Insomnia meds

[Stagg737]

3 points.

1. A quick few questions from STOP-BANG is worth asking when people complain about poor sleep, especially sleep maintenance problems.

2. Melatonin type meds (either otc or ramelteon type) work better as a daily regimen, rather than PRN for circadian disturbance and sleep onset problems

3. Lots of sleep maintenance insomnia folks withdraw from nicotine in the middle of the night. And worse, they regularly smoke upon awakening before going back to bed creating an ingrained pattern.

I find discussing their tobacco/nicotine use pattern especially pre/during bed can be very helpful for improving their sleep quality and pattern. I have even used patches at night in people not wanting to quit as a way to improve sleep, and as a side effect it lowered their NUD burden. Really good angle to bring up IMO for nicotine users with sleep problems. They use stimulants right before bed and wonder why it’s hard to sleep. Or they get up and hit the stim and find it hard to get back to sleep. No duh.

Agree with the first 2, your third point is interesting and not something I often ask about, but may start doing that more often. The bolded is interesting to me. I've always been taught that nicotine patches need to be removed before bed d/t nightmares and other side effects, but for heavy smokers or chain smokers I can certainly seen the logic there. Have you seen any actual studies that support that? I've never really looked into it before...

Thoughts on using z-drugs in patient with mild-moderate OSA? Is this a big no no? Any specific drugs you might recommend over another if going the z drug route?

Depends on the patient. If they're compliant with their CPAP or whatever sleep medicine recommended and they're not on other CNS depressants I don't have a problem with it short-term or even long-term in some cases. If they're already on other CNS depressants like opiates or muscle relaxers I have much more hesitation. Active alcohol UD is an absolute contraindication for me. I usually try Doxepin or Trazodone with these patients first though just because of the safety profile.

I have actually seen quite a bit of disorientation, delirium, sleepwalking, and parasomnias that are very severe associated with Z-drugs, and it has certainly affected my prescribing of them. I will also say that the people who have been on zolpidem longterm, have had so much trouble even reducing doses very slowly that it competes with my patients on long-term alprazolam in terms of difficulty of deprescribing.

That said, I would agree that the the perinatal and post-partum population are one of the few that actually get zolpidem from me with some regularity, because of said benefits. OBs here love it too.

I definitely see that with long-term users, especially the people who take it every night. Just getting them to cut down to 5 nights a week is really difficult. I try and play the sleep restriction card and tell them that the lack of sleep that night will get them better sleep the following night when they take the Ambien again, but it's a hard sell. I don't see a lot of perinatal/post-partum patients other than on consults as we have 2 perinatal psych specialists that have their own outpatient clinics. I do like it short-term for those populations though, especially if they have good family support to care for the kid and let them get some decent sleep.

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[whopper]

We Americans are fatties.

As such a lot of our people with insomnia have OSA. Despite this I see a lot of doctors medicating the OSA with sleep meds instead of telling the patient to get treated for OSA.

100% of my patients that are overweight, snore, and have problems staying asleep vs falling asleep all have had OSA when told to get a sleep evaluation. 100%. I haven't tallied the number but it's well over 100. Whenever I see people with this triad I refer them for a sleep evaluation. Again it's been 100%.

The paradigm for treating insomnia should push this to the forefront given how many people are overweight these days.

 

[randomdoc1]

We Americans are fatties.

As such a lot of our people with insomnia have OSA. Despite this I see a lot of doctors medicating the OSA with sleep meds instead of telling the patient to get treated for OSA.

100% of my patients that are overweight, snore, and have problems staying asleep vs falling asleep all have had OSA when told to get a sleep evaluation. 100%. I haven't tallied the number but it's well over 100. Whenever I see people with this triad I refer them for a sleep evaluation. Again it's been 100%.

The paradigm for treating insomnia should push this to the forefront given how many people are overweight these days.

I can second this. What I find interesting is how many pts with OSA are on sleepers both controlled substance and non-controlled substance. Something I just randomly wondered though, people on chronic benzos, I've always wondered if there is a side effect of weight gain as often I see patients on this and less physically active. Reminds me of interesting cases I ran across when a psychiatrist retired. So many were on two benzos, maybe some ambien, maybe also some seroquel and trazodone and (insert another QTc prolonging agent). Or some were just on two benzos but one of them was so snowed all the time and so incredibly sedentary that over the years she just became huge from barely moving a muscle day to day. Interesting cases indeed.

 

[Merovinge]

I can second this. What I find interesting is how many pts with OSA are on sleepers both controlled substance and non-controlled substance. Something I just randomly wondered though, people on chronic benzos, I've always wondered if there is a side effect of weight gain as often I see patients on this and less physically active. Reminds me of interesting cases I ran across when a psychiatrist retired. So many were on two benzos, maybe some ambien, maybe also some seroquel and trazodone and (insert another QTc prolonging agent). Or some were just on two benzos but one of them was so snowed all the time and so incredibly sedentary that over the years she just became huge from barely moving a muscle day to day. Interesting cases indeed.

Interesting, crushingly depressing examples of iatrogenic harm. Potatoe potatoh.

 

[whopper]

Add to the problem that when people wake up from OSA they do so because they're suffocating. So the right thing to do is to keep them asleep? I think not.

Now this can't be high-risk life-threatening cause if it were, with so many obese Americans with untreated OSA with some idiot doctor giving them Zolpidem 10 mg at bedtime we would've seen in the news dozens if not more people dying, but the thought that so many doctors are giving these people OSA the wrong treatment, and a medication that's not recommended for long-term use as a long-term med without addressing the real issue shows the iatrogenic harm going on.

Each person that I referred for OSA that were found to have OSA and on Zolpidem I asked them, "did you PCP consider OSA?" and all of them said no.

A side story. Showing OSA in pics is highly more effective because this is a serious case where a good pic says 1000 words. I'd typically go on a search engine, type in "OSA" and show them the following pic, pointing out that overweight people have fat tongues and as such it blocks the airway.

The problem one day was I did this, typed in OSA and didn't know that there's an porn star of the same name and that particular time instead of Obstructive Sleep Apnea pics coming up it was pics of the porn start Osa doing her thing. Given that search engines tend to put porn pics up higher in the search algorithm because they're hit more often, they were all the first few dozen pics. They weren't there before so it must've been weeks after this person made her debut.

I was embarrassed. Not embarrassed cause it was sex pics, but because I try to have a professional atmosphere in my office!

Luckily the patient had a laugh and said "hey doc, you just made my day.

 

[medhead1990]

PGY4 here. This is a great thread! I actually asked our psycho-pharm proctor if we could go through insomnia meds, and should be doing it in the next few weeks. Its interesting because I am defiantly familiar with all the options/names but have very little experience with patients actually being on orexin pathway meds, any of the melatonin pathway meds other than melatonin itself (both of these are likely because of insurance issues is my assumption). While I have defiantly had patients who have either HAD or have been on ZZZ's, I have such a bad taste in my mouth because of all the horror stories that I have never initiated them as a prescription for these. I'm sure there is a time and a place but as of yet I have not found a level of comfort with them to be able to appropriately Rx when that happens. Similar story with the TCA's (I had to do a double take when I saw doxipin so early in someone's escalation of care), they tend to strike me as only old school last resort antidepressants more so than sleeping meds.

If someone could help explain the where and when you feel comfortable providing the above (probably more so the zzz and TCA's) I would love to hear it. At this current moment I have them as tools in my toolbox but frankly expect unless I get more comfortable with them they will only collect dust over the next few years.

My current series of escalation is melatonin (which stays on through the rest of the escalation), Benadryl/Atarax, Trazadone vs Remeron (if Remeron is appropriate), Seroquel, and then MAYBE zyprexa (haven't actually done this but i guess its an option), and then I hit a rut with ZZZ's and TCA's and benzos (all of which i am very uncomfortable at this time Rx'ing).

I suspect orexin and ramelteon family stuff should be around the Benadryl / Atarax level however again I have zero interest in doing a PA for those so I avoid them at this time.

Anecdotally as well sleep therapy ROCKS. After our second kid my wifes sleep was horrific, and she did sleep therapy (I think it was CBT-I techniques but not a ridged CBT-I curriculum) and it worked wonders for her. Im spoiled to have a sleep and anxiety ( which is what she used) clinic at my institution and I probably refer 25% of my patients too it (unfortunately its a 5 month waitlist).

*Also I am Med-Psych and OSA is a HUGE deal! Its estimated that something like 20-40% of the population has some level of OSA and a very small number of them are actually being treated. Being wise with sleep med referrals and using your STOP-BANG can make a HUGE difference in mental and physical health. I see OSA as something as bad as poorly controlled DM. It can lead to some really scary stuff such as pulm HTN, uncontrolled HTN, heart failure, chronic ischemic changes in the brain (think about it these people are essentially being repeatedly partially asphyxiated every single night), and more. OH MY!. Long and short someone getting an OSA diagnosis followed by appropriate Tx can make MASSIVE differences in mental and physical health.

Again great thread thanks yall, Again I would love some words to help boost my comfort level regarding ZZZ and TCA's (unless of course my level of discomfort with them is appropriate and I should never RX them- which i somewhat doubt.).

 

[ObsequiousAplomb]

To answer your question about TCAs:

I use TCAs for insomnia with depression or insomnia in the context of schizophrenia quite frequently. For primary insomnia it's in my algorithm but not always first.

TCAs are safer and better tolerated than Seroquel, Zyprexa, or any antipsychotic when it's just for sleep. It's only in overdose or in patients with serious heart problems that they're dangerous. Doxepin in ultra low doses is incredibly safe, even in people with some medical conditions. Swallowing 90 tabs of doxepin 3 mg is still only 270 mg and wouldn't be fatal. Of course, I don't write for 90 tabs of any TCA unless it's been a stable med for more than 10 years but even then I prefer to write it in 30 day w/ 2 refill increments. More importantly, if a patient is having acute insomnia I don't write 90 day supply for any drugs.

I use doxepin and Elavil most often as they tend to be the most sedating. Doxepin if it's mostly sleep, chronic pain and depression, Elavil if there's something like migraines, non-migraine headaches, IBS, chronic pain, or depression.

If they have severe OCD and major sleep issues then I prefer clomipramine over Luvox or Prozac, etc. Though, of course, I have done Prozac or Luvox with trazodone too. It's usually patient need specific (seldom do I get an OCD patient who hasn't tried at least one or two SSRIs already).

Chronic insomnia I won't treat with chronic meds without two things: a sleep study and a trial of CBT-i. After OSA and other sleep disorders have been ruled out, then I would consider the options.

Overall, I think TCAs have a bad rap as "last resort" and in non-psychotic, non-bipolar patients I would use one before an antipsychotic.

 

[clausewitz2]

Chronic insomnia I won't treat with chronic meds without two things: a sleep study and a trial of CBT-i.

The trial of CBT-I I can totally get behind but sleep studies are not generally indicated for insomnia. You have reason to suspect OSA, that's different, but I am surprised you don't get more insurance pushback.

 

[ObsequiousAplomb]

The trial of CBT-I I can totally get behind but sleep studies are not generally indicated for insomnia. You have reason to suspect OSA, that's different, but I am surprised you don't get more insurance pushback.

I don't get much chronic insomnia that doesn't meet screening criteria for OSA. On the rare chance that I do, they're usually people who respond to CBT-I.

Most of my patients with insomnia have a mood or anxiety disorder that I treat and the insomnia improves with treatment of the underlying disorder.

I think I'm just not getting as many referrals for primary insomnia as others. I agree that if there's no suspicion for a sleep disorder that would benefit from a sleep study, then there isn't much of a reason to order a sleep study and insurance would push back.

Interestingly, I get most of my insomnia referrals from a sleep doc who tried CBT-I and several meds but felt the problem was an underlying psychiatric condition.

 

[Mass Effect]

I would definitely try trazodone, hydroxyzine, mirtazapine and doxepin before jumping to quetiapine. Quetiapine is way, way, way, way, way down on my list of sleep aids.

 

[calvnandhobbs68]

My current series of escalation is melatonin (which stays on through the rest of the escalation), Benadryl/Atarax, Trazadone vs Remeron (if Remeron is appropriate), Seroquel, and then MAYBE zyprexa (haven't actually done this but i guess its an option), and then I hit a rut with ZZZ's and TCA's and benzos (all of which i am very uncomfortable at this time Rx'ing).

I suspect orexin and ramelteon family stuff should be around the Benadryl / Atarax level however again I have zero interest in doing a PA for those so I avoid them at this time.

Anecdotally as well sleep therapy ROCKS. After our second kid my wifes sleep was horrific, and she did sleep therapy (I think it was CBT-I techniques but not a ridged CBT-I curriculum) and it worked wonders for her. Im spoiled to have a sleep and anxiety ( which is what she used) clinic at my institution and I probably refer 25% of my patients too it (unfortunately its a 5 month waitlist).

*Also I am Med-Psych and OSA is a HUGE deal! Its estimated that something like 20-40% of the population has some level of OSA and a very small number of them are actually being treated. Being wise with sleep med referrals and using your STOP-BANG can make a HUGE difference in mental and physical health. I see OSA as something as bad as poorly controlled DM. It can lead to some really scary stuff such as pulm HTN, uncontrolled HTN, heart failure, chronic ischemic changes in the brain (think about it these people are essentially being repeatedly partially asphyxiated every single night), and more. OH MY!. Long and short someone getting an OSA diagnosis followed by appropriate Tx can make MASSIVE differences in mental and physical health.

Again great thread thanks yall, Again I would love some words to help boost my comfort level regarding ZZZ and TCA's (unless of course my level of discomfort with them is appropriate and I should never RX them- which i somewhat doubt.).

I would almost 100% of the time use Doxepin 3-10mg QHS over Seroquel or Zyprexa (unless we're dealing with a primary psychotic d/o or bipolar d/o). Doxepin actually has more evidence behind it than Trazodone (but likely because someone wanted to try to patent the 3-6mg versions) and as such is actually recommended by AASM for sleep maintenance insomnia. As mentioned before, at doses <20mg, doxepin is basically a pure H1 antagonist and less of a TCA.

I've paired low dose TCAs and SSRIs with no issue as well (ex someone's on low dose amitriptyline for migraines and I have them on an SSRI).

Z drugs I basically never rx. Technically there is evidence for zolpidem/zaleplon/eszopiclone and maybe I should actually use them but there's so many reports of parasomnias/complex sleep behaviors and it gets so hard to get people off them that I just don't love them.

 

[clausewitz2]

I've paired low dose TCAs and SSRIs with no issue as well (ex someone's on low dose amitriptyline for migraines and I have them on an SSRI).

Agreed, in treating OCD something like 40 mg of Lexapro and 50 of clomipramine is not that uncommon. It is also perfectly safe to combine full doses of basically any TCA that isn't imipramine or clomipramine with an MAOI.

In fact, there is theorizing that TCAs will actually inhibit the tyramine pressor response and make MAOIs safer and there is a clinical trial running at the moment to this effect involving direct tyramine challenges.

 

[hallowmann]

I would almost 100% of the time use Doxepin 3-10mg QHS over Seroquel or Zyprexa (unless we're dealing with a primary psychotic d/o or bipolar d/o). Doxepin actually has more evidence behind it than Trazodone (but likely because someone wanted to try to patent the 3-6mg versions) and as such is actually recommended by AASM for sleep maintenance insomnia. As mentioned before, at doses <20mg, doxepin is basically a pure H1 antagonist and less of a TCA.

I've paired low dose TCAs and SSRIs with no issue as well (ex someone's on low dose amitriptyline for migraines and I have them on an SSRI).

Z drugs I basically never rx. Technically there is evidence for zolpidem/zaleplon/eszopiclone and maybe I should actually use them but there's so many reports of parasomnias/complex sleep behaviors and it gets so hard to get people off them that I just don't love them.

We pretty regularly dose low dose TCAs for chronic pain/migraines in patients already on even high dose SRIs all the time, and I agree that doxepin is early on the list at 5-10 mg.

I agree, most people with Z drugs are people I'm weaning or have failed to get off of them. I have prescribed lemborexant on a handful of occasions, but it's usually not covered unless they have failed like 3-4 other drugs including a Z drug, so have only had a couple actually get it. I think they have some progress.

Inpatient/ICU we have a handful of people that absolutely love ramelteon specifically because of the one ICU delirium study, but I have not seen much evidence it's better than melatonin at 100x the price.

In terms of other special populations, we use doxylamine (and B6) for patients with "morning" sickness that often helps with nausea and sleep, and later in pregnancy Ambien infrequently as mentioned earlier.

 

[whopper]

I use TCAs for insomnia with depression or insomnia in the context of schizophrenia quite frequently. For primary insomnia it's in my algorithm but not always first.

It's overly simplistic to say this is wrong but I think it's a wrong move as a first-line med in the overwhelming majority. Why? Cause TCAs are prone to cause weight gain and have correlation with dementia (likely from the anticholinergic effect) with long-term use although I've seen newer data suggesting the dementia risk isn't increased if the TCA is a low dosage such as Doxepin about 10 mg or less.

Of course, medicine is complicated and you may have some people who can't sleep who need to gain weight, or may have other uses for the TCA such as chronic pain or IBS. Again almost nothing is ALWAYS WRONG in medicine.

Trazodone, last time I checked, didn't have the dementia correlation. Just checked again and didn't see it. Trazodone use and risk of dementia: A population-based cohort study

And Trazodone being very similar to a TCA puts it higher up in my algorithm for insomnia before a TCA.

Ramelteon-I've seen several people do well on this who haven't done well on Melatonin. If Melatonin doesn't work I still tell people to give Ramelteon a try. The problems I have with it aren't that it's simply "expensive Melatonin" as some people put it and I've seen it be far superior to OTC Melatonin. The problems I have are it only comes in 1 dose and I've seen some people want to try lower or higher dosages. Another problem is despite that it's a generic it's an expensive generic and despite it being out for over a decade insurance companies don't often times cover it.

 

[calvnandhobbs68]

It's overly simplistic to say this is wrong but I think it's a wrong move as a first-line med in the overwhelming majority. Why? Cause TCAs are prone to cause weight gain and have correlation with dementia (likely from the anticholinergic effect) with long-term use although I've seen newer data suggesting the dementia risk isn't increased if the TCA is a low dosage.

I think this is the key. Big difference in receptor profile in 10mg doxepin vs 100mg doxepin...and I've had older psychiatrists definitely do the "more must be better" thing for TCAs for sleep. If low dose TCAs aren't working, I don't keep cranking them up unless I'm actually trying to get antidepressant/pain effects.

 

[whopper]

Not really relevant but I just terminated a patient on Zolpidem 20 mg PO Q HS for been on it for years. I gave her a year to lower it. She never did. She was already on it before she saw me and I told her I'm only willing to take her on to get her off of the medication and not to continue it long-term.

We tried several other meds, some being out of the box such as treating potential ADHD because that often times causes insomnia. She alleged none of them worked.
I opted to lower the medication very slowly, at a rate of about 1-2 mg/day/month. Still no success per her.
I told her to see a sleep doctor-she never did.

I typically would've terminated her after about 6 months to a year but right around that time COVID hit and she alleged this was making it hard for her to find a sleep doctor. Well, over a year later still not seeing a sleep doctor and I think I gave her enough time.

Part of me has doubts with my decision. She may have been one of those one in a million weird cases where Zolpidem was the only option, but still proceeded to terminate because, as I told her, I need another specialist to solidify that theory and she never did her responsibility to make that happen.

 

[Mass Effect]

My current series of escalation is melatonin (which stays on through the rest of the escalation), Benadryl/Atarax, Trazadone vs Remeron (if Remeron is appropriate), Seroquel, and then MAYBE zyprexa (haven't actually done this but i guess its an option), and then I hit a rut with ZZZ's and TCA's and benzos (all of which i am very uncomfortable at this time Rx'ing).

When would you consider Remeron inappropriate for sleep? I would use it right after trazodone and before Seroquel every time. I also don't usually use Benadryl/Atarax, though I would before Seroquel.

 

[ObsequiousAplomb]

Whopper, I agree. That's why I said it wasn't first.

For the schizophrenia patients already taking a sedating antipsychotic and who weren't helped by trazodone 25-300 in the past or with me (which usually has been tried in the past for this population) or who don't accept trazodone as a prn, doxepin 3,6,10, or 25 mg as a prn is usually fine. I think it's probably better to avoid Ambien, other z-hypnotics, and benzodiazepines in non-agitated chronically psychotic patients who can't sleep. Save the benzos for when there's a secondary indication.

For non-psychotic patients, again I said TCAs weren't first but were in my algorithm. Certainly before highly anticholinergic antipsychotics like Seroquel or Zyprexa, as had been mentioned above and what I was responding to, which are even more strongly associated with weight gain than the TCAs. I don't know for sure who gains more weight: the patient taking Remeron or the patient taking Elavil?

As for times I've gone the other direction, from Remeron or a TCA (usually coming from another provider) to trazodone? People shed that weight like it's nobody's business. They don't usually sleep any better though.

 

[Stagg737]

My current series of escalation is melatonin (which stays on through the rest of the escalation), Benadryl/Atarax, Trazadone vs Remeron (if Remeron is appropriate), Seroquel, and then MAYBE zyprexa (haven't actually done this but i guess its an option), and then I hit a rut with ZZZ's and TCA's and benzos (all of which i am very uncomfortable at this time Rx'ing).

Not trying to be harsh, but this escalation is almost the exact opposite of what EBM suggests, if you put SGAs first then it would be. There's almost no data that melatonin alone is helpful for primary insomnia and I generally don't bother unless there's an actual indication as it's just another pill to swallow. Antihistamines are also recommended against d/t the high likelihood of developing tolerance with chronic, regular use and lack of efficacy for maintaining sleep. Trazodone is fine d/t the low side effect profile, but I avoid Remeron unless I'm trying to use the sedation as a secondary effect. Benzos and Z-drugs have the evidence, but I agree that it's right to be cautious with them. It would be good to get comfortable with the TCAs as they're underutilized in general and at lower doses can do wonders for sleep in the right patient. I'd try this out asap if you're a PGY-4, no better time to get comfortable with it than in residency...

Again great thread thanks yall, Again I would love some words to help boost my comfort level regarding ZZZ and TCA's (unless of course my level of discomfort with them is appropriate and I should never RX them- which i somewhat doubt.).

You should definitely prescribe them if you've got the right patient. Low dose Doxepin as significantly changed my prescribing practices for sleep, and amitriptyline can be great for the right patients too (co-morbid pain). Z-drugs I use more caution with, but for patients just needing a short course to get their sleep cycle back on track or where other meds are contraindicated (pregnancy) they can be really useful. I also use Ambien with PTSD patients at times as a large percent of VA patients on them said it's the only thing that helps them sleep because they just don't dream with it. I'm not really a fan, but if it gets them from 2-3 hours of sleep per night to 7-8 and they're tolerating it, I'll take the lesser evil.

In terms of other special populations, we use doxylamine (and B6) for patients with "morning" sickness that often helps with nausea and sleep, and later in pregnancy Ambien infrequently as mentioned earlier.

I also pull out the doxylamine, usually as my first true anti-histamine. I look at it similarly to trazodone in the sense that it's low enough risk that it's worth a shot and patients can get it OTC if they want. I generally advise against Benedryl for sleep unless it's a rare PRN, in which case I'm ambivalent. I typically prefer doxylamine over hydroxyzine unless the patient has concurrent allergies or higher baseline anxiety as it's metabolized into cetirizine, so you're getting at least 10 hours of anti-histaminergic activity and maybe up to 25-30 with limited anticholinergic issues.

When would you consider Remeron inappropriate for sleep? I would use it right after trazodone and before Seroquel every time. I also don't usually use Benadryl/Atarax, though I would before Seroquel.

Basically always if you're primarily using it for insomnia without other indications. That being said, there are plenty of concurrent co-morbidities that make it a reasonable option. However, I also think any SGA without a co-morbid indication is inappropriate for insomnia and would certainly pick Remeron over those.

 

[Mass Effect]

Basically always if you're primarily using it for insomnia without other indications.

Why?

That being said, there are plenty of concurrent co-morbidities that make it a reasonable option. However, I also think any SGA without a co-morbid indication is inappropriate for insomnia and would certainly pick Remeron over those.

I'd pick mirtazapine over most of the other choices given. Typically, my go-tos are trazodone --> doxepin --> mirtazapine --> --> --> --> --> anything else.

 

[Stagg737]

Why?



I'd pick mirtazapine over most of the other choices given. Typically, my go-tos are trazodone --> doxepin --> mirtazapine --> --> --> --> --> anything else.

The data for mirtazapine is relatively poor, it carries a significant risk of weight gain (I see some pretty dramatic gain in some patients), it's basically just an antihistamine at low doses, and also has a very long half-life with a greater risk of grogginess/sedation the following day.

If you're prescribing it for chronic use, I think that's fair if other more benign options like trazodone, doxepin, or even doxylamine have failed. Especially if it's just being used PRN. Again though, I don't like the metabolic side effects and have found weight gain at times to be nearly as bad as quetiapine or zyprexa when taken nightly. That being said, I do prescribe it a fair amount as I see plenty of patients with a significant decrease in appetite or severe GI issues that it also helps with, but then I'm not using it for straight insomnia anymore. I'm actually most likely to use it in PTSD patients as I've anecdotally had some incredible responses to PTSD symptoms with Mirtazapine without needing other adjunct medications.

 

[hallowmann]

When would you consider Remeron inappropriate for sleep? I would use it right after trazodone and before Seroquel every time. I also don't usually use Benadryl/Atarax, though I would before Seroquel.

Pretty much the only reason is weight gain, but it's a big and common reason. Virtually everyone is either already overweight or obese or they hear that side effect and say absolutely no.

That said, I love Remeron for Geriatric patients with anxiety, sleep and weight loss/poor appetite. I have seen a ton of success with this group when many other medications have failed. I also like that I almost never reach higher doses, where'd I'd lose a lot of the sleep benefit I'm targeting.

You should definitely prescribe them if you've got the right patient. Low dose Doxepin as significantly changed my prescribing practices for sleep, and amitriptyline can be great for the right patients too (co-morbid pain). Z-drugs I use more caution with, but for patients just needing a short course to get their sleep cycle back on track or where other meds are contraindicated (pregnancy) they can be really useful. I also use Ambien with PTSD patients at times as a large percent of VA patients on them said it's the only thing that helps them sleep because they just don't dream with it. I'm not really a fan, but if it gets them from 2-3 hours of sleep per night to 7-8 and they're tolerating it, I'll take the lesser evil.

It's a pretty hard no from me for any daily Ambien use for a lot of my VA patients. Many of them are heavy drinkers, some already with benzo or opioid dependence. No need to add to that. I've seen enough prazosin and in some cases propranolol do wonders in that population if titrated appropriately slowly.

 

[Mass Effect]

Pretty much the only reason is weight gain, but it's a big and common reason. Virtually everyone is either already overweight or obese or they hear that side effect and say absolutely no.

True but my thinking is that TCAs can do that too. The only sleep meds that don't cause weight gain are Trazodone and benzos.

 

[birchswing]

Pretty much the only reason is weight gain, but it's a big and common reason. Virtually everyone is either already overweight or obese or they hear that side effect and say absolutely no.

That said, I love Remeron for Geriatric patients with anxiety, sleep and weight loss/poor appetite. I have seen a ton of success with this group when many other medications have failed. I also like that I almost never reach higher doses, where'd I'd lose a lot of the sleep benefit I'm targeting.


It's a pretty hard no from me for any daily Ambien use for a lot of my VA patients. Many of them are heavy drinkers, some already with benzo or opioid dependence. No need to add to that. I've seen enough prazosin and in some cases propranolol do wonders in that population if titrated appropriately slowly.

<Not a doctor>

You use propranolol for sleep or anxiety more generally?

I can't tolerate propranolol due to asthma, but use another beta blocker, and they mess with melatonin production (decrease), which is why I was surprised to see it associated with helping sleep, but I know propranolol has more general anti-anxiety effects than other beta blockers do so maybe that is why it can be used for that.

 

[hallowmann]

<Not a doctor>

You use propranolol for sleep or anxiety more generally?

I can't tolerate propranolol due to asthma, but use another beta blocker, and they mess with melatonin production (decrease), which is why I was surprised to see it associated with helping sleep, but I know propranolol has more general anti-anxiety effects than other beta blockers do so maybe that is why it can be used for that.

Only in certain populations. I prefer prazosin in patients with PTSD associated nightmares or PTSD with parasomnias that might suggest the presence of nightmares. Most people describe it as the difference between watching the nightmare and living through it.

Propranolol, I honestly use if it's more the ruminating thoughts that delay sleep onset. Neither are really for primary insomnia, and propranolol is not really for insomnia in general, but it may help with secondary causes. It's relatively low risk in people with normal HR, BP, and no asthma or psoriasis (or pregnancy) and people either like it or they don't.

 

[Stagg737]

It's a pretty hard no from me for any daily Ambien use for a lot of my VA patients. Many of them are heavy drinkers, some already with benzo or opioid dependence. No need to add to that. I've seen enough prazosin and in some cases propranolol do wonders in that population if titrated appropriately slowly.

It's certainly not a first-line choice for me. The ones I prescribed it to are either people I had inherited already on it or a few patients that were just resistant to everything else which usually also includes topiramate, clonidine, and cyproheptadine when nightmares are primarily involved. One of our PTSD specialists at our PTSD clinic/program is fairly liberal with Ambien and his mantra is basically "get them to sleep". According to him, most of the guys with severe PTSD are barely sleeping and other treatments aren't going to have any effect until they're sleeping. I'm still cautious with Ambien, but after my outpatient year, but I definitely agree with him that my first priority is getting them sleep. Like I've said, I've had great luck with Mirtazapine in that population and have actually found that between Remeron, prazosin/cyproheptadine, and gabapentin even the severe PTSD patients do pretty well. Haven't really used propranolol unless daytime symptoms were bad, but certainly not a bad thought.

 

[Stagg737]

True but my thinking is that TCAs can do that too. The only sleep meds that don't cause weight gain are Trazodone and benzos.

I've occasionally also found topiramate to be very helpful for patients with insomnia + nightmares and won't cause weight gain. I haven't had to go very high either, just 50-100mg QHS does wonders for some people.

 

[FlowRate]

I've occasionally also found topiramate to be very helpful for patients with insomnia + nightmares and won't cause weight gain. I haven't had to go very high either, just 50-100mg QHS does wonders for some people.

This is interesting, I almost never independently choose to use dopamax because so many people c/o the cognitive effects.

 

[clausewitz2]

This is interesting, I almost never independently choose to use dopamax because so many people c/o the cognitive effects.

I get a lot of migraneurs who drink too much so I prescribe it not too infrequently. Also folks who are gaining weight on a neuroleptic even with metformin but don't want to go off. Surprisingly well tolerated in general so far.

 

[watto]

I get a lot of migraneurs who drink too much so I prescribe it not too infrequently. Also folks who are gaining weight on a neuroleptic even with metformin but don't want to go off. Surprisingly well tolerated in general so far.

It's a carbonic anhydrase inhibitor and has been used for central sleep apnea (I always wonder if there is some of that happening in the patients this works for).

 

[hallowmann]

This is interesting, I almost never independently choose to use dopamax because so many people c/o the cognitive effects.

This discussion has definitely come up on the forums before. It certainly is at times poorly tolerated, but for some with bad PTSD it can actually be quite helpful. Plus it's one of the few that might actually decrease appetite/promote weight loss unlike so many of our meds.

 

[Stagg737]

This is interesting, I almost never independently choose to use dopamax because so many people c/o the cognitive effects.

My patients have tolerated it surprisingly well, especially when only using QHS dosing for nightmares/sleep. I think many of them are already so distressed that their thinking is already poor, so even if there is some cognitive blunting it's better to them than constant anxiety or the blunting that their insomnia is already causing.

My patients on it for metabolic syndrome have also tolerated it pretty well. I also typically keep it at fairly low doses though, so that may also play a role but idk.

It's a carbonic anhydrase inhibitor and has been used for central sleep apnea (I always wonder if there is some of that happening in the patients this works for).

Huh, I either didn't know or forgot about its use for CSA, thanks for the nice little pearl I'll.

 

[FlowRate]

My patients have tolerated it surprisingly well, especially when only using QHS dosing for nightmares/sleep. I think many of them are already so distressed that their thinking is already poor, so even if there is some cognitive blunting it's better to them than constant anxiety or the blunting that their insomnia is already causing.

My patients on it for metabolic syndrome have also tolerated it pretty well. I also typically keep it at fairly low doses though, so that may also play a role but idk.

Again interesting, I think my differing experience likely relates to a somewhat higher functioning patient panel who were mostly on it for migraines.

I agree the weight mgt pts seem to tolerate it well, although I haven't seen any of the weight management options clearly work for those patients which makes me wonder if it's due to the selected subgroup of weight mgt patients who are also active psychiatry patients.