![]() 22 Like benzodiazepines, the z-drugs bind to the GABA A receptor, causing hyperpolarization of the cell. 21 Numerous trials have demonstrated the effectiveness of these drugs, including a recent meta-analysis that showed that they decreased sleep latency by an average of 42 minutes vs. The most commonly prescribed class of medication for insomnia is the so-called z-drugs, zaleplon (Sonata), zolpidem (Ambien), and eszopiclone (Lunesta). Persons with sleep apnea or chronic lung disease with nocturnal hypoxia should be evaluated by a sleep specialist before sedating medications are prescribed. Sedating antihistamines, antiepileptics, and atypical antipsychotics are not recommended unless they are used primarily to treat another condition. Although the orexin receptor antagonist suvorexant appears to be relatively effective, it is no more effective than the z-drugs and much more expensive. Benzodiazepines are not recommended because of their high abuse potential and the availability of better alternatives. For those who have difficulty staying asleep, low-dose doxepin and the z-drugs should be considered. For the general population with difficulty falling asleep, controlled-release melatonin and the z-drugs can be considered. Controlled-release melatonin and doxepin are recommended as first-line agents in older adults the so-called z-drugs (zolpidem, eszopiclone, and zaleplon) should be reserved for use if the first-line agents are ineffective. Understanding the risks and benefits of insomnia medications is critical. Although behavioral interventions are the mainstay of treatment, pharmacologic therapy may be necessary for some patients. Histamine receptor inverse agonists (APD-125, eplivanserin, and LY2624803) improve slow-wave sleep but, for various reasons, the drug companies withdrew their products.Insomnia accounts for more than 5.5 million visits to family physicians each year. Piromelatine may improve sleep maintenance. Phase II studies of dual orexin receptor antagonists (almorexant, lemborexant, and filorexant) have shown some improvement in sleep maintenance and sleep continuity. Valerian is relatively safe but has equivocal benefits on sleep quality. Tryptophan decreases sleep onset in adults, but data in the elderly are not available. Melatonin slightly improves sleep onset and sleep duration, but product quality and efficacy may vary. Non-FDA-approved hypnotic agents that are commonly used include melatonin, diphenhydramine, tryptophan, and valerian, despite limited data on benefits and harms. Tiagabine, sometimes used off-label for insomnia, is not effective and should not be utilized. Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks. Benzodiazepines should not be used routinely. Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings. Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance. Suvorexant or low-dose doxepin can improve sleep maintenance. Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia. The choice of a hypnotic agent in the elderly is symptom-based. We review the indications, dosing, efficacy, benefits, and harms of these drugs in the elderly, and discuss data on drugs that are commonly used off-label to treat insomnia, and those that are in clinical development. This review focuses on Food and Drug Administration (FDA)-approved drugs for insomnia, including suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon. Current drugs for insomnia fall into different classes: orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines. Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies. Various specialty societies view psychological/behavioral therapies as the initial treatment intervention. The main modalities in the treatment of insomnia in the elderly are psychological/behavioral therapies, pharmacological treatment, or a combination of both. Chronic insomnia burdens society with billions of dollars in direct and indirect costs of care. Chronic insomnia affects 57% of the elderly in the United States, with impairment of quality of life, function, and health.
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |