem.

I put it in quotes to reinforce if this was applicable to very low doses of TCA. Of course, anticholinergic burden is a known fact with TCAs. I just wanted to know if I should be concerned with this burden at doses of 3/6 mg of Doxepin.

Thats all.

 

[HarryMTieboutMD]

Just fyi- some people like using it for opioid withdrawal (lack of substantial literature notwithstanding), but in order to target insomnia in opioid withdrawal you generally need 25-50mg (the reasons for this are unclear, just what I see clinically).

 

[OldPsychDoc]

The reason why Silenor is approved at 3 and 6mg dosages is allegedly for this reason: selective H1 activity for sedation and little to no anticholinergic activity. Apparently you don't start affecting m1 and other receptors until above 10mg.

And here I thought it was to re-brand a generic medication in a new dosing formulation in order to make more money off of it...

 

[PistolPete]

And here I thought it was to re-brand a generic medication in a new dosing formulation in order to make more money off of it...

Indeed very likely, just what I read!

 

[Ceke2002]

I wonder how many of the self-reported chronic insomniacs truly don't sleep overnight without napping during the day. To hear my outpatients some of them haven't slept in years which I just don't buy especially compared to the large numbers of flawed perception/reports of not sleeping on the inpatient unit when they absolutely slept through round checks all night.

Umm *raises hand*. I'm quite possibly a unicorn in this case, or at the very least a zebra, but thanks to delayed sleep phase disorder I have occasional non circadian days - 24-36 hours is about the average for me, but I have gone as long as 5 days (no drugs, no 5 minute refresher naps here and there, just zero sleep). It's really weird though, because when I'm in a non circadian cycle it's like no amount of medication or depressant like substances will work; I could take a TCA, throw a benzo chaser on top of it, add in some promethazine for good measure, smoke a few bowls, and wash the whole lot down with liberal amounts of alcohol, and I'd still be sitting there going, "Great, now I'm drunk and stoned, and I still can't sleep". The only thing that does work is just waiting for it to pass eventually, at which point I'll end crashing 12+ hours.

There is a point in all of this, some patients really don't know the meaning of the word insomnia and think if they don't fall asleep as soon as their head hits the pillow then they must need some sort of pharmacological intervention, other patients actually do have sleep disorders (some of which may not have the best track record in terms of responding to medication), so any good work up for claims of 'insomnia' should probably take that into consideration. But I have a feeling I'm preaching to the choir here.

 

[Shikima]

I use it quite frequently. Some people are super sensitive to the 10mg, others experience the effect of pissing into the wing. There is a correlation between emotional intensity and the failure of hypnotics.

 

[jettavr6]

I use it quite frequently. Some people are super sensitive to the 10mg, others experience the effect of pissing into the wing. There is a correlation between emotional intensity and the failure of hypnotics.

Do you start at 10mg? We are having a lot of difficulty getting the 3mg dosage covered by insurance.

 

[Shikima]

Do you start at 10mg? We are having a lot of difficulty getting the 3mg dosage covered by insurance.

That's because it's brand name and costs a ton. 10mg is generic and covered by insurance. Start at 10mg with lots of psychoeducation and CBTI - this is key. Tell them not to expect the Michael Jackson treatment paradigm.

 

[PistolPete]

Do you start at 10mg? We are having a lot of difficulty getting the 3mg dosage covered by insurance.

You can also try the generic liquid formulation and have the pharmacist dispense a dropper that can measure out 0.3 and 0.6mL.

 

[benlinus]

I've had folks open up the 10mg capsule, dump about half out, and stick the capsule back together, with good results.

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[666357]

Just going to add- #30 10mg taken as an intentional OD is within the therapeutic range of one dose of Doxepin for depression/anxiety (though on the upper end of the dose range).