Diphenhydramine in insomniac family practice patients: a double-blind study

Expert Consensus on the Use of Diphenhydramine for Short-Term Insomnia: Efficacy, Safety, and Clinical Applications

Insomnia is the most prevalent sleep disorder, estimated to affect at least one-third of the global population. There are a variety of treatment options available for both acute and chronic insomnia. Currently, the pharmacological arsenal for treating insomnia includes short- or intermediate-acting benzodiazepine hypnotics, non-benzodiazepine hypnotic sedatives, melatonin receptor agonists, orexin receptor antagonist, and sedating antidepressants. Diphenhydramine, a first-generation antihistamine, is commonly used in the treatment of allergies and dermatitis. This review examines the preclinical and clinical efficacy and safety evidence of diphenhydramine in treating short-term insomnia. Additionally, it provides expert consensus on its implementation as an over-the-counter medication for this condition. The available evidence indicates that diphenhydramine is an effective treatment for acute insomnia in adults, offering a safe and affordable option for most patients suffering from this condition. Experts concur that there is strong evidence supporting the recommendation of diphenhydramine for the treatment of acute insomnia in adults.

Over-the-counter products for insomnia in adults: A scoping review of randomised controlled trials

BACKGROUND

Insomnia is highly prevalent and poses significant personal and socio-economic challenges. While the National Institute for Health and Care Excellence (NICE) recommendations define possible medical approaches, over-the-counter products are commonly used to self-manage insomnia symptoms. This scoping review aims to determine the size and scope of the evidence-base regarding the effectiveness and safety of over-the-counter products for insomnia symptoms in adults.

METHODS

The electronic databases of CENTRAL, MEDLINE, EMBASE, PsycINFO, and AMED were searched from inception to December 19th, 2022, for all randomised controlled trials evaluating over-the-counter products compared to placebo, in adults aged 18-65 with insomnia symptoms. Results were synthesised descriptively.

RESULTS

51 randomised controlled trials were included, evaluating herbal products (n = 34), dietary supplements (n = 15), herbal-dietary combinations (n = 4), and over-the-counter medicines (n = 2). Sample sizes ranged between 10 and 405 participants. Eleven studies were conducted in participants with co-morbidities. Interventions were most frequently given as monotherapy and compared against placebo. Most studies (n = 41) demonstrated interventions' positive effects on insomnia symptoms. Among the most studied products, valerian and melatonin have substantial evidence to demonstrate their effectiveness and safety. Promising products demonstrating benefits compared with prescription medication alone included: valerian; lemon balm and fennel; and valerian, hops, and passionflower. Intervention-related side effects were mostly mild and transient. No serious adverse events were reported across all studies.

CONCLUSIONS

Over-the-counter products show promising, but inconclusive findings in alleviating insomnia symptoms in adults. Future research should focus on investigating products currently used in real life, consider economic evaluations, and be evaluated in populations with co-morbidities and ethnic minorities, to better guide clinical advice.

A scoping review of over-the-counter products for depression, anxiety and insomnia in older people

BACKGROUND

Depression, anxiety, and insomnia are prevalent in older people and are associated with increased risk of mortality, dependency, falls and reduced quality of life. Prior to or whilst seeking treatment, older people often manage these symptoms or conditions using products purchased over the counter (OTC), such as medication or herbal products. This review aims to map the evidence available for OTC medications, herbal medicines and dietary supplements for depression, anxiety and insomnia in older adults.

METHODOLOGY

We carried out a scoping review, including searches of five databases to identify relevant randomised controlled trials (inception-Dec 2022). We took an inclusive approach to products to represent the wide range that may be available online. Trials were summarised according to condition and product.

RESULTS

We included 47 trials and 10 ongoing trial protocols. Most targeted insomnia (n = 25), followed by depression (n = 20), and mixed conditions (n = 2). None evaluated products targeted at anxiety alone. Where reported, most products appeared to be safe for use, but studies rarely included people with multiple comorbidities or taking concomitant medication. Some types of melatonin for insomnia (n = 19) and omega-3 fatty acids for depression (n = 7) had more substantive evidence compared to the other products.

CONCLUSION

There is a substantial gap in evidence for OTC products for anxiety in older people. This should be addressed in future trials. Research should also focus on products that are widely used, and these need to be tested in older populations that are similar to those who would use them in practice.

[Treatment of sleep disturbances associated with chronic non-specific low back pain: results of prospective randomized multicenter open-label clinical trial]

OBJECTIVE

A comparative study of the effectiveness and safety of novel combination naproxen sodium and diphenhydramine in subjects with low back pain along with transient insomnia.

MATERIAL AND METHODS

It was an open label, randomized, comparative, parallel group and multi-center clinical study. Subjects were randomised into one of three treatment arms: naproxen sodium 440 mg/diphenhydramine 50 mg, naproxen sodium 550 mg, Paracetamol 1000 mg/diphenhydramine 50 mg. All the subjects were advised to apply study drug ones before sleep for 3 days. All subjects also received naproxen sodium 275 mg as background therapy. The primary end-point was wake time after sleep onset (WASO) measured by actigraphy. Other secondary sleep and pain end-points were also assessed.

RESULTS

Efficacy analysis was performed for intent-to-treat population (n=235 subjects). naproxen sodium 440 mg/diphenhydramine 50 mg combination showed significant improvements in WASO vs. naproxen sodium 550 mg (-42 min p=0.0174), while differences vs. Paracetamol 1000 mg/diphenhydramine 50 mg (-30 min, p=0.0891) were not significant. According to the average pain intensity difference in the lumbosacral spine combination product naproxen sodium 440 mg/diphenhydramine 50 mg was significantly improved compared with naproxen sodium 550 mg (-9.42, p<0.001) and Paracetamol 1000 mg/diphenhydramine 50 (-7.15, p<0.05).

CONCLUSION

Naproxen sodium 440 mg/diphenhydramine 50 mg combination demonstrated improvement in sleep maintenance (WASO) vs. naproxen sodium 550 mg and higher efficiency in average daily pain reduction compared with the comparison groups. The treatment was well tolerated There were no serious or unexpected adverse events reported in the study.

Efficacy of the triple-combination SM-1 in a 5-h phase advance transient insomnia model

Thomas Dahl, PO Box 404, Guilford, CT 06437 USA. Email: tadahl@outlook.com. The objectives of the study were to demonstrate the efficacy and safety of SM-1 in a circadian challenge model of transient insomnia. Randomized, double-blind, placebo-controlled cross-over study utilizing a 5-h phase advance model of transient insomnia. Subjects were 85 healthy adults reporting a history of transient insomnia, with an average age of 38.9 years. Both SM-1 and placebo were administered to all subjects in a randomly assigned sequence, with at least 1 week between treatments. The primary endpoint was total sleep time determined by polysomnography. Secondary endpoints included wakefulness after sleep onset, latency to persistent sleep, number of awakenings, subjective total sleep time and subjective sleep onset latency, total sleep time by quarters of the night, subjective number of awakenings, and sleep quality. Safety endpoints included adverse events, Karolinska Sleepiness Scale, Digit Symbol Substitution Test, and predischarge evaluation (tandem gait and Romberg tests). SM-1 provided an increase of 94.4 min in total sleep time over placebo (p < 0.0001). Wakefulness after sleep onset, subjective total sleep time, subjective sleep onset latency, and total sleep time in the first quarter of the night also showed significant improvement. SM-1 was well-tolerated with both type and frequency of adverse events being comparable to placebo, and no residual sleepiness upon awakening (i.e., after 8 h). SM-1 provided a robust and statistically significant increase in total sleep time compared to placebo in a circadian model of transient insomnia, without evidence of next-day impairment.

Over-The-Counter Remedies in Older Adults: Patterns of Use, Potential Pitfalls, and Proposed Solutions

Over-the-counter (OTC) products such as pharmaceuticals, dietary supplements, vitamins, and herbal remedies are widely available and copiously used by older adults for health maintenance and symptom management. Owing to physiology, multimorbidity, and polypharmacy, this population is particularly vulnerable to inappropriate use of OTC products, adverse effects, and drug interactions. While OTC pharmaceuticals are bound by FDA-approved standards, dietary supplements are regulated differently, resulting in variable quality and increased possibility for adulteration. Internationally, standards for OTC products vary widely. Accessible educational information, improved provider-patient communication, and revision of regulatory policy could improve safety for older adult users of OTC products.

Efficacy of Triprolidine in the Treatment of Temporary Sleep Disturbance

Triprolidine, a first-generation antihistamine for allergic rhinitis, has a shorter half-life and fewer persistent effects relative to other antihistamines and may be useful in the treatment of temporary sleep disturbance. Patients aged ≥18 years old were randomized 1:1:1 to receive either triprolidine 2.5 mg (n = 65), triprolidine 5 mg (n = 66), or placebo (n = 67) on 3 consecutive nights. Sleep disturbance index was monitored via wrist actimeter. Subjective measures were assessed via diary card. Triprolidine 2.5 mg had a significantly lower sleep disturbance index versus placebo on night 1 (P = .02); however, when adjusted for outliers, sleep disturbance index did not significantly differ between either dose of triprolidine versus placebo on night 1. Adjusted sleep disturbance index was significantly lower with triprolidine 2.5 and 5 mg versus placebo on night 3 (P = .0017 and P = .011, respectively) and for the mean of all 3 nights (P = .01 and P = .015, respectively). Sleep latency was significantly improved for triprolidine 2.5 mg versus placebo on nights 2 and 3 and for the mean of all 3 nights and for triprolidine 5 mg versus placebo for the mean of all 3 nights. Subjective measures showed those on both doses of triprolidine felt more refreshed on awakening versus placebo for the mean of all 3 nights, with no increase in daytime sleepiness. The frequency of adverse events was similar across groups. The optimum dose of triprolidine for treatment of temporary sleep disturbance was 2.5 mg. There were improvements in both objective and subjective measures of sleep quality versus placebo, with no safety concerns raised.

QT interval prolongation and rhabdomyolysis associated with diphenhydramine toxicity: a case report

Diphenhydramine is a widely available, over-the-counter medication used for allergies and as a sleeping aid. When used in prescription doses, it is generally safe.

Overdose of the medication has been associated with dangerous and life-threatening outcomes. Our case describes diphenhydramine toxicity manifesting with two rare but potentially

life-threatening complications, rhabdomyolysis, and QT prolongation. Laboratory testing for diphenhydramine levels are not widely available. We recommend a high degree of suspicion for these complications when evaluating patients with diphenhydramine overdose, to adequately manage and prevent untoward outcomes.

Efficacy of SM-1 in a transient insomnia model

OBJECTIVES

The objectives of this study were primarily to assess the efficacy and safety of SM-1 in a circadian challenge model of transient insomnia and secondarily, to assess the contribution of diphenhydramine to the combination.

METHODS

Randomized, double-blind, placebo-controlled three-way cross-over study with a 5-hr phase advance. Subjects were 39 healthy adults reporting a history of transient insomnia. All treatments (SM-1, SM-1 without diphenhydramine, or placebo) were administered to all subjects in a randomly assigned sequence, with at least 1 week between treatments. The primary endpoint was total sleep time (TST) determined by polysomnography. Secondary endpoints included wakefulness after sleep onset (WASO), latency to persistent sleep, number of awakenings (NAW), subjective TST (sTST) and sleep latency (sSL), TST, and NAW by quarters of the night and sleep quality. Safety endpoints included adverse events, Karolinska Sleepiness Scale digit symbol substitution test, and subject-reported alertness level.

RESULTS

SM-1 provided an increase of 126.7 min in TST over placebo (p < .001). WASO, sTST, sleep quality, and sSL also showed significant improvement. Diphenhydramine demonstrated a significant (p = .014) contribution of 43.7 min to TST. SM-1 was well-tolerated with type and frequency of adverse events comparable with placebo, and no residual sleepiness upon awakening after 8 hr.

CONCLUSIONS

SM-1 provided a robust and statistically significant increase in TST compared with placebo in a circadian model of transient insomnia, without evidence of next-day impairment. Diphenhydramine contributed to the effect.

Pharmacodynamic and pharmacokinetic profile of SM-1, a triple-drug combination to increase total sleep time

OBJECTIVE

The primary objective was to characterize the pharmacokinetics and pharmacodynamics of SM-1 after administration of a single oral dose to healthy volunteers in a placebo-controlled double-blind trial of daytime sedation. Secondary objectives were to determine the onset, duration, and offset of the sedative effects using subjective and objective measures of sedation. Safety and tolerability of SM-1 were also investigated.

METHODS

Males and females 18-45 years of age received SM-1, a combination drug product comprised of diphenhydramine, zolpidem (delayed release), and lorazepam (delayed release). The pharmacokinetic profile of each drug was determined from blood samples. Sedative effects were assessed by visual analog scale, digit symbol substitution test, memory test, and quantitative electroencephalography.

RESULTS

Similar number and severity of adverse events were observed following administration of SM-1 and placebo. Onset of sedation, as determined by subjective, performance, and electroencephalography measures, occurred 0.5-1 hr postdose, lasting about 7-7.5 hr. Plasma concentration curves for the two delayed-release components were altered compared with published data for unmodified drugs. Exposure values obtained with the combination product were in good agreement with published values of the drugs given individually.

CONCLUSIONS

SM-1 was well tolerated and has pharmacologic activity starting within an hour of ingestion, lasting approximately 7-8 hr. Sedative activity was seen with subjective, psychomotor, and electroencephalography assays.

Sleep modulating agents

Sleep and wake are two fundamental states of human existence. Conditions such as insomnia and hypersomnia can have profound negative effects on human health. Many pharmacological interventions impacting sleep and wake are available or are under development. This brief digest surveys early approaches to sleep modulation and highlights recent developments in sleep modulating agents.

Self-Medication for Sleep in College Students: Concurrent and Prospective Associations With Sleep and Alcohol Behavior

OBJECTIVE/BACKGROUND

College students are at an increased risk for poor sleep and associated sleep problems. Emerging evidence suggests that a substantial subset of college students self-medicate with alcohol, marijuana, or over-the-counter medications to help sleep. The current study identified demographic, psychosocial, and sleep- and alcohol-related correlates of self-medication for sleep, and assessed its concurrent and prospective associations with insomnia symptoms, alcohol drinking, and negative drinking consequences.

PARTICIPANTS

Undergraduate students (N = 171; mean age = 19 years [SD = 1.35], 32% male, 74% White) enrolled in a four-year university in the northeastern United States.

METHODS

Data were drawn from a short-term two-wave longitudinal study. Participants completed two online surveys, separated by an average interval of 68 days (SD = 10.22).

RESULTS

At Time 1, 25% of students reported using at least one substance (alcohol, marijuana, or over-the-counter medications) for sleep aid in the past two weeks. Male and older students were more likely to report using substances for sleep. Sleep aid use at Time 1 was concurrently associated with greater levels of alcohol frequency, negative drinking consequences, and insomnia symptoms. Further, sleep aid use at Time 1 was associated with an increase in negative drinking consequences from Time 1 to Time 2, but not with changes in alcohol frequency or insomnia symptoms.

CONCLUSIONS

These findings indicate that substances are widely used among college students for sleep aid. Sleep aid use is associated with greater concurrent drinking and insomnia symptoms, and increases in negative drinking consequences over a short time period.

Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline

INTRODUCTION

The purpose of this guideline is to establish clinical practice recommendations for the pharmacologic treatment of chronic insomnia in adults, when such treatment is clinically indicated. Unlike previous meta-analyses, which focused on broad classes of drugs, this guideline focuses on individual drugs commonly used to treat insomnia. It includes drugs that are FDA-approved for the treatment of insomnia, as well as several drugs commonly used to treat insomnia without an FDA indication for this condition. This guideline should be used in conjunction with other AASM guidelines on the evaluation and treatment of chronic insomnia in adults.

METHODS

The American Academy of Sleep Medicine commissioned a task force of four experts in sleep medicine. A systematic review was conducted to identify randomized controlled trials, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the evidence. The task force developed recommendations and assigned strengths based on the quality of evidence, the balance of benefits and harms, and patient values and preferences. Literature reviews are provided for those pharmacologic agents for which sufficient evidence was available to establish recommendations. The AASM Board of Directors approved the final recommendations.

RECOMMENDATIONS

The following recommendations are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults, when such treatment is indicated. Under GRADE, a STRONG recommendation is one that clinicians should, under most circumstances, follow. A WEAK recommendation reflects a lower degree of certainty in the outcome and appropriateness of the patient-care strategy for all patients, but should not be construed as an indication of ineffectiveness. GRADE recommendation strengths do not refer to the magnitude of treatment effects in a particular patient, but rather, to the strength of evidence in published data. Downgrading the quality of evidence for these treatments is predictable in GRADE, due to the funding source for most pharmacological clinical trials and the attendant risk of publication bias; the relatively small number of eligible trials for each individual agent; and the observed heterogeneity in the data. The ultimate judgment regarding propriety of any specific care must be made by the clinician in light of the individual circumstances presented by the patient, available diagnostic tools, accessible treatment options, and resources. We suggest that clinicians use suvorexant as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use eszopiclone as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zaleplon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use zolpidem as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use triazolam as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use temazepam as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use ramelteon as a treatment for sleep onset insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians use doxepin as a treatment for sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use trazodone as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tiagabine as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use diphenhydramine as a treatment for sleep onset and sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use tryptophan as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK). We suggest that clinicians not use valerian as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults. (WEAK).

The Neuropharmacology of Sleep Disorders: Better Sleeping Through Chemistry?

Sleep and wake states involve interaction among many brain centers via multiple neurotransmitters, including dopamine, norepinephrine, hypocretin, acetylcholine, histamine and serotonin (wake promoting), and γ amino butyric acid (GABA) and melatonin (sleep promoting). Most medications for insomnia or hypersomnia act on elements of these neural systems. Initial treatment of insomnia includes sleep hygiene measures. Cognitive-behavioral therapy for insomnia is useful. Medications approved by the Food and Drug Administration for insomnia act on GABA receptors or on melatonin receptors. A frequent cause of insomnia is restless legs syndrome, which is linked to reduced dopaminergic activity in brain structures; idiopathic restless legs syndrome is best treated with dopamine agonists such as ropinerole or pramipexole. Excessive daytime sleepiness is most often due to insufficient sleep hours or sleep apnea but is also caused by medications, illnesses, narcolepsy, or idiopathic hypersomnia. Stimulants generally act through enhanced dopamine action (amphetamines, methylphenidate) or acetylcholine action (caffeine). Modafinil may act through enhanced central histamine, hypocretin, and possibly dopamine action. A newer agent, γ -hydroxybutyrate (GHB), acts on GABA and GHB receptors to consolidate sleep, improving daytime sleepiness in narcolepsy. Improving knowledge of sleep/wake mechanisms should lead to more specific and rational treatments for sleep disorders.

New Developments in Insomnia Medications of Relevance to Mental Health Disorders

Many insomnia medications with high specificity have become available recently. They provide a window into the clinical effects of modulating specific brain systems and establish a new guiding principal for conceptualizing insomnia medications: "mechanism matters." A new paradigm for insomnia therapy in which specific drugs are selected to target the specific type of sleep difficulty for each patient includes administering specific treatments for patients with insomnia comorbid with particular psychiatric disorders. This article reviews insomnia medications and discusses the implications for optimizing the treatment of insomnia occurring comorbid with psychiatric conditions.

Sleep Health and Appropriate Use of OTC Sleep Aids in Older Adults-Recommendations of a Gerontological Society of America Workgroup

Getting a good night's sleep can be challenging for older adults with chronic medical conditions, which often interfere with sleep. As a result, many older adults turn to over-the-counter (OTC) sleep aids, that is, products with diphenhydramine or doxylamine. However, these products are indicated only for occasional difficulty with sleep, not for chronic use; and their safety and efficacy has not been well established in general and in older adults specifically. To engage national stakeholders in a discussion of OTC sleep aids in older adults, the Gerontological Society of America (GSA) convened a multidisciplinary workgroup. The Workgroup examined differences between younger and older adults in sleep health and use of OTC sleep aids using data from the National Health and Wellness Survey; assessed the pharmacologic properties and medication effects of OTC sleep aids; and worked with stakeholders to promote strategies for safe and effective use. Older adults are more likely to take diphenhydramine or doxylamine products 15 or more days in a month, an indicator of inappropriate use. The Workgroup recommends research to investigate the ways older people use OTC sleep aids. The goal should be reduction in inappropriate use and associated risks, such as daytime sedation, compromised cognitive function, and falls. In addition, the Workgroup recommends a greater role for community pharmacists in counseling older adults on appropriate use of OTC sleep aids.

Efficacy and tolerability studies evaluating a sleep aid and analgesic combination of naproxen sodium and diphenhydramine in the dental impaction pain model in subjects with induced transient insomnia

STUDY OBJECTIVES

The aim of this study was to evaluate the efficacy and tolerability of novel combination naproxen sodium (NS) and diphenhydramine (DPH) in subjects with postoperative dental pain along with transient insomnia induced by 5 h sleep phase advance. The present studies aimed to demonstrate the added benefit and optimal dosages of the combination product over individual ingredients alone in improving sleep and pain.

METHODS

Each of the two studies was a two-centre, randomised, double-blind and double-dummy trial. In the first study, subjects were randomised into one of the following treatment arms: NS 440 mg/DPH 50 mg, NS 220 mg/DPH 50 mg, NS 440 mg or DPH 50 mg. In the second study, subjects received either NS 440 mg/DPH 25 mg, NS 440 mg or DPH 50 mg. The co-primary end-points in both studies were wake time after sleep onset (WASO) and sleep latency (SL) measured by actigraphy. Other secondary sleep and pain end-points were also assessed.

RESULTS

The intent-to-treat population included 712 and 267 subjects from studies one and two, respectively. In the first study, only the NS 440 mg/DPH 50 mg combination showed significant improvements in both WASO vs. NS alone (-70.3 min p = 0.0002) and SL vs. DPH alone (25.50 and 41.50 min respectively, p < 0.0001). In the second study, the NS 440 mg/DPH 25 mg combination failed to show any significant improvements vs. either component alone.

CONCLUSIONS

Only the NS 440 mg/DPH 50 mg combination demonstrated improvement in both sleep latency vs. DPH 50 mg and sleep maintenance (WASO) vs. NS 440 mg. There were no serious or unexpected adverse events reported in either study.

CLINICAL TRIAL REGISTRATION

NCT01280591 (study 1); NCT01495858 (study 2).

Optimizing the Pharmacologic Treatment of Insomnia: Current Status and Future Horizons

A number of medications are available for treating patients with insomnia. These medications include agents approved as insomnia therapies by the U.S. Food and Drug Administration (FDA), agents approved by the FDA for another condition that are used "off-label" to treat insomnia, and agents available "over-the-counter" that are taken by individuals with insomnia. These agents differ in their properties, their safety and efficacy when used for different insomnia patient subtypes, and the available data on their efficacy and safety in these subtypes. As a result, optimizing the medication treatment of insomnia for a given patient requires that the clinician select an agent for use which has characteristics that make it most likely to effectively and safely address the type of sleep difficulty experienced by that individual. This article is intended to assist clinicians and researchers in carrying out this optimization. It begins by reviewing the basic characteristics of the medications used to treat insomnia. This is followed by a review of the fundamental ways that individuals with insomnia may differ and affect the choice of medication therapy. This review includes discussions that illustrate how to best choose a medication based on the characteristics of the available medications, the key differences among insomnia patients, and the available research literature. Lastly, we discuss future directions for the optimizing pharmacologic management of insomnia. It is hoped that the treatment tailoring methods discussed herein serve as a means of improving the clinical management of insomnia and, thus, improve the lives of the many patients who suffer from this common and impairing condition.

Psychiatric care in Parkinson's disease

OBJECTIVE

Parkinson's disease (PD) is a degenerative and disabling disease in which medical providers focus mainly on ameliorating problems in day-to-day functioning. This review summarizes current knowledge about the efficacy and tolerability of psychopharmacological agents in the treatment of depression, anxiety, psychosis, and insomnia in patients with PD. Recommended or promising nonpharmacological interventions are also reviewed.

METHOD

Studies were identified using computerized searches, with further references obtained from the bibliographies of the reviewed articles.

RESULT

Findings in the research literature provide growing evidence concerning the antidepressant treatment of patients with PD. Psychoeducational interventions for managing depression and anxiety symptoms also appear promising. Music therapy has proven to be particularly effective for patients with PD. Psychosis is common in patients with PD. When psychosis is induced by antiparkinson drugs, a dose reduction can be considered, but it is seldom successful. Patients with PD do not generally tolerate conventional antipsychotic medications, justifying evaluation of newer atypical agents in this population. Cholinesterase inhibitors have also become increasingly important in the treatment of PD in recent years. Finally, insomnia is a very frequent complaint in patients with PD and may also contribute to the development of depression. Patients should be encouraged to improve sleep hygiene and use behavioral interventions. Definitive trials of treatments for sleep disorders in this population are also warranted.

CONCLUSION

Therapeutic approaches to the treatment of PD and its associated psychiatric symptoms must be individualized and may involve a combination of antiparkinson drugs, psychopharmacological treatment, and/or psychotherapeutic interventions.

Histamine in the regulation of wakefulness

The histaminergic system is exclusively localized within the posterior hypothalamus with projection to almost all the major regions of the central nervous system. Strong and consistent evidence exist to suggest that histamine, acting via H₁ and/or H₃ receptor has a pivotal role in the regulation of sleep-wakefulness. Administration of histamine or H₁ receptor agonists induces wakefulness, whereas administration of H₁ receptor antagonists promotes sleep. The H₃ receptor functions as an auto-receptor and regulates the synthesis and release of histamine. Activation of H₃ receptor reduces histamine release and promotes sleep. Conversely, blockade of H₃ receptor promotes wakefulness. Histamine release in the hypothalamus and other target regions is highest during wakefulness. The histaminergic neurons display maximal activity during the state of high vigilance, and cease their activity during non-rapid eye movement (NREM) and rapid eye movement (REM) sleep. The cerebrospinal levels of histamine are reduced in diseased states where hypersomnolence is a major symptom. The histamine deficient L-histidine decarboxylase knockout (HDC KO) mice display sleep fragmentation and increased REM sleep during the light period along with profound wakefulness deficit at dark onset, and in novel environment. Similar results have been obtained when histamine neurons are lesioned. These studies strongly implicate the histaminergic neurons of the TMN to play a critical role in the maintenance of high vigilance state during wakefulness.

Skin disorders and sleep in adults: where is the evidence?

Sleep deprivation has been shown to have detrimental effects on behavioural, physiological and psychological functioning. Skin disorders are variably associated with sleep disturbance and sleep deprivation, some associated with specific sleep disorders such as obstructive sleep apnoea. Paradoxically, there is very little literature focussed on the management of sleep problems in the context of skin disorders. Furthermore, randomised controlled trials of treatments for skin conditions are few and rarely measure sleep as an outcome, either subjectively or objectively. This review focuses on common skin disorders and how they affect sleep.

Sleep disturbances in Parkinson's disease

Sleep disturbances are very common in patients with PD and are associated with a variety of negative outcomes. The evaluation of sleep disturbances in these patients is complex, as sleep may be affected by a host of primary sleep disorders, other primary medical or psychiatric conditions, reactions to medications, aging or the neuropathophysiology of PD itself. In this article, we review the evaluation of the common disturbances of sleep seen in PD. This includes the primary sleep disorders, the interaction of depression and insomnia, the impact that medications for PD have on sleep, as well as the role of factors such as nocturia, pain, dystonia, akinesia, difficulty turning in bed, and vivid dreaming. The treatment of sleep disturbances in PD is largely unstudied but recommendations based on clinical experience in PD and research studies in other geriatric populations can be made. Important principles include, diagnosis, treating the specific sleep disorder or co-occurring disorder, and control of the motor aspects of PD.

Sleep in hospitalized medical patients, part 2: behavioral and pharmacological management of sleep disturbances

BACKGROUND

As described in Part 1 of this article, multiple factors lead to disrupted sleep in hospitalized medical patients. Recognizing and addressing these factors can help clinicians more effectively manage patients' sleep complaints.

METHODS

A PubMed search was conducted by cross-referencing the terms "sleep deprivation," "insomnia," and "sleep"; "hospitalized," "acutely ill," and "critically ill"; and "medication," "drugs," "hypnotics," "benzodiazepines," and "sedatives." The search was limited to English-language articles published between 1997 and 2008. Subsequent PubMed searches were performed to clarify the data described in the initial search.

RESULTS

Few articles addressed the topic of the assessment and management of sleep problems in hospitalized medical patients. In Part 2, we propose an evaluation and treatment algorithm that includes recommendations regarding the use of nonpharmacologic and pharmacologic therapies as clinicians consider relevant clinical data. The algorithm is accompanied by 5 tables that include pertinent and practical information to assist clinicians as they manage their inpatients' sleep complaints.

CONCLUSIONS

Assessment of a sleep complaint should include a review of factors that could exacerbate patients' sleep. The treatment could then focus on ameliorating these factors, and the judicious use of nonpharmacologic strategies and psychopharmacologic agents.

Effects of some H1-antagonists on the sleep-wake cycle in sleep-disturbed rats

The present study was undertaken to investigate the effects of some H(1)-antagonists on the sleep-wake cycle in sleep-disturbed rats in comparison with those of nitrazepam. Electrodes were chronically implanted into the frontal cortex and the dorsal neck muscle of rats for the electroencephalogram (EEG) and electromyogram (EMG), respectively. EEG and EMG were recorded with an electroencephalograph. SleepSign ver. 2.0 was used for EEG and EMG analysis. The total times of waking, non-rapid eye movement (non-REM), and rapid eye movement (REM) sleep were measured from 10:00 to 16:00. Nitrazepam showed a significant decrease in sleep latency, total waking time, and delta activity and an increase in the total non-REM sleep time. A significant decrease in the sleep latency was observed with diphenhydramine, chlorpheniramine, and cyproheptadine. Cyproheptadine also caused a significant decrease in the total waking time and increases in total non-REM sleep time, REM sleep time, slow wave sleep, and delta activity, although no remarkable effects were observed with diphenhydramine and chlorpheniramine. In conclusion, cyproheptadine can be useful as a hypnotic, having not only sleep inducing-effects, but also sleep quantity- and quality-increasing effects.

Therapeutic Options for Sleep-Maintenance and Sleep-Onset Insomnia

Insomnia, defined as difficulty falling asleep, staying asleep, and/or experiencing restorative sleep with associated impairment or significant distress, is a common condition resulting in significant clinical and economic consequences. Many options are available to treat insomnia, to assist with either falling asleep (sleep onset) or maintaining sleep. We searched MEDLINE for articles published between January 1996 and January 2006, evaluated abstracts from recent professional meetings, and contacted the manufacturer of the most recent addition to the pharmacologic armamentarium for insomnia treatment (ramelteon) to gather information. Nonpharmacologic options include stimulus control, sleep hygiene education, sleep restriction, paradoxical intention, relaxation therapy, biofeedback, and cognitive behavioral therapy. Prescription and over-the-counter drug therapies include benzodiazepine and nonbenzodiazepine sedative-hypnotic agents; ramelteon, a melatonin receptor agonist; trazodone; and sedating antihistamines. Herbal and alternative preparations include melatonin and valerian. Before recommending any treatment, clinicians should consider patient-specific criteria such as age, medical history, and other drug use, as well as the underlying cause of the sleep disturbance. All pharmacotherapy should be used with appropriate caution, at minimum effective doses, and for minimum duration of time.

Oral sedation: a primer on anxiolysis for the adult patient

The use of sedatives has established efficacy and safety for managing anxiety regarding dental treatment. This article will provide essential information regarding the pharmacology and therapeutic principles that govern the appropriate use of orally administered sedatives to provide mild sedation (anxiolysis). Dosages and protocols are intended for this purpose, not for providing moderate or deeper sedation levels.

Pharmacologic Management of Chronic Insomnia

Chronic insomnia is a common disorder that is under recognized, under diagnosed and under treated. Initial assessment should focus on identifying and treating, if present, any secondary causes of insomnia. Primary insomnia can be treated with behavioral and/or pharmacological therapy. A thorough sleep history can identify the type of insomnia present, its severity, and can consequently guide therapy. Behavioral therapy has been shown to be equivalent to or superior to pharmacologic therapy, at least in some patients. It is a reasonable initial approach, although there are barriers to its use. There are several pharmacologic agents available, some of which are more effective at reducing time to fall asleep and others for maintaining sleep. There is some evidence to indicate that combining the approaches may impair outcomes. There is little data on the long-term use of pharmacologic agents.

Pharmacologic management of insomnia: past, present, and future

Views on the etiology and morbidities associated with insomnia are evolving and affect clinicians' approach to the pharmacologic management of insomnia. Currently, benzodiazepine receptor agonists (BzRAs) and a single melatonin receptor agonist are recognized as safe and efficacious hypnotics. Variability in BzRAs, pharmacokinetics, and manipulation of dose provide clinicians with options that meet the needs of most patients. Other drugs (eg, sedating antidepressants) also are used commonly in clinical practice to treat insomnia, but evidence is lacking to support this most cases. Improvement in managing insomnia will result from systematic research with these drugs, with drugs in development, and with novel uses, such as co-therapy.

Current patterns and future directions in the treatment of insomnia

BACKGROUND

Despite the high prevalence and the high burden associated with chronic insomnia, it remains largely unrecognized and often inadequately treated by physicians.

METHODS

A review was undertaken of the literature on barriers to both acute and chronic treatment of insomnia, as well as recent trials of pharmacologic and nonpharmacologic agents for insomnia.

RESULTS

Obstacles to appropriate treatment of the condition include outdated insomnia management guidelines, which have contributed to US Food and Drug Administration restrictions on longer-term prescription of hypnotic agents; lack of research demonstrating the benefit of treating insomnia; and fears of tolerance and withdrawal effects of long-term use of hypnotic agents, as well as an absence of longer-term, randomized, controlled, double-blind trials of existing agents used to treat insomnia.

CONCLUSIONS

There is evidence that improved sleep may improve outcome in some medical and psychiatric illnesses. Both behavioral and pharmacologic therapies have shown efficacy in chronic insomnia. In addition, a recent 6-month, randomized, controlled study has demonstrated that at least one agent may be safe and effective in longer-term use.

Effect of dextromethorphan, diphenhydramine, and placebo on nocturnal cough and sleep quality for coughing children and their parents

OBJECTIVES

To determine whether the commonly used over-the-counter medications dextromethorphan and diphenhydramine are superior to placebo for the treatment of nocturnal cough and sleep difficulty associated with upper respiratory infections and to determine whether parents have improved sleep quality when their children receive the medications when compared with placebo.

METHODS

Parents of 100 children with upper respiratory infections were questioned to assess the frequency, severity, and bothersome nature of the nocturnal cough. Their answers were recorded on 2 consecutive days, initially on the day of presentation, when no medication had been given the previous evening, and then again on the subsequent day, when either medication or placebo was given before bedtime. Sleep quality for both the child and the parent were also assessed for both nights.

RESULTS

For the entire cohort, all outcomes were significantly improved on the second night of the study when either medication or placebo was given. However, neither diphenhydramine nor dextromethorphan produced a superior benefit when compared with placebo for any of the outcomes studied. Insomnia was reported more frequently in those who were given dextromethorphan, and drowsiness was reported more commonly in those who were given diphenhydramine.

CONCLUSIONS

Diphenhydramine and dextromethorphan are not superior to placebo in providing nocturnal symptom relief for children with cough and sleep difficulty as a result of an upper respiratory infection. Furthermore, the medications given to children do not result in improved quality of sleep for their parents when compared with placebo. Each clinician should consider these findings, the potential for adverse effects, and the individual and cumulative costs of the drugs before recommending them to families.

Sleep in the Elderly: Burden, Diagnosis, and Treatment

Insomnia is commonly seen in elderly populations and is associated with numerous individual and socioeconomic consequences. Elderly patients are more likely to suffer from chronic insomnia characterized by difficulty maintaining sleep than difficulty initiating sleep. Management of insomnia in these patients requires very careful evaluation and exclusion of an underlying medical or psychiatric condition. Nonpharmacologic interventions in elderly patients, especially use of behavioral therapy, have demonstrated some success. Commonly prescribed medications have also been effective, though they have limitations. Newer agents currently under investigation for insomnia hold promise for good efficacy and safety in the elderly population. The following review presents clinical studies, survey results, and guidelines retrieved from peer-reviewed journals in the PubMed database using the search terms elderly, temazepam, trazodone, zolpidem, zaleplon, insomnia, and prevalence and the dates 1980 to 2003. In addition, newer research with emerging agents has been included for completeness.

Treating Sleep Problems in Patients with Burn Injuries: Practical Considerations

Sleep disorders are a frequent but under-addressed complication of burn injuries. Burn injuries can potentially disrupt sleep for a variety of reasons, including the physiological effects of trauma as well as ramifications of treatment (ie, intensive care unit environment, pain, itching, medications). The literature on sleep disorders and burn injuries is reviewed, and suggestions for treatment are provided. Treatment is divided into two major types: nonpharmacologic and pharmacologic. Nonpharmacologic treatment, also referred to as behavioral techniques, may include any one or combination of the following: sleep hygiene, stimulus control, sleep restriction, relaxation techniques, cognitive, and light therapy. Pharmacologic therapies may include hypnotics (benzodiazepine, nonbenzodiazepine, or benzodiazepine receptor agonists), antidepressants, over-the-counter preparations, hormone replacement therapy, herbs, and melatonin.

Management of insomnia in patients with chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is a common medical disorder, which causes considerable morbidity and mortality. Given the chronic and symptomatic nature of the disease, the patient is often seen in the physician's office with complaints of dyspnea. However, more than 50% of COPD patients also have sleep complaints characterised by longer latency to falling asleep, more frequent arousals and awakenings, and/or generalised insomnia. Sleep disturbance tends to be more severe with advancing disease and substantially reduces the COPD patients' quality of life. In approaching the COPD patient who complains of insomnia it is important to take a complete sleep history. Having characterised the degree and duration of the problem, medical management of the underlying COPD must first optimise oxygen saturation while minimising the effects of many of the medications used for COPD. While aerosol therapies may be systemically absorbed and contribute to sleep disruption, anticholinergics, such as ipratropium bromide, are the least likely to do so and indeed have been shown to improve sleep quality in this population. Many of the traditional sedatives and hypnotics have been used in the COPD population including benzodiazepines, imidazopyridines, pyrazolopyrimidines and, less commonly, antidepressants and phenothiazines. Clinical trials support the role of numerous agents in treating insomnia in this population but do not always provide reassurance that these therapies can be used safely, particularly in the patient with severe COPD with hypercarbia. Benzodiazepines are among the most commonly employed agents, but case reports and series continue to describe adverse pulmonary events. Although the newer pyridine derivatives also have the potential to worsen pulmonary function, they appear less likely to do so. Data to date are limited with the tricyclic antidepressants and phenothiazines, although they appear to be very well tolerated from a respiratory point of view. Since sleep disturbances are often long-standing and associated with maladaptive behaviours towards sleep, cognitive/behavioural approaches are often useful and are more effective in the long-term than are hypnotics. When prescription of a sedative is to be made, extra caution is required for those patients at increased risk of adverse respiratory effects, such as those with advanced disease and hypercarbia in whom pharmacological therapy is often best avoided. Selection of the various options will depend upon the degree of underlying disease and the patient's specific complaints of insomnia. Finally, it is important to remember that while most hypnotics work in an acute setting, the long-term management will require an integrated approach.

Insomnia in Adults

Insomnia is a prevalent condition, existing as both a symptom and a syndrome, and is associated with significant impairments of daytime functioning, reduced quality of life, and increased risk of depression. When insomnia is secondary to a psychiatric, medical, or another sleep disorder, treatment should focus initially on the underlying condition. For acute and situational insomnia, treatment should address the precipitating factors when possible, but in certain circumstances (eg, stressful events, travel, or jet lag), a hypnotic medication is necessary to alleviate sleep difficulties. Benzodiazepine-receptor agents are the treatment of choice among the pharmacologic options. For chronic and primary insomnia, behavior treatment should represent the main intervention, with hypnotic medications serving as an adjunct. Behavior and pharmacologic treatments can be effectively combined in order to take advantage of the faster results obtained from medication administration, and the longer-lasting benefits associated with behavior interventions. For recurrent insomnia, the use of intermittent medication can be very useful to prevent or minimize continued sleep difficulties.