Thoughts on treating insomnia?

[allantois]

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.

Seroquel? Lol

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[liquidshadow22]

Doxepin is wickedly anticholinergic. I would avoid as opposed to trazodone. Much safer for brain in the long run

 

[splik]

Doxepin is wickedly anticholinergic. I would avoid as opposed to trazodone. Much safer for brain in the long run

Doxepin is anticholinergic but does not have much anticholinergic effects at the very low doses (3-6mg) typically used to treat insomnia. Its affinity for the H1 receptor is about 350x greater than its affinity for M1 muscarinic receptors. There is no evidence that doxepin is particularly bad for your brain in the long run, and I very frequently use it in patients with neurological disorders including TBI and neurocognitive impairment. There is some data suggesting chronic (i.e. years) use of doxepin may elevate risk of dementia very slightly, but at 10mg or greater.

 

[liquidshadow22]

I knew they

Doxepin is anticholinergic but does not have much anticholinergic effects at the very low doses (3-6mg) typically used to treat insomnia. Its affinity for the H1 receptor is about 350x greater than its affinity for M1 muscarinic receptors. There is no evidence that doxepin is particularly bad for your brain in the long run, and I very frequently use it in patients with neurological disorders including TBI and neurocognitive impairment. There is some data suggesting chronic (i.e. years) use of doxepin may elevate risk of dementia very slightly, but at 10mg or greater.

I knew they manufactured the 6 mg doxepin but none of my attending ever recommended it in residency and barely ever saw it prescribed. Appears there is limited anticholinergic effect until you reach 25 mg. I have prescribed the 10s and 25s in the past without too much success, albeit low sample size. Will give this a more thorough trial with my chronic insomniacs. Thanks.

 

[randomdoc1]

Never ceases to amaze me how many patients just will not incorporate seeing a CBT-I provider despite the overwhelming evidence. Everyone already gave very good input. I educate about the risks versus benefits of sleep aids. My own philosophy is benzos unless for matters like etoh withdrawal, seizure abortion, or catatonia do not have much use. Contrary to what many patients think, benzos are NOT a medical necessity outside of those settings and can create great harm. Patients do seem to be more understanding when you show them the direct medical literature. Then I say, let's gather some more history, data. If we don't have a clear idea of what is going on, does it really sound logical to throw pills at symptoms? I've had patients either keep a sleep log or wear a fit bit. I say no exceptions. No napping, strict going to bed and wake up time. I guarantee patients their body will not leave them in persistent accruing sleep deprivation. Unless they have something like perhaps fatal familial insomnia? And guess what? I have NEVER contrary to what subjective histories say seen a consistent "four hours of sleep every night." I've seem people not fall asleep until 5 am but it takes no more than 48 hours for them to hit the pillow hard and that cardian clock finally reset. Had this happen lately to a geriatric patient who asked for lorazepam and was taking benadryl in the meantime. I saw her twice a week for two weeks. Bam, done. People are interesting for sure.

 

[Batman's Underwear]

R/o other causes including sleep study!
Treat other causes including OSA.
Many SSRIs have no benefits in regard to insomnia unless insomnia is 2/2 to depression. Actually they cause further defragmentation of sleep architecture during acute period. Prozac is the worse in regard to this matter. CBT-I is the best. You can augment with Z-drug or low dose doxepin (3-6), low dose of Amitriptyline and Z-drug. Trazodone, mirtazapine and Seroquel are okish but they don't do much unless, again, sleep is 2/2 to underlying psychiatric illness. Developing substance use disorder from Z-drug is quite rare (per manufacturing company), and side effects of sleep behaviors are rare, especially for people who never experienced any complex sleep behaviors.

 

[romanticscience]

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

I finally got around to looking into this as well. I found the following devices:

CleveMed’s SleepView Direct
type III ApneaLink Air by ResMed

 

[sloh]

I guarantee patients their body will not leave them in persistent accruing sleep deprivation. Unless they have something like perhaps fatal familial insomnia? And guess what? I have NEVER contrary to what subjective histories say seen a consistent "four hours of sleep every night." I've seem people not fall asleep until 5 am but it takes no more than 48 hours for them to hit the pillow hard and that cardian clock finally reset. Had this happen lately to a geriatric patient who asked for lorazepam and was taking benadryl in the meantime. I saw her twice a week for two weeks. Bam, done.

This is something that should be communicated to patients more often. A lot of insomnia is due to the worry around not being able to fall asleep.

 

[calvnandhobbs68]

I knew they

I knew they manufactured the 6 mg doxepin but none of my attending ever recommended it in residency and barely ever saw it prescribed. Appears there is limited anticholinergic effect until you reach 25 mg. I have prescribed the 10s and 25s in the past without too much success, albeit low sample size. Will give this a more thorough trial with my chronic insomniacs. Thanks.

Liquid doxepin is also generic bc insurance will rarely pay for the 3mg and 6mg doses in my experience unless you’ve tried a bunch of other insomnia meds. I start with 10 and if it’s too much I’ve asked if they want to try liquid 6mg.

 

[allantois]

Liquid doxepin is also generic bc insurance will rarely pay for the 3mg and 6mg doses in my experience unless you’ve tried a bunch of other insomnia meds. I start with 10 and if it’s too much I’ve asked if they want to try liquid 6mg.

Liquid doxepin seems as expensive on GoodRx. Carlat Report suggests telling patients to spill contents of a capsule into a glass of juice and have them drink half of it.. Never quite told anyone that yet, but I also haven't been prescribing doxepin

 

[calvnandhobbs68]

Liquid doxepin seems as expensive on GoodRx. Carlat Report suggests telling patients to spill contents of a capsule into a glass of juice and have them drink half of it.. Never quite told anyone that yet, but I also haven't been prescribing doxepin

Haha what?

GoodRx CVS in my area:
Doxepin 10mg capsule- $9.63 for 30
Doxepin 6mg tablet- $138.28 for 30
Doxepin 10mg/ml solution- $14.52 for 120ml (so 200 doses of 6mg...)