Clonazepam for the management of sleep disorders

At least 150 min per week of Tai chi practice improves sleep quality in the older people: evidence from a meta-analysis

OBJECTIVE

To conduct a meta-analysis to explore the optimal dosage of Tai chi exercise that positively influences the sleep quality of the older people.

METHODS

A literature search was conducted from 2004 to October 2024 in PubMed, Embase, Web of Science, Google Scholar, Cochrane Library, and Chinese databases (CNKI and Wanfang) for randomised controlled trials in Chinese and English on Tai chi improving sleep quality in the older people. Data extraction and verification were performed by two independent researchers. Additionally, a meta-analysis of the mean difference (MD) and 95% confidence interval (CI) was conducted using RevMan 5.4.

RESULTS

A total of nine randomised controlled trials involving 1,166 older participants were included. Compared with the control group, Tai chi significantly reduced the total Pittsburgh Sleep Quality Index (PSQI) scores in the older people [MD =  - 1.53, 95% CI (- 2.18, - 0.89), p < 0.001], with heterogeneity results Q = 53.63, df = 12, and I2 of 78% (p < 0.001); Total weekly duration of Tai chi exercise: Less than 150 min reduced PSQI scores, but the difference was not statistically significant [MD =  - 1.47, 95% CI (- 3.89, 0.95), p = 0.23]. Between 150-300 min significantly reduced PSQI scores [MD =  - 1.54, 95% CI (- 2.00, - 1.08), p < 0.001]; Duration of Tai chi exercise programme: 8-12 weeks significantly reduced PSQI scores [MD =  - 1.93, 95% CI (- 2.60, - 1.25), p < 0.001]; 16-24 weeks significantly reduced PSQI scores [MD =  - 1.27, 95% CI (- 2.27, - 0.26), p = 0.01]; Single session duration of Tai chi exercise: 60 min significantly reduced PSQI scores [MD =  - 2.17, 95% CI (- 3.15, - 1.18), p < 0.001]; Less than 60 min (25-45 min) significantly reduced PSQI scores [MD =  - 0.92, 95% CI (- 1.63, - 0.20), p = 0.01].

CONCLUSION

Older individuals engaging in at least 150 min per week of Tai chi practice can improve sleep quality. Beyond this threshold, extending the duration of individual practice sessions or the exercise programme does not yield additional benefits for sleep quality.

Spectrofluorimetric Determination of 7-Aminoclonazepam, a Major Clonazepam Metabolite, in Human Urine: A Factorial Design of Experiment Approach to Optimize Method Development

Clonazepam, a high-potency benzodiazepine widely prescribed for seizure and panic disorders, carries a risk of abuse and dependency. This study developed a sensitive and selective spectrofluorimetric method for determining 7-aminoclonazepam, the major metabolite of clonazepam, in human urine. A 26-2 factorial design was employed to screen the optimal conditions for derivatization with NBD-Cl as the fluorescent label, considering factors such as pH, reagent volumes, temperature, and reaction time. A significant model was attained (p < 0.0001) revealing alkaline pH (9), elevated temperature (80°C), and high reagent concentrations as crucial for maximizing fluorescence intensity. The method demonstrated excellent linearity from 10 to 500 ng/mL (R2 = 0.9997), with limits of detection and quantitation of 3.3 and 10 ng/mL, respectively. Intra- and inter-day precision (% RSD) were less than 4%, and recoveries ranged from 97.59% to 106.12%. The method also showed no significant interference from endogenous compounds, pharmaceutical excipients, or the parent drug. Applicability of the method was validated in human subjects receiving clonazepam therapy; 7-aminoclonazepam was first detected after 12 h, peaked at 24 h (54.61 ± 9.870 ng/mL), and remained detectable up to 72 h post-dose, offering a simple, cost-effective spectrofluorimetric method for monitoring clonazepam metabolism in clinical and forensic settings.

Protein phosphatase 2A inhibitors: a possible pharmacotherapy for benzodiazepine dependence

OBJECTIVES

Benzodiazepines (BZDs) activate the γ-aminobutyric acid (GABA) subtype A (GABAA) receptors, and thus are widely used medicines for the treatment of anxiety and insomnia. For chronic use, tolerance to BZDs is a major problem. Patients with chronic insomnia that develop tolerance to BZDs lose therapeutic effects but also potentially suffer from BZD dependence resulting in BZD withdrawal. The development of such treatments is important for the appropriate use of BZDs.

METHODS

Research articles regarding investigation of BZD dependence were searched on PubMed, Embase, and Scopus databases using keywords "benzodiazepine", "dependence", "treatment".

KEY FINDINGS

When BZDs are taken chronically, continuous GABAA binding results in up-regulation of α-amino-3-hydroxy-5-methyl-4-lisoxazolepropionic acid (AMPA) glutamate receptor function and release of brain-derived neurotrophic factor (BDNF). Released BDNF binds to its specific receptor tropomyosin-related kinase receptor B (TrkB). Enhanced BDNF-TrkB signaling activates protein phosphatase 2A (PP2A). Activated PP2A dephosphorylates GABAA receptors, resulting in the downregulation of the GABAA receptor function. Reduced GABAA receptor function augments long-term potentiation (LTP), AMPA-mediated glutamatergic neuroplasticity, by reducing LTP inhibition by GABAA receptor function. Augmented LTP enhances extreme anxiety, which leads to BZD dependence.

CONCLUSION

Therefore, iInhibiting dephosphorylation of the GABAA receptor by PP2A, PP2A inhibitors could reduce LTP and anxiety, restoring BZD effectiveness and resulting in possible therapeutic effects for BZD dependence.

Polysomnographic features associated with clonazepam and melatonin treatment in isolated REM sleep behavior disorder: Time for new therapeutic approaches?

AIMS

Although clonazepam (CLO) and melatonin (MLT) are the most frequently used treatments for REM sleep behavior disorder, the polysomnographic features associated with their use are little known. The aim of this study was to evaluate polysomnographic and clinical parameters of patients with idiopathic/isolated REM sleep behavior disorder (iRBD) treated chronically with CLO, sustained-release MLT, alone or in combination, and in a group of drug-free iRBD patients.

METHODS

A total of 96 patients were enrolled: 43 drug-free, 21 with CLO (0.5-2 mg), 20 with sustained-release MLT (1-4 mg), and 12 taking a combination of them (same doses). Clinical variables and polysomnography were collected.

RESULTS

Although clinical improvement was reported in all groups, MLT impacted sleep architecture more than the other treatments, with significant and large increase in N3 stage, moderate reduction in N2 and REM sleep, and moderate increase in REM latency. CLO moderately increased the percentage of both REM sleep and especially N2, while reducing N1 and wakefulness. Patients treated with both CLO and MLT did not show major changes in sleep architecture.

CONCLUSION

These results suggest that the administration of MLT or CLO impacts (positively) on sleep parameters of iRBD patients. However, there is a need to better stratify patients, in order to treat them in a targeted manner, depending on the patient's individual sleep architecture and expected differential effects of these agents.

Effectiveness of High-dose Clonazepam Versus Low-Dose Clonazepam With Cognitive Behavioral Therapy in Older Adults With Moderately Severe Insomnia: A Prospective Cohort Study

PURPOSE

To evaluate the effectiveness of high-dose clonazepam (1 mg) versus low-dose clonazepam (0.5 mg) with cognitive behavioral therapy for insomnia (CBT-i) in older adults with moderately severe insomnia.

METHODS

A prospective cohort study was conducted in patients who did not respond to low-dose clonazepam for insomnia secondary to chronic medical conditions. After starting with 0.25 mg of clonazepam, their dose was increased to 0.5 mg, then to 1 mg (Group A), or to the same dose with additional CBT-i (Group B). They were followed for 24 weeks, and scores of the insomnia severity index (ISI) and subjective units of distress scale (SUDS) were recorded. Patient adverse drug reactions (ADRs) were documented and assessed for their causality. ISI and SUDS scores were considered primary outcome measures.

FINDINGS

Between-group analysis revealed a significant decline in the mean score of ISI at week 16 (P < 0.05) and for SUDS at week 20 (P < 0.05) in group B compared to group A. Similarly, within-group analysis also revealed a statistically significant reduction of the mean score in ISI and SUDS scores at week 4 and 8 (P < 0.05) in both groups. ADRs occurred more frequently in group A (14%) than in group B (5%). Assessments of causality showed that the majority of cases were possible.

IMPLICATIONS

For individuals who were resistant to 0.5 mg of clonazepam, adding CBT-i with low-dose clonazepam is a viable alternative to increasing the dose to 1 mg.

Adsorption and photocatalytic-conjugated activity of a chitosan-functionalized titanate coating for the removal of the drug clonazepam from drinking water

This research evaluated H2TiO7 nanotubes (TiNTs) functionalized with 1 (1TiCN), 5 (2TiCN), and 10 (3TiCN) wt.% of chitosan for the removal of clonazepam by an adsorption/photocatalysis-conjugated method. The samples were immobilized on glass, and their mechanical stability was tested by washings. The functionalization of the samples was verified by the FTIR and DRS techniques. SEM images displayed nanotubes in the samples and thickness of 4.24 μm for the 2TiCN coating. The chemical composition of the 2TiCN coating was obtained by EDS. The XRD patterns evidenced chitosan and titanate phases in the functionalized samples. Furthermore, the 2TiCN coating was evaluated in the removal of clonazepam, reaching 80.79% (4.38 and 49.64% more than the TiNT and commercial TiO2 powders, respectively) after 240 min and being 6.88% more efficient after 4 reuses than the 2TiCN powders. OH- ions were the main oxidizing species found by scavenger tests. The surface area of 2TiCN (168.6 m2/g) was 2 times higher than that of TiNTs, and its bandgap (2.95 eV) was the lowest. Therefore, the 2TiCN coating is an excellent alternative to remove clonazepam.

Residual insomnia in major depressive disorder: a systematic review

Introduction

The ultimate goal in major depressive disorder (MDD) treatment is recovery. A proportion of MDD patients with formal remission experience persistent difficulties, which impair their daily functioning. Residual insomnia is one of the most common residual symptoms. Patients with residual insomnia experience relapse significantly earlier and have a poor prognosis. Little is known about possible ways of treatment and what subtype of insomnia is mostly reported.

Methods

A systematic literature review was carried out in PubMed and Web of Science to synthesize the current status of knowledge about effective treatment methods and insomnia subtypes in residual insomnia in MDD.

Results

A few non-pharmacological treatment methods e.g., Cognitive Behavioral Therapy for Insomnia (CBT-I), Mindfulness-Based Cognitive Therapy (MBCT), behavioral activation (BA) and pharmacological methods (gabapentin, clonazepam) have proven to mitigate residual insomnia. Cognitive Behavioral Therapy for Depression (CBT-D) ameliorates insomnia complaints to a limited extent. Mid-nocturnal insomnia is the most common residual insomnia subtype in MDD patients.

Conclusion

Residual insomnia is a very common complaint and most often appears as mid-nocturnal insomnia. Scarce data points out the benefits from pharmacotherapy, psychotherapy, and BA. More research is needed.