preferred soporific

[Neuro111]

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what are your guys' choices?
inpatient v/s outpatient
sleep inducer v/s sustain-er
'responsible' vs patient's w/ substance use.
preggos
geri

 

[slappy]

 

[st2205]

what are your guys' choices?
inpatient v/s outpatient
sleep inducer v/s sustain-er
'responsible' vs patient's w/ substance use.
preggos
geri

1. Trazodone or hydroxyzine only, unless they’re on something I may reluctantly resume inpatient. If they’re manic then I’m willing to use anything.

2. I’ve found things helping with sleep onset vs. maintenance to be more theoretical in nature and individual differences/responses account for too much variability to expect specific results. Nevertheless, may sell trazodone having a longer half-life when talking about sleep maintenance. Regardless, if it’s chronic insomnia, we have a discussion of how their Z drugs and benzos are worsening their insomnia and discuss gradual taper in the future. This is usually where they defensively state that it’s the only thing that works, after they spent the previous 15 minutes detailing that their insomnia is so bad that nothing works. If it’s chronic insomnia, I try to sell CBT-I... not that I believe very many will take me up on it, but to start setting expectation that medications won’t be a long-term solution. This helps not to reinforce maladaptive coping skills, lifestyle choices and personality dysfunction — things chronic complaints of insomnia are ripe with — and which any sleep medication will facilitate tacit avoidance of.

3. I typically won’t differentiate as it’s incredibly rare that I reach for a Z drug or benzo, which I’d simply be less inclined to do if they’re abusing substances. However, I maintain plenty of people on these for a period of time if they came to me on it. I suppose substance use would shorten the duration of time that I’d maintain them on it before taper.

4. I start with Benadryl. Not that blindly following pregnancy categories means much but it’s a category B. Trazodone is category C only because it’s lumped in as an “antidepressant” in studies. I haven’t seen any specific trazodone studies in pregnancy and I shy away from it. If insomnia is disabling, may consider Ambien (pregnancy is a time-limited condition [at least in all of the cases I’ve seen]).

5. Trazodone, though eyeballing other orthodtatic meds or the dose of trazodone. Sometimes Remeron.

Overall I’m not a huge fan of Rx’ing insomnia if it’s not clear that they could really use acute treatment. I believe consistent complaints of insomnia should be a criterion for a PD somewhere.

Get familiar with who does CBT-I in your area and find out if they’re any good at it.

 

[tr]

what are your guys' choices?
inpatient v/s outpatient
sleep inducer v/s sustain-er
'responsible' vs patient's w/ substance use.
preggos
geri

I don't prescribe any sleeper for long term use, they are a short term fix only. I like z drugs because they most closely recapitulate the staging and EEG pattern of physiological sleep, and they don't result in AM grogginess like trazodone. Ambien is usually the only one covered without prior authorization, I use regular if onset is the only issue and CR if there is awakening.
Never benzos obviously.

Belsomra is a good option for people who have already maxed out their GABA receptors with benzos or alcohol.

General outpt algorithm:
1. Insomnia acute or chronic? Signs of OSA?
If acute, clearly related to mood/anxiety sx, and no snoring/gasping/daytime sleepiness, will usually rx Ambien first if they haven't tried it, otherwise if they have already failed will try another z drug or trazodone, rarely gabapentin or Seroquel if they already take for other sx anyway. Will explain risks of tolerance/dependence but these people typically come off the sleeper easily once mood improves. If not they will go to CBTi and I will wean the sleeper.

If +sx of OSA I refer to Sleep Clinic to r/o sleep disordered breathing, if neg they will get sent on to CBTi from there. If no sx of OSA but insomnia is chronic I refer directly to CBTi and let them know I will be working with the therapist to wean the sleeper as they get better control over their sleep habits.

Pregnant women: first Unisom/Diclegis, then Benadryl. I have seen Ob pass out Ambien but literature is thin, however there was a recent reassuring study that found Ambien compared favorably to healthy control, without the fetal growth and neonatal adaptation issues of benzos. So I'm less rigid about getting it off now if they come to me mid pregnancy already dependent. Trazodone has studies but they are older and smaller, and the range of outcomes addressed is limited. I try to avoid.
R/o OSA especially important in this population as incidence soars in pregnancy and it's related to htn and pre-eclampsia.

Gero: Lots of these patients do well on Remeron which is good because it can double as a sleeper, reducing polypharmacy.

All patients with insomnia get an interrogation of their sleep hygiene, personalized recs and a sleep hygiene handout at intake.

 

[Merovinge]

For the CAP population:
Melatonin if there is delayed phase (low dose and around dinner time), on inpatient medium dose as a soporific with few downsides (although this is mostly placebo)
Clonidine if there is any problems with ADHD or hyperarousal, is actually just a fine sleeping medication in absence of other sx.
Benadryl is a classic for inpatients who are having trouble sleeping due to seperation anxiety or just being in a psych unit insomnia; Short courses or PRN use as outpatient
Trazodone is still reasonable for middle insomnia, start low to avoid daytime sedation
Prazosin if nightmares are present
Absolutely no benzos or Z drugs for basically any reason except odd sleep pathology or inpatient manic episode

Sleep hygeine is likely even more beneficial for the average CAP pt with all the cell phones in bed and late night social media. Getting families to install parental time controls does not make you popular, but all my patients have gotten over it.

 

[Salpingo]

I don't prescribe any sleeper for long term use, they are a short term fix only. I like z drugs because they most closely recapitulate the staging and EEG pattern of physiological sleep, and they don't result in AM grogginess like trazodone. Ambien is usually the only one covered without prior authorization, I use regular if onset is the only issue and CR if there is awakening.
Never benzos obviously.

Belsomra is a good option for people who have already maxed out their GABA receptors with benzos or alcohol.

General outpt algorithm:
1. Insomnia acute or chronic? Signs of OSA?
If acute, clearly related to mood/anxiety sx, and no snoring/gasping/daytime sleepiness, will usually rx Ambien first if they haven't tried it, otherwise if they have already failed will try another z drug or trazodone, rarely gabapentin or Seroquel if they already take for other sx anyway. Will explain risks of tolerance/dependence but these people typically come off the sleeper easily once mood improves. If not they will go to CBTi and I will wean the sleeper.

If +sx of OSA I refer to Sleep Clinic to r/o sleep disordered breathing, if neg they will get sent on to CBTi from there. If no sx of OSA but insomnia is chronic I refer directly to CBTi and let them know I will be working with the therapist to wean the sleeper as they get better control over their sleep habits.

Pregnant women: first Unisom/Diclegis, then Benadryl. I have seen Ob pass out Ambien but literature is thin, however there was a recent reassuring study that found Ambien compared favorably to healthy control, without the fetal growth and neonatal adaptation issues of benzos. So I'm less rigid about getting it off now if they come to me mid pregnancy already dependent. Trazodone has studies but they are older and smaller, and the range of outcomes addressed is limited. I try to avoid.
R/o OSA especially important in this population as incidence soars in pregnancy and it's related to htn and pre-eclampsia.

Gero: Lots of these patients do well on Remeron which is good because it can double as a sleeper, reducing polypharmacy.

All patients with insomnia get an interrogation of their sleep hygiene, personalized recs and a sleep hygiene handout at intake.

Whats been your experience with Belsomra? Do you get feedback from patients after they go to CBTi (or use a program)?

 

[tr]

Whats been your experience with Belsomra? Do you get feedback from patients after they go to CBTi (or use a program)?

I only use it for people who have clearly overloaded their GABA receptors because it's a pain to get covered. In general it seems to be helpful, better than piling on yet another GABAergic med.

Yes I can see all the CBTi notes and communicate with the therapist. Most people who stick with it (it's only 6 sessions) seem to benefit, and anecdotally I've had several tell me it was life changing. There's a contingent of people who only go reluctantly and ghost after 1-2 sessions. Those people tend to ghost out of my clinic as well, presumably because they've found a more compliant prescriber elsewhere.

I've had no luck getting people to do online CBTi. I think it just demands too much initiative on the part of the patient.

 

[Liquid8]

Initially will choose from the following:
Melatonin
Phenergan
Zopiclone
Temazepam
Zolpidem
Seroquel/CPZ

Feel that the Z drugs can be just as addictive as benzodiazepines so I try to prescribe both only for the short term and set out the expectation to patients that if it’s not likely to help in the long term.

If I’m sceptical about a patient’s intentions, I will often not prescribe the maximum quantity or add specific restrictions to the script – eg. dispense only 7/14 day supply. Most are ok with this, but every now and then I will get a call from a pharmacy notifying me that they wants an early pickup or the patient will cancel their followup appointment and go elsewhere.

Otherwise, the choice depends on the individual situation.

If a patient is primarily depressed and weight gain is not a concern will consider mirtazapine, although have recently had some good results with tricyclics (nortriptyline in particular) with depression and insomnia. Have also had a few who had improved sleep on Vortioxetine or Valdoxan, although I’m not really convinced that the latter is a great antidepressant.

If manic or psychotic: Olanzapine/Risperidone +/- Lorazepam/Clonazepam. Used to use IM zuclopenthixol acetate (+/- IM Olanzapine) in the most agitated patients, but haven’t needed to do so since leaving the public system.

If PTSD/nightmares are a significant issue, I have had good results with low dose prazosin. However, patients need to be warned about postural drops and the increased falls risk if they get up at night.

These days the heaviest combination I’d prescribe in private would be pericyazine +/- nitrazepam, although I usually reserve this for my inpatients where sleeping problems have been documented by the night nurses and other medications has not worked.

For oldies would prefer mirtazapine or oxazepam if considering a benzo. Have used tiny doses of antipsychotics in the past, mainly in severe BPSD patients.

From what I can tell, Trazodone is not available in Australia. Don’t have any experience using Belsomra – has only just been approved for use here and haven’t really looked into it yet.

 

[Crayola227]

on my rotations I've been told by more than one GI doc to essentially never use Phenergen, that it's devil as far as side effects go, and they consider it a drug of last resort

I wonder what they would make of it being used for insomnia....

 

[watto]

Having done CBT for insomnia and straight treatment of sleep-related breathing disorder, I encourage everyone to read some of Dr. Barry Krakow's work on complex insomnia.

A Missing Link: Dr Barry Krakow's Research on Insomnia and SDB - Sleep Review

He has found (and in my referrals to sleep testing, this has been borne out) that treatment-responsive insomnia even without frank "positive" answers to the usual sleep apnea screening questions has had frequent etiology in respiratory-effort-related arousals. His thoughts on these and PTSD are also interesting.

It's a good interview, I encourage you guys to check it out above.

 

[Shikima]

For those thinking globally about other causes of insomnia, don't forget about RLS-drug induced RLS/PLMs, other medications causing insomnia such as beta blockers as one example, not keeping with a circadian rhythm so that their timing is off, etc.

 

[clausewitz2]

What is the clinical experience of this board with low-dose doxepin? I know some guidelines recommend it and I would obviously only prescribe half a 10 mg tablets to start (f everything about paying brand prices for a 3 mg tab). My attendings often look at my like I have three heads when I suggest it and our pharmacy is convinced that 5 mg doxepin and 25 Zoloft are going to cause serotonin syndrome (whereas duloxetine and tramadol are totally fine), but I assume that is a local culture thing. Doxepin at low doses should be almost 100% histaminergic, so does it actually work in practice?

 

[thoffen]

What is the clinical experience of this board with low-dose doxepin? I know some guidelines recommend it and I would obviously only prescribe half a 10 mg tablets to start (f everything about paying brand prices for a 3 mg tab). My attendings often look at my like I have three heads when I suggest it and our pharmacy is convinced that 5 mg doxepin and 25 Zoloft are going to cause serotonin syndrome (whereas duloxetine and tramadol are totally fine), but I assume that is a local culture thing. Doxepin at low doses should be almost 100% histaminergic, so does it actually work in practice?

I've used it. It works like an antihistamine should. But like you I haven't rx silenor for $$ reasons. I've chosen it specifically because it has an FDA indication unlike other antihistamines. But I'm rarely the person that starts or adds a sleep medicine in the first place. I think it's rarely the right approach to treating a chronic sleep problem which is almost all the sleep problems I see.

 

[MedMan80]

What is the clinical experience of this board with low-dose doxepin? I know some guidelines recommend it and I would obviously only prescribe half a 10 mg tablets to start (f everything about paying brand prices for a 3 mg tab). My attendings often look at my like I have three heads when I suggest it and our pharmacy is convinced that 5 mg doxepin and 25 Zoloft are going to cause serotonin syndrome (whereas duloxetine and tramadol are totally fine), but I assume that is a local culture thing. Doxepin at low doses should be almost 100% histaminergic, so does it actually work in practice?

Used it while rotating at the VA, worked particularly well for patient's with hx of SUD's, pretty sedating