Thoughts on treating insomnia?

[deleted1100659]

Im just curious about everyone's thoughts on treating sleep issues/what your general approach is as far as when you start controlled substances/overall treatment preference, if you use the z drugs, etc.

---

Members don't see this ad.

 

[the5thelement]

Educate about sleep hygiene . Get them to download cbti coach app. Keep a sleep diary. The problem with controlled substances is that patients develop tolerance and also have to deal with rebound insomnia once discontinued. Short term (<2 weeks) of Ambien / Lunesta usually does the trick.

 

[Stagg737]

My general approach:
1. Diagnosis/issues with insomnia. Ie, is this a primary insomnia? Secondary d/t something else? Is it actually a circadian rhythm disorder? I also make sure to r/o OSA, as this tends to be far more common than people suspect. If OSA, refer to sleep medicine. If it's secondary insomnia, treat the primary issue. If primary, then continue.

2a. Discussion about sleep hygiene, CBT-I, education of CBT-I Coach app, and if time some brief CBT-I.
2b. Referral to therapy for CBT-I if possible.

After this I start meds, oftentimes after 2a since 2b often doesn't/can't happen.

If insomnia is acute, I may jump straight to a low dose of Ambien if the issue is just falling asleep, but I do not provide more than 1 Rx (no refills), usually for 20 doses. I sometimes do this even without having them actually do CBT-I, for the right people ongoing CBT-I may be more than they need to do. I've found this is often adequate to get people back into a normal sleep pattern, as even a couple of nights of good sleep improves their function enough to address acute issues.

If their insomnia continues or if a patient has had more chronic issues, I always emphasize CBT-I. I've found that patients with true primary insomnia are usually willing to try anything to help with sleep and aren't just looking for a magic pill. For meds, I usually start with doxepin 10mg and tell them they can increase to 20mg if needed, but to give 10mg at least 4-5 days. I don't go above 25mg just for insomnia, if it's not providing a significant benefit by then going higher probably won't make a difference. After that, it varies depending on whether or not there's something else the med can help for. I consider trazodone, mirtazapine, and amitriptyline, less commonly gabapentin and hydroxyzine. One of my attendings loved trying 50-100mg of hydroxyzine, but I don't typically do this. After that, I'll consider Z-drugs and temazepam, much less often SGAs unless they've got a h/o psychotic d/o then I may use them sooner. After that, it's ramelteon and orexin antagonists. I'd like to move these up before the z-drugs, but insurance typically prevents this.

Obviously, this is all dependent on the individual, but this is pretty much my baseline algorithm for sleep. If I'm ever concerned about other sleep-related disorders or some neurologic aspect I refer them out.

 

[WisNeuro]

As much as you can, use MI for CBTi. If they can get in with a competent provider, very good success rate with this tx if they are compliant.

 

[deleted1100659]

Ive had trouble finding people who do CBTi in the past but maybe this will improve at the new location. I think there will be more resources at least. I do start trazodone for sleep though somewhat commonly. Sometimes intermittent melatonin dosing. And of course the obvious stuff of sleep hygiene. Sometimes if they have sleep issues and comorbid depression/anxiety ill do a little remeron. If they have trouble with sleep initiation 2/2 to anxiety I consider vistaril or gabapentin. When I was a resident, an issue was with ambien (mainly at the VA) where if you give them 15-20 doses they get extremely pissy with you and want to use it every night.

In the community health setting, i see a lot of seroquel being used for sleep which im not very fond of doing.

 

[WisNeuro]

Ive had trouble finding people who do CBTi in the past but maybe this will improve at the new location. I think there will be more resources at least. I do start trazodone for sleep though somewhat commonly. Sometimes intermittent melatonin dosing. And of course the obvious stuff of sleep hygiene. Sometimes if they have sleep issues and comorbid depression/anxiety ill do a little remeron. If they have trouble with sleep initiation 2/2 to anxiety I consider vistaril or gabapentin. When I was a resident, an issue was with ambien (mainly at the VA) where if you give them 15-20 doses they get extremely pissy with you and want to use it every night.

In the community health setting, i see a lot of seroquel being used for sleep which im not very fond of doing.

Look into your state psychological association. See if they'd be willing to put a message with your contact info on their listserv just saying that you are looking to expand your referral network and are specifically looking for people trained and skilled in CBTi. Should at least get a few hits to add to your list.

 

[Stagg737]

Look into your state psychological association. See if they'd be willing to put a message with your contact info on their listserv just saying that you are looking to expand your referral network and are specifically looking for people trained and skilled in CBTi. Should at least get a few hits to add to your list.

Didn't even realize we could do this, but would be very helpful as getting patients in with someone is one of my biggest difficulties. We have 2 psychologists in our system who specialize in CBT, but it's typically several months before we could even get patients an initial appointment. CBT-I is one of the 2 modalities I really wanted to get proficient at that I'm still not comfortable with.

Ive had trouble finding people who do CBTi in the past but maybe this will improve at the new location. I think there will be more resources at least. I do start trazodone for sleep though somewhat commonly. Sometimes intermittent melatonin dosing. And of course the obvious stuff of sleep hygiene. Sometimes if they have sleep issues and comorbid depression/anxiety ill do a little remeron. If they have trouble with sleep initiation 2/2 to anxiety I consider vistaril or gabapentin. When I was a resident, an issue was with ambien (mainly at the VA) where if you give them 15-20 doses they get extremely pissy with you and want to use it every night.

In the community health setting, i see a lot of seroquel being used for sleep which im not very fond of doing.

I had similar experiences at the VA. Patients seemed to either demand Ambien or want nothing to do with it. I typically only prescribed it (outpt) at the VA for the patients with really severe PTSD who otherwise couldn't sleep without it, and I was just continuing it for them. My general policy there was that if they wanted Ambien started they needed to talk to sleep medicine first. Fortunately, I don't see seroquel for sleep too frequently but I also strongly dislike it for insomnia unless there's another indication for it.

 

[mistafab]

My first step is to evaluate them for sleep apnea. If that step is negative than I do things as others have pointed to above.

 

[deleted1100659]

Look into your state psychological association. See if they'd be willing to put a message with your contact info on their listserv just saying that you are looking to expand your referral network and are specifically looking for people trained and skilled in CBTi. Should at least get a few hits to add to your list.

interesitng, I did not know about that. Luckily though, im starting at a new practice in a new state pretty soon and it seems like they have a lot more resources in the area im going to.

 

[TheRightMedication]

Stagg, bless you for reminding us to start with assessment and diagnosis. I'm sure I've been guilty of jumping to treatment when a patient complains of insomnia. Out of curiosity, why is doxepin your go to over trazodone?

 

[shoomer]

https://jcsm.aasm.org/doi/full/10.5664/jcsm.6470

What are the thoughts regarding this? Pretty weak evidence for everything, but they recommend doxepin, ramelteon, some z-drugs and benzos, while recommending against melatonin and trazodone.

 

[clausewitz2]

Can't speak for @Stagg737 but doxepin has formal evidence for sleep maintenance that trazodone does not. Additionally, people are way less likely to get orthostatic with doxepin so works out better in the elderly. Strictly anecdotally, a lot fewer people complain to me about a sleep hangover the next morning and being unable to wake up with doxepin than trazodone, although admittedly I very rarely prescribe more than 10.

 

[birchswing]

https://jcsm.aasm.org/doi/full/10.5664/jcsm.6470

What are the thoughts regarding this? Pretty weak evidence for everything, but they recommend doxepin, ramelteon, some z-drugs and benzos, while recommending against melatonin and trazodone.

<Not a doctor or medical student>

Well I skipped to the parts that interested me: benzodiazepines and melatonin. Benzodiazepines for the reason that I'm curious why they would be recommending them this day in age and melatonin because I often see people using way too high of dosages and was curious what they used.

While they found temazepam worked, they wrote:

"Limited data on adverse effects of temazepam 15 and 30 mg are available. "

Really?

I guess we should wait another century for that to roll in.

And keep in mind, this was a recommendation for chronic insomnia.

As for the dose of melatonin I have heard is most effective (300 mcg), there was one study they included in their meta-analysis with that dose which did seem to help sleep efficiency at the least:

Melatonin treatment for age-related insomnia - PubMed

Older people typically exhibit poor sleep efficiency and reduced nocturnal plasma melatonin levels. The daytime administration of oral melatonin to younger people, in doses that raise their plasma melatonin levels to the nocturnal range, can accelerate sleep onset. We examined the ability of...

pubmed.ncbi.nlm.nih.gov

They talk about people in old age having melatonin depleted, but beta blockers also deplete melatonin. It was nice to see them look at amount that is equivalent to restoring normal levels rather than the supratherapeutic dosages often used.

I should say to their credit, they made clear that none of the recommendations had strong evidence. Although, when you list all of the evidence as weak, I'm not sure a practitioner would necessarily take that into account when choosing which option among all of the ones with equally weak evidence is best. And compounded again by not listing the obvious harms of benzodiazepines—they only seemed to mention the harms in the studies themselves. By that virtue, you could just study propofol and give it the highest ranking.

 

[lockian]

My first step is to evaluate them for sleep apnea. If that step is negative than I do things as others have pointed to above.

Agree. And if they have suspected or untreated sleep apnea, I do not use rozerem, temazepam or z drugs because contraindication. I hardly ever start temazepam or z drugs either, though somehow a lot of my practice partners use z drugs, since I do coverage refills of those with some regularity.

I’ve also been increasing using doxepin over trazodone because it is FDA approved for insomnia and telling patients that can improve their buy in. Of course ambien is also FDA approved for insomnia….

Also, I try to assess for medications and substances that may be contributing to insomnia. I found several people that way who were taking their venlafqxine or bupropion at night >.<

 

[clausewitz2]

Agree. And if they have suspected or untreated sleep apnea, I do not use rozerem, temazepam or z drugs because contraindication. I hardly ever start temazepam or z drugs either, though somehow a lot of my practice partners use z drugs, since I do coverage refills of those with some regularity.

I’ve also been increasing using doxepin over trazodone because it is FDA approved for insomnia and telling patients that can improve their buy in. Of course ambien is also FDA approved for insomnia….

Also, I try to assess for medications and substances that may be contributing to insomnia. I found several people that way who were taking their venlafqxine or bupropion at night >.<

'I don't know what the problem is, doc, when i wake up at 2 thirsty and get a drink I just can't get back to sleep.'

'What do you usually drink?'

'Like half a thing of Pepsi.'

'...when you say thing, what do you mean? Like one of the 2L bottles?'

'Yeah, exactly.'

Mystery solved.

 

[lockian]

'I don't know what the problem is, doc, when i wake up at 2 thirsty and get a drink I just can't get back to sleep.'

'What do you usually drink?'

'Like half a thing of Pepsi.'

'...when you say thing, what do you mean? Like one of the 2L bottles?'

'Yeah, exactly.'

Mystery solved.

People are also often surprised just how long caffeine can last in their body. Not to mention the diabetics with the middle of the night BG lows, and the people with the alcoholic nightcaps that cause a rebound awakening in the middle of the night.

One thing I do still have a challenge with is the people who suffer from physical ailments of some kind, usually pain, that interfere with sleep. I suppose CBT-I can also work for them, but it's a more uphill battle.

 

[allantois]

Agree. And if they have suspected or untreated sleep apnea, I do not use rozerem, temazepam or z drugs because contraindication. I hardly ever start temazepam or z drugs either, though somehow a lot of my practice partners use z drugs, since I do coverage refills of those with some regularity.

I’ve also been increasing using doxepin over trazodone because it is FDA approved for insomnia and telling patients that can improve their buy in. Of course ambien is also FDA approved for insomnia….

Also, I try to assess for medications and substances that may be contributing to insomnia. I found several people that way who were taking their venlafqxine or bupropion at night >.<

Is it really contraindicated tho? The literature is mixed at best

 

[lockian]

Is it really contraindicated tho? The literature is mixed at best

I prefer to err on the side of caution on this one. I don't want people to stop breathing in their sleep.

 

[allantois]

I prefer to err on the side of caution on this one. I don't want people to stop breathing in their sleep.

Me too. I would still say that they probably don't worsen OSA. Recently talked to a sleep specialist who made a point that PCPs probably prescribe these drugs to patients with (undiagnosed OSA) all the time. I get patients with OSA on CPAP who still complain of insomnia.. In fact their CPAP almost never helps them sleep in my experience

 

[allantois]

I have recently discovered a patient who drinks 14 pops of diet coke and 4 espresso shots who I've been trying to wean off seroquel for sleep (which in my opinion is just about the worst thing to rx for sleep). So far, we've made a lot of progress switching to caffeine-free coke

 

[allantois]

A lot of their issues can be environmental too (like spouse is on CPAP or snores or sleeps with TV). I remember suggesting to an older lady to sleep in a different room from her husband and being accused of blasphemy

 

[lockian]

Me too. I would still say that they probably don't worsen OSA. Recently talked to a sleep specialist who made a point that PCPs probably prescribe these drugs to patients with (undiagnosed OSA) all the time. I get patients with OSA on CPAP who still complain of insomnia.. In fact their CPAP almost never helps them sleep in my experience

True, adjusting to CPAP in and of itself often requires a course of CBT-I and short-term sleep aids.

I think it's more accurate to say that in the product information/package inserts the meds I mentioned have precautions against using in context of sleep apnea. There is evidence that temazepam at 10 mg doesn't worsen OSA and the evidence for z-drugs is indeed mixed, but honestly I don't quite trust that data. Mechanistically, they are gaba modulators and those can relax muscles and worsen sleep apnea. We may just not have enough practical evidence yet.

A lot of their issues can be environmental too (like spouse is on CPAP or snores or sleeps with TV). I remember suggesting to an older lady to sleep in a different room from her husband and being accused of blasphemy

Earplugs?

 

[birchswing]

'I don't know what the problem is, doc, when i wake up at 2 thirsty and get a drink I just can't get back to sleep.'

'What do you usually drink?'

'Like half a thing of Pepsi.'

'...when you say thing, what do you mean? Like one of the 2L bottles?'

'Yeah, exactly.'

Mystery solved.

I'm not sure how but my Swedish relatives drink really strong coffee right before bed. The last time they were visiting, the coffee wasn't strong enough to their liking and added espresso powder they were traveling with to it and then went to bed, to no ill effect to my knowledge.

Maybe they just had extreme tolerance, not sure.

I get sleepy from sugar--I think the sugar in Pepsi would outweigh any wakefulness from the caffeine for me.

 

[birchswing]

A lot of their issues can be environmental too (like spouse is on CPAP or snores or sleeps with TV). I remember suggesting to an older lady to sleep in a different room from her husband and being accused of blasphemy

The aristocracy had their own wings let alone bedrooms for the lady and gentleman of the house. And they were supposedly the closest to God mere mortals could be.

 

[lockian]

I'm not sure how but my Swedish relatives drink really strong coffee right before bed. The last time they were visiting, the coffee wasn't strong enough to their liking and added espresso powder they were traveling with to it and then went to bed, to no ill effect to my knowledge.

Maybe they just had extreme tolerance, not sure.

I get sleepy from sugar--I think the sugar in Pepsi would outweigh any wakefulness from the caffeine for me.

People with ADHD are settled down by coffee. It may have a paradoxical effect on them, like prescribed stimulants. I literally saw a friend of mine with ADHD drink a cup of coffee and fall asleep where they sat.

 

[hamstergang]

People with ADHD are settled down by coffee. It may have a paradoxical effect on them, like prescribed stimulants. I literally saw a friend of mine with ADHD drink a cup of coffee and fall asleep where they sat.

Neither I nor my father have ADHD, but both of us are unaffected by coffee. It doesn't wake us up, and it doesn't interfere with sleep. Maybe we just need a stronger than normal dose.

 

[WisNeuro]

'I don't know what the problem is, doc, when i wake up at 2 thirsty and get a drink I just can't get back to sleep.'

'What do you usually drink?'

'Like half a thing of Pepsi.'

'...when you say thing, what do you mean? Like one of the 2L bottles?'

'Yeah, exactly.'

Mystery solved.

Yeah, I've had more than a handful of people who will wake up in the middle of the night and grab a few cigarettes and some coffee, and somehow be surprised that they have a hard time falling back to sleep.

 

[deleted1100659]

I dont understand why they recommend against melatonin dosing, unless they mean against daily use. Intermittent melatonin works fine for sleep initation. Ive never seen anyone like rozerem.

Doxepin is a reasonable choice, agreed.

They like belsomra because it has lower abuse potential or am i wrong?

Trazodone I think at 50-100mg is generally tolerated ok for the eldlerly unless heart issues or on seroquel/other bp meds.

Generally most of the people i see with insomnia issues its 2/2 to anxiety or doing stupid stuff like drinking tons of caffeine and eating sugar in the evening.

 

[forchinet121]

I dont understand why they recommend against melatonin dosing, unless they mean against daily use. Intermittent melatonin works fine for sleep initation. Ive never seen anyone like rozerem.

Doxepin is a reasonable choice, agreed.

They like belsomra because it has lower abuse potential or am i wrong?

Trazodone I think at 50-100mg is generally tolerated ok for the eldlerly unless heart issues or on seroquel/other bp meds.

Generally most of the people i see with insomnia issues its 2/2 to anxiety or doing stupid stuff like drinking tons of caffeine and eating sugar in the evening.

Why heart issues matter with trazodone?

 

[docksan]

People with ADHD are settled down by coffee. It may have a paradoxical effect on them, like prescribed stimulants. I literally saw a friend of mine with ADHD drink a cup of coffee and fall asleep where they sat.

This is literally me.

 

[lockian]

I dont understand why they recommend against melatonin dosing, unless they mean against daily use. Intermittent melatonin works fine for sleep initation. Ive never seen anyone like rozerem.

Doxepin is a reasonable choice, agreed.

They like belsomra because it has lower abuse potential or am i wrong?

Trazodone I think at 50-100mg is generally tolerated ok for the eldlerly unless heart issues or on seroquel/other bp meds.

Generally most of the people i see with insomnia issues its 2/2 to anxiety or doing stupid stuff like drinking tons of caffeine and eating sugar in the evening.

If I had a penny for every time I’m told by patients about “racing thoughts” keeping them up… sometimes it’s anxiety, sometimes undertreated ADHD (particularly if the thoughts are random rather than worried per se) but either way I know we need an IV infusion of mindfulness, sleep hygiene, and CBT-I.

 

[jbomba]

Why heart issues matter with trazodone?

Maybe they are thinking because it can cause orthostasis? That's my guess.

 

[aim-agm]

Agree with above about primacy of diagnostic/etiologic clarity, behavioral interventions, CBTi. My thoughts/approach on medication treatment of insomnia, which I break down by mechanism of action:

Melatonin: First line with great risk:reward ratio, often at least partially effective, and incredibly safe and virtually impossible to overdose on (therapuetic index >>10,000). Slightly finicky to use because of chronotropic effects, so I typically use scheduled rather than PRN. Sometimes use ramelteon but usually due to insurance/cost issues

Sympatholytics: Very effective, especially when etiology of insomnia is hyperarousal (e.g. anxiety, PTSD), usually well tolerated but effects on BP can be limiting in elderly. Alpha-1 antagonism (i.e. prazosin) is most within the beaten path, alpha-2 agonism (e.g. clonidine, guanfacine) seems to be more powerful and treats some non-psychiatric contributors to insomnia (e.g. pain). Use beta-blockers less frequently, but they are also option.

Antihistamines: Other mainstay, usually effective and well tolerated, have added benefit of being easy to also use as PRNs for anxiety. Need to be wary of anticholinergic effects. My other concern with them is that most have very long half-lives, which means that daytime side effects are more likely as is development of tolerance, e.g. one dose of mirtazapine 15 mg will have enough H1 occupancy for continuous soporific effect for days and days.
Anticholinergics: Sometimes in select patients (i.e. young), in large part because diphenhydramine has one of the shorter half lives among antihistamines.

5-HT2 Antagonists: There aren't any "pure" 5HT2 antagonists as far as I'm aware. For example, trazodone also is avid for alpha-1, and to a lesser degree H1. Cyproheptadine is a much, much more potent 5-HT2 antagonist but is also a very, very avid H1 antagonist, and has the same order of magnitude Ki for muscarininc receptors as 5HT2. Notably, they both have ~8 hour half life which is a point in their favor. I use trazodone quit a bit with good efficacy and tolerability (usually start at 25-50 mg and titrate to effect). Cyproheptadine should be great for sleep but I haven't really used it much at all.

Benzos/Zdrugs: Rarely, have a very small amount of patients on them that essentially trialled and failed everything else.

Orexin antagonists: Have considered multiple times but ultimately cost is prohibitive.

Misc: Gabapentin and D2 antagonists can be useful for sedating effects, although risk:reward is usually less favorable

 

[deleted1100659]

Why heart issues matter with trazodone?

Qtc prolongation and orthostatic hypotension

 

[Stagg737]

Stagg, bless you for reminding us to start with assessment and diagnosis. I'm sure I've been guilty of jumping to treatment when a patient complains of insomnia. Out of curiosity, why is doxepin your go to over trazodone?

Doxepin has better evidence and very small doses are generally very safe, well-tolarated, and can be very effective. Agree with what Clause said, but I go up to 25mg for sleep (without other indications) as that's when you're going to start getting non-histaminergic effects.

Me too. I would still say that they probably don't worsen OSA. Recently talked to a sleep specialist who made a point that PCPs probably prescribe these drugs to patients with (undiagnosed OSA) all the time. I get patients with OSA on CPAP who still complain of insomnia.. In fact their CPAP almost never helps them sleep in my experience

Depends on how bad their sleep issues are and if they've been seen for OSA. If I'm suspicious of significant OSA I'm very unlikely to use any CNS depressant without the patient being assessed by sleep medicine. I've talked to several people who knew someone who died in their sleep from OSA while waiting to be evaluated by sleep medicine. Idc what the PCP does, I'm not willing to knowingly increase that risk. Same if they get tested and have severe apnea which isn't properly controlled or if they're non-compliant with their CPAP.

If a patient's OSA is well controlled and they're compliant or their apnea is very mild, I'm much less concerned. I'll still try to avoid starting those meds, but they'll at least be back in my algorithm and I'd be okay continuing them if that's what's worked for the patient.

I dont understand why they recommend against melatonin dosing, unless they mean against daily use. Intermittent melatonin works fine for sleep initation.

Because the evidence for melatonin for non-circadian sleep disorders sucks. Sometimes it works, but the placebo effect can be strong. Most guidelines don't actually recommend against using melatonin though. They specifically "do not recommend use" which is typically the same category as trazodone in those guidelines and they cite the evidence as weak. Additionally, people often don't take melatonin the correct way (several hours before sleep time, at a consistent time, scheduled) and instead will take it like a sedative, sometimes PRN, for which there's basically no evidence for the average patient.

There are some populations where there are exceptions for this. Geriatric patients, patients with chronic alcohol use, and patients with some other sleep disorders which are misdiagnosed as an insomnia disorder are all situations where melatonin does have evidence and can provide significant benefit on its own. I also start it prophylactically for metabolic syndrome for anyone I start on an antipsychotic with significant metabolic side effects (usually olanzapine).

Qtc prolongation and orthostatic hypotension

I'll give you OH, but unless their cardiac hx has some significant arrhythmias or really long QTc, I've got no cardiac concerns with elderly patients having 25-50mg of trazodone for sleep. QTc is kind of finicky, but APA actually has a pretty thorough set of guidelines for it:

QTc Prolongation and Psychotropic Medications

Psychiatrists and other clinicians frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsades de pointes (TdP). The corrected QT interval (QTc) is the most widely used and accepted marker of TdP risk. This resource document was...

www.psychiatry.org

 

[forchinet121]

Doxepin has better evidence and very small doses are generally very safe, well-tolarated, and can be very effective. Agree with what Clause said, but I go up to 25mg for sleep (without other indications) as that's when you're going to start getting non-histaminergic effects.


Depends on how bad their sleep issues are and if they've been seen for OSA. If I'm suspicious of significant OSA I'm very unlikely to use any CNS depressant without the patient being assessed by sleep medicine. I've talked to several people who knew someone who died in their sleep from OSA while waiting to be evaluated by sleep medicine. Idc what the PCP does, I'm not willing to knowingly increase that risk. Same if they get tested and have severe apnea which isn't properly controlled or if they're non-compliant with their CPAP.

If a patient's OSA is well controlled and they're compliant or their apnea is very mild, I'm much less concerned. I'll still try to avoid starting those meds, but they'll at least be back in my algorithm and I'd be okay continuing them if that's what's worked for the patient.



Because the evidence for melatonin for non-circadian sleep disorders sucks. Sometimes it works, but the placebo effect can be strong. Most guidelines don't actually recommend against using melatonin though. They specifically "do not recommend use" which is typically the same category as trazodone in those guidelines and they cite the evidence as weak. Additionally, people often don't take melatonin the correct way (several hours before sleep time, at a consistent time, scheduled) and instead will take it like a sedative, sometimes PRN, for which there's basically no evidence for the average patient.

There are some populations where there are exceptions for this. Geriatric patients, patients with chronic alcohol use, and patients with some other sleep disorders which are misdiagnosed as an insomnia disorder are all situations where melatonin does have evidence and can provide significant benefit on its own. I also start it prophylactically for metabolic syndrome for anyone I start on an antipsychotic with significant metabolic side effects (usually olanzapine).



I'll give you OH, but unless their cardiac hx has some significant arrhythmias or really long QTc, I've got no cardiac concerns with elderly patients having 25-50mg of trazodone for sleep. QTc is kind of finicky, but APA actually has a pretty thorough set of guidelines for it:

QTc Prolongation and Psychotropic Medications

Psychiatrists and other clinicians frequently prescribe psychotropic drugs that may prolong cardiac repolarization, thereby increasing the risk for torsades de pointes (TdP). The corrected QT interval (QTc) is the most widely used and accepted marker of TdP risk. This resource document was...

www.psychiatry.org

Melatonin for metabolic syndrome? I’m learning so much reading these threads

 

[drechie]

Melatonin for metabolic syndrome? I’m learning so much reading these threads

My thoughts exactly.

 

[Stagg737]

Melatonin for metabolic syndrome? I’m learning so much reading these threads

Yup. Meds with the best evidence are metformin, topiramate, and melatonin in that order. I've been perpetually looking for a review article I read in residency about that and am still yet to find it. Will post it on here if I ever find it.

 

[whopper]

1) A rant here. There's an entire specialization for sleep disorders and despite this whenever I refer to a sleep doctor and I've tried several, all I usually hear (edit "I incorrectly wrote "here") is "we only test for OSA and that's all we treat."

What? Your entire specialty is just this? I doubt it but this is the impression several have given me. I've only seen 2 sleep doctors willing to try CBT-I.

2) A sleep treatment that I've found works in several that I don't see anyone trying is Alpha-Stimulation with an electronic device. I've seen several benefit from it.

3) With so many people being overweight these days you figure PCPs would rule out OSA before giving out a sleep med but I'm one of the only doctors I see factoring in that OSA could be the cause of insomnia. Almost everyone I know of simply just prescribes a sleep med with the first complaint of insomnia.

4) Ramelteon is a melatonin agonist so you figure it's safe right? It's contraindicated with Fluvoxamine and Qelbree. This is one of those things where I'm wondering is this contraindication over-exaggerated? I don't know and I'm not going to make a patient a guinea pig to find out.

 

[docksan]

OSA is literally the first thing I look into. Interesting about the Alpha Stim though. Do you refer to Neuro for that?

 

[WisNeuro]

I have not yet seen any good data for Alpha-stim and sleep. I'm mostly aware of the data with older adults, but the data that actually utilizes sham control conditions show's no differences between the groups (e.g., Rose et al., 2009; Gao et al 2019 meta). Does this look different in younger samples, are is the success you've seen anecdotal?

 

[PikminOC]

Takes forever here to get into a sleep doc and to get the CPAP. Patient needs treatment while they are waiting.

 

[docksan]

Takes forever here to get into a sleep doc and to get the CPAP. Patient needs treatment while they are waiting.

I have a patient who had a sleep consult placed a year ago and they STILL don't have a CPAP.

 

[allantois]

I have a patient who had a sleep consult placed a year ago and they STILL don't have a CPAP.

I think there’s a way to order a home study; I know PCPs do this but never looked into it

 

[allantois]

1) A rant here. There's an entire specialization for sleep disorders and despite this whenever I refer to a sleep doctor and I've tried several, all I usually hear (edit "I incorrectly wrote "here") is "we only test for OSA and that's all we treat."

What? Your entire specialty is just this? I doubt it but this is the impression several have given me. I've only seen 2 sleep doctors willing to try CBT-I.

This seems to happen especially if the Md is pulm..

 

[tr]

1) A rant here. There's an entire specialization for sleep disorders and despite this whenever I refer to a sleep doctor and I've tried several, all I usually hear (edit "I incorrectly wrote "here") is "we only test for OSA and that's all we treat."

What? Your entire specialty is just this? I doubt it but this is the impression several have given me. I've only seen 2 sleep doctors willing to try CBT-I.

Uh, this is fine? CBTi is 100% in our wheelhouse. I am fine if sleep can rule out OSA and turf back to me for the psychotherapeutic intervention. Sleep medicine at my previous institution did offer a rapid CBTi protocol but I think that was above and beyond on their part actually. Why would we expect pulm to do psychotherapy?

 

[allantois]

Uh, this is fine? CBTi is 100% in our wheelhouse. I am fine if sleep can rule out OSA and turf back to me for the psychotherapeutic intervention. Sleep medicine at my previous institution did offer a rapid CBTi protocol but I think that was above and beyond on their part actually. Why would we expect pulm to do psychotherapy?

I think the issue is they don’t offer any pharmacological management

 

[whopper]

I talked to a sleep doctor yesterday about the "we only diagnose and treat OSA" BS I see among almost all sleep doctors these days. She told me the problem is reimbursement and that almost all insurance companies don't reimburse well unless it's for OSA.

Whether or not this is true I don't know but I do know this sleep doctor is well respected, isn't a pulmonologist sleep doctor, and actually got out of sleep medicine because of the low reimbursements outside of OSA per her. She also mentioned that because so many sleep doctors these days are pulmonologists they're only specifically looking for the breathing problem side of insomnia and have given themselves professionally-induced blinders to much else.

 

[ObsequiousAplomb]

I think the issue is they don’t offer any pharmacological management

The sleep medicine specialists I get referrals from usually have an extensive network of CBT-i therapists they refer to. They also usually offer in sequence a z drug, an antihistamine, and an SSRI (12 weeks, too!).

After a trial of all that doesn't seem satisfactory enough I end up seeing them and I do whatever I do.

 

[allantois]

I talked to a sleep doctor yesterday about the "we only diagnose and treat OSA" BS I see among almost all sleep doctors these days. She told me the problem is reimbursement and that almost all insurance companies don't reimburse well unless it's for OSA.

Whether or not this is true I don't know but I do know this sleep doctor is well respected, isn't a pulmonologist sleep doctor, and actually got out of sleep medicine because of the low reimbursements outside of OSA per her. She also mentioned that because so many sleep doctors these days are pulmonologists they're only specifically looking for the breathing problem side of insomnia and have given themselves professionally-induced blinders to much else.

Sigh this is like dermatologists not treating rashes or psych SMI. I can see internists forgetting sleep can be a BRAIN issue lol