Aspirin and human sleep

Investigation of pain sensitivity following 3 nights of disrupted sleep in healthy individuals

BACKGROUND

Poor quality sleep is a common complaint among people with chronic pain. The co-occurrence of poor sleep quality and chronic pain often comes with increased pain intensity, more disability and a higher cost of healthcare. Poor sleep has been suggested to affect measures of peripheral and central pain mechanisms. To date, sleep provocations are the only models proven to affect measures of central pain mechanisms in healthy subjects. However, there are limited studies investigating the effect of several nights of sleep disruption on measures of central pain mechanisms.

METHODS

The current study implemented three nights of sleep disruption with three planned awakenings per night in 30 healthy subjects sleeping at home. Pain testing was conducted at the same time of day at baseline and follow-up for each subject. Pressure pain thresholds were assessed bilaterally on the infraspinatus and gastrocnemius muscles. Using handheld pressure algometry, suprathreshold pressure pain sensitivity and area were also investigated on the dominant infraspinatus muscle. Cuff-pressure pain detection and tolerance thresholds, temporal summation of pain and conditioned pain modulation were investigated using cuff-pressure algometry.

RESULTS

Temporal summation of pain was significantly facilitated (p = 0.022), suprathreshold pain areas (p = 0.005) and intensities (p < 0.05) were significantly increased, and all pressure pain thresholds were decreased (p < 0.005) after sleep disruption compared to baseline.

CONCLUSIONS

The current study found that three consecutive nights of sleep disruption at home induced pressure hyperalgesia and increased measures of pain facilitation in healthy subjects, which is consistent with previous findings.

SIGNIFICANCE

Poor quality of sleep is often experienced by patients with chronic pain, with the most common complaint being nightly awakenings. This exploratory study is the first to investigate changes in measures of central and peripheral pain sensitivity in healthy subjects after sleep disruptions for three consecutive nights without any restrictions on total sleep time. The findings suggest that disruptions to sleep continuity in healthy individuals can induce increased sensitivity to measures of central and peripheral pain sensitization.

Drug-Induced Insomnia and Excessive Sleepiness

Undesirable side effects of insomnia and/or sleepiness may occur with many prescribed drugs, psychotropics as well as non-psychotropics. These central nervous system effects can be explained by the interactions of the drug with any of the numerous neurotransmitters and receptors that are involved in sleep and wakefulness. Also a close - sometimes bidirectional - relationship between disease and (disturbed) sleep/wakefulness is often present e.g. in chronic pain; drug effects may lead this vicious circle in both ways. Besides the importance for health and quality of life, effects on sleep or waking function can be a potential source of non-compliance.

Why It Is Important to Consider the Effects of Analgesics on Sleep: A Critical Review

We review the known physiological mechanisms underpinning all of pain processing, sleep regulation, and pharmacology of analgesics prescribed for chronic pain. In particular, we describe how commonly prescribed analgesics act in sleep-wake neural pathways, with potential unintended impact on sleep and/or wake function. Sleep disruption, whether pain- or drug-induced, negatively impacts quality of life, mental and physical health. In the context of chronic pain, poor sleep quality heightens pain sensitivity and may affect analgesic function, potentially resulting in further analgesic need. Clinicians already have to consider factors including efficacy, abuse potential, and likely side effects when making analgesic prescribing choices. We propose that analgesic-related sleep disruption should also be considered. The neurochemical mechanisms underlying the reciprocal relationship between pain and sleep are poorly understood, and studies investigating sleep in those with specific chronic pain conditions (including those with comorbidities) are lacking. We emphasize the importance of further work to clarify the effects (intended and unintended) of each analgesic class to inform personalized treatment decisions in patients with chronic pain. © 2021 American Physiological Society. Compr Physiol 11:1-31, 2021.

Sleep deficiency and chronic pain: potential underlying mechanisms and clinical implications

Pain can be both a cause and a consequence of sleep deficiency. This bidirectional relationship between sleep and pain has important implications for clinical management of patients, but also for chronic pain prevention and public health more broadly. The review that follows will provide an overview of the neurobiological evidence of mechanisms thought to be involved in the modulation of pain by sleep deficiency, including the opioid, monoaminergic, orexinergic, immune, melatonin, and endocannabinoid systems; the hypothalamus-pituitary-adrenal axis; and adenosine and nitric oxide signaling. In addition, it will provide a broad overview of pharmacological and non-pharmacological approaches for the management of chronic pain comorbid with sleep disturbances and for the management of postoperative pain, as well as discuss the effects of sleep-disturbing medications on pain amplification.

The Sleep-Immune Crosstalk in Health and Disease

Sleep and immunity are bidirectionally linked. Immune system activation alters sleep, and sleep in turn affects the innate and adaptive arm of our body's defense system. Stimulation of the immune system by microbial challenges triggers an inflammatory response, which, depending on its magnitude and time course, can induce an increase in sleep duration and intensity, but also a disruption of sleep. Enhancement of sleep during an infection is assumed to feedback to the immune system to promote host defense. Indeed, sleep affects various immune parameters, is associated with a reduced infection risk, and can improve infection outcome and vaccination responses. The induction of a hormonal constellation that supports immune functions is one likely mechanism underlying the immune-supporting effects of sleep. In the absence of an infectious challenge, sleep appears to promote inflammatory homeostasis through effects on several inflammatory mediators, such as cytokines. This notion is supported by findings that prolonged sleep deficiency (e.g., short sleep duration, sleep disturbance) can lead to chronic, systemic low-grade inflammation and is associated with various diseases that have an inflammatory component, like diabetes, atherosclerosis, and neurodegeneration. Here, we review available data on this regulatory sleep-immune crosstalk, point out methodological challenges, and suggest questions open for future research.

Headache, drugs and sleep

Background

Headache and sleep mechanisms share multiple levels of physiological interaction. Pharmacological treatment of headache syndromes may be associated with a broad range of sleep disturbances, either as a direct result of the pharmacology of the drug used, or by unmasking physiological alterations in sleep propensity seen as part of the headache symptom complex.

Purpose

This review summarises known sleep and circadian effects of various drugs commonly used in the management of headache disorders, with particular attention paid to abnormal sleep function emerging as a result of treatment.

Method

Literature searches were performed using MEDLINE, PubMed, and the Cochrane database using search terms and strings relating to generic drug names of commonly used compounds in the treatment of headache and their effect on sleep in humans with review of additional pre-clinical evidence where theoretically appropriate.

Conclusions

Medications used to treat headache disorders may have a considerable impact on sleep physiology. However, greater attention is needed to characterise the direction of the changes of these effects on sleep, particularly to avoid exacerbating detrimental sleep complaints, but also to potentially capitalise on homeostatically useful properties of sleep which may reduce the individual burden of headache disorders on patients.

Trazodone for the treatment of fibromyalgia: an open-label, 12-week study

Background

Despite its frequent use as a hypnotic, trazodone has not been systematically assessed in fibromyalgia patients. In the present study have we evaluated the potential effectiveness and tolerability of trazodone in the treatment of fibromyalgia.

Methods

A flexible dose of trazodone (50-300 mg/day), was administered to 66 fibromyalgia patients for 12 weeks. The primary outcome measure was the Pittsburgh Sleep Quality Index (PSQI). Secondary outcome measures included the Fibromyalgia Impact Questionnaire (FIQ), the Beck Depression Inventory (BDI), the Hospital Anxiety and Depression Scale (HADS), the Brief Pain Inventory (BPI), the Short-Form Health Survey (SF-36), and the Patients' Global Improvement Scale (PGI). Trazodone's emergent adverse reactions were recorded. Data were analyzed with repeated measures one-way ANOVA and paired Student's t test.

Results

Trazodone markedly improved sleep quality, with large effect sizes in total PSQI score as well on sleep quality, sleep duration and sleep efficiency. Significant improvement, although with moderate effect sizes, were also observed in total FIQ scores, anxiety and depression scores (both HADS and BDI), and pain interference with daily activities. Unexpectedly, the most frequent and severe side effect associated with trazodone in our sample was tachycardia, which was reported by 14 (21.2%) patients.

Conclusions

In doses higher than those usually prescribed as hypnotic, the utility of trazodone in fibromyalgia management surpasses its hypnotic activity. However, the emergence of tachycardia should be closely monitored.

Trial registration

This trial has been registered with ClinicalTrials.gov number NCT-00791739.

Effects of ibuprofen on sleep quality as measured using polysomnography and subjective measures in healthy adults

BACKGROUND

Although some literature has suggested that NSAIDs may affect sleep physiology, this observation is not consistent with clinical use of these drugs and has not been verified using standard sleep-research methodologies.

OBJECTIVE

This study was undertaken to determine whether ibuprofen 400 mg administered at 3, 7, and 11 pm (total daily dose, 1200 mg) produced any significant alterations in the character and quality of night-time sleep as measured by standard sleep laboratory polysomnography (PSG) and subjective measures.

METHODS

This 4-day, multiple-dose, double-blind, randomized, placebo-controlled trial was conducted in a hospital-based, sleep laboratory in the United States (DENT Neurological Institute at Millard Fillmore Hospital, Buffalo, New York). Healthy subjects aged > or = 18 years spent 3 consecutive nights in a sleep laboratory. Day 1/night 1 was for acclimation; day 2/night 2, for baseline PSG and subjective sleep assessments; and day 3/night 3, for treatment effects on sleep character and quality. All subjects received placebo on days 1 and 2. On day 3, subjects received ibuprofen 400 mg or placebo TID.

RESULTS

All 30 subjects (15 per group) completed the study (18 men, 12 women; all white). The mean age (SD) was 28.6 years and mean body weight was 71.4 kg. In both groups, mean values for sleep efficiency and quality of sleep were significantly higher on night 3 compared with baseline; the mean (SD) changes from baseline were not significantly different between the ibuprofen and control groups (sleep efficiency, 0.4 [6.3] and 0.3 [6.2]; quality of sleep, 8.6 [26.8] and 3.3 [21.3]). Mean night-3 sleep efficiency in the ibuprofen group was 88.6%--substantially higher than the minimally acceptable sleep efficiency of 75% stated in the protocol. Three mild adverse events were reported in 2 subjects.

CONCLUSION

This study found that in these subjects a total daily dose of 1200 mg ibuprofen did not produce any clinically or statistically significant alterations in the character and quality of nighttime sleep as measured using standard sleep laboratory PSF and subjective measures.

Acetaminophen does not affect 24-h body temperature or sleep in the luteal phase of the menstrual cycle

Body temperature and sleep change in association with increased progesterone in the luteal phase of the menstrual cycle in young women. The mechanism by which progesterone raises body temperature is not known but may involve prostaglandins, inducing a thermoregulatory adjustment similar to that of fever. Prostaglandins also are involved in sleep regulation and potentially could mediate changes in sleep during the menstrual cycle. We investigated the possible role of central prostaglandins in mediating menstrual-associated 24-h temperature and sleep changes by inhibiting prostaglandin synthesis with a therapeutic dose of the centrally acting cyclooxygenase inhibitor acetaminophen in the luteal and follicular phases of the menstrual cycle in young women. Body temperature was raised, and nocturnal amplitude was blunted, in the luteal phase compared with the follicular phase. Acetaminophen had no effect on the body temperature profile in either menstrual cycle phase. Prostaglandins, therefore, are unlikely to mediate the upward shift of body temperature in the luteal phase. Sleep changed during the menstrual cycle: on the placebo night in the luteal phase the women had less rapid eye movement sleep and more slow-wave sleep than in the follicular phase. Acetaminophen did not alter sleep architecture or subjective sleep quality. Prostaglandin inhibition with acetaminophen, therefore, had no effect on the increase in body temperature or on sleep in the midluteal phase of the menstrual cycle in young women, making it unlikely that central prostaglandin synthesis underlies these luteal events.

Polysomnography in drug development

Polysomnography in drug development is used to detect desirable and undesirable effects of drugs on normal and disturbed sleep. Although this method is essential for the approval of new hypnotic drugs, it is quite often neglected in the development of drugs that show unwanted side effects on normal sleep. In this review, the requirements for qualified polysomnography are described, the strong and weak points of the method are discussed, and its importance for the drug development process is pointed out.

Effect of chronic REM sleep deprivation on pituitary, hypothalamus and hippocampus PGE2 and PGD2 biosynthesis in the mouse

Given the often reported relationships between sleep-wake regulation and the cerebral prostaglandins (PGs), the effect of chronic rapid eye movement (REM) sleep deprivation on brain PGE2 and PGD2 biosynthesis in mouse was evaluated, since they are known to have opposite actions as respectively wake- and sleep-inducing substances. Mice were subjected to 5 and 10 days of REM sleep deprivation by the flower pot technique. After sacrifice, PGE2 and PGD2 were determined in the pituitary, hypothalamus and hippocampus. Except in the pituitary where no changes were shown, the PGE2/PGD2 ratio was significantly enhanced after 5 and 10 days of REM sleep loss, when compared to control. These results showed an alteration of cerebral PGE2 and PGD2 biosynthesis, resulting in a shift from PGD2 toward PGE2. These results were not consistent with a role of PGD2 as a sleep-promoting substance as, if that was the case, it would be increased during the REM sleep deprivation. But they do not rule out its involvement as a facilitating substance.

Nonsteroidal anti-inflammatory drugs affect normal sleep patterns in humans

Previous studies have demonstrated that some nonsteroidal anti-inflammatory drugs (NSAIDs), specifically aspirin and indomethacin, have acute negative effects on sleep in humans and animals. Whether this finding can be replicated and extended to other NSAIDs, particularly the widely used over-the-counter drugs ibuprofen and acetaminophen, was the focus of the present investigation. Thirty-seven male and female subjects slept in the sleep laboratory on 2 consecutive nights; sleep was polygraphically recorded on the second night. Three doses of a prostaglandin-inhibiting drug (i.e., aspirin, acetaminophen, or ibuprofen) or placebo were administered, one each at 2300 h on the day prior to sleep recording, and at 0815 h and 2300 h on the day sleep was recorded. Subjects slept from 2400-0800 h both nights. Aspirin and ibuprofen disrupted sleep in comparison to placebo by increasing the number of awakenings and percentage of time spent in stage wake, and by decreasing sleep efficiency. Ibuprofen also delayed the onset of the deeper stages of sleep. Acetaminophen did not differ significantly from placebo on any measure of polygraphically recorded sleep. However, every index of objective sleep reflected slight, albeit nonsignificant, sleep disruption for each drug group relative to placebo. The mechanisms of sleep disruption after NSAID administration may relate to direct and indirect consequences of inhibiting prostaglandin synthesis, including decreases in prostaglandin D2, suppression of nighttime melatonin levels, and changes in body temperature.

Objective and subjective sleep disturbances in patients with rheumatoid arthritis. A reappraisal

OBJECTIVE

To assess objective and subjective evidence of sleep disturbances in patients with rheumatoid arthritis (RA) and to examine correlations between parameters of inflammatory activity and sleep pathology.

METHODS

Nineteen RA patients and 19 age-matched healthy control subjects underwent all-night polysomnography on 2 consecutive nights. RA patients were also evaluated for daytime sleepiness by mean sleep latency test and responded to a self-report questionnaire on their first night.

RESULTS

Whereas normal sleep architecture is conserved in RA, we confirmed former findings of severe sleep fragmentation and an enhanced presence of primary sleep disorders. No correlation exists between RA activity and the sleep disorders. Subjective assessment was not consistent with the objective evidence of sleep disruption, unlike the findings in patients with fibrositis.

CONCLUSION

Sleep is severely disturbed in patients with RA, regardless of the inflammatory disease activity. The specificity of the sleep disorders assessed needs confirmation, as does specific sleep therapy for these patients.

Prostaglandins E2 and D2 have little effect on rabbit sleep

Prostaglandins (PGs) are hypothesized to be involved in sleep regulation; PGE2 and PGD2 are major PGs in the hypothalamus of many species and are proposed to reciprocally promote wakefulness and sleep respectively. PGD2 and PGE2 are also major PGs in rabbit cerebrospinal fluid, yet their effects on rabbit sleep have not heretofore been systematically investigated. We report here that a bolus injection of PGE2 into a lateral cerebral ventricle induces dose-dependent fevers and transient sleep responses in rabbits. PGE2 induces a suppression of sleep of 24 min duration. In contrast, PGD2, across a wide range of doses (0.25-500 nmol) failed to alter sleep; however, at the highest dose it induced fever. We conclude that if PGs are involved in sleep regulation, a chronic stimulation of their production by other sleep factors is necessary.

Acetylsalicylic acid activates antinociceptive brain-stem reflex activity in headache patients and in healthy subjects

The exteroceptive suppression (ES) of electrical activity in the temporal muscle is an inhibitory antinociceptive brain-stem reflex. We investigated whether aspirin can significantly modulate latencies or durations of the early (ES1) and late (ES2) exteroceptive suppression periods of electrical activity in the temporal muscle. Participating in the randomized double-blind crossover study were 20 patients with migraine without aura, 20 patients with tension-type headache, and 20 healthy subjects. ES1 and ES2 elicited by an electrical stimulus of 20 mA lasting 0.2 msec were recorded during maximal voluntary contraction of the mastication muscles before and 30 min after medication. In a randomized and double-blind fashion half of the subjects were given 1200 mg of aspirin in the form of an effervescent solution and the other half were given an identically tasting solution without aspirin. One week later the experiment was repeated with the substances exchanged in crossover fashion. The administration of placebo as well as aspirin caused a highly significant increase in ES1 duration (P less than or equal to 0.001). While aspirin caused a highly significant increase in ES2 duration (P less than or equal to 0.001) the taking of placebo showed no significant effect on ES2 duration. In giving aspirin as opposed to the placebo, there was a significant interaction between groups and drug effect on the latency of ES1; whereas in migraine patients and in patients with tension-type headache the latency of ES1 was reduced by administration of aspirin, it was increased in healthy subjects (P less than or equal to 0.05). Neither aspirin nor placebo significantly varied the ES2 latency.(ABSTRACT TRUNCATED AT 250 WORDS)

Alpha-like EEG activity in non-REM sleep and the fibromyalgia (fibrositis) syndrome

The occurrence and characteristics of alpha-like activity during non-REM (NREM) sleep were examined in 11 subjects suffering from non-inflammatory (non-rheumatoid) musculoskeletal pain--fibromyalgia ('fibrositis'), and in 15 symptom-free controls. Both groups claimed to be good sleepers. Mean percentage alpha-like activity in sleep stages 2, 3, 4 and for NREM as a whole were greatest for the fibromyalgia group, but not significantly different from those of the controls. Overlap in the distribution of NREM alpha-like activity in sleep between the two groups indicated that it is not directly related to musculoskeletal symptoms. Spectral analyses showed a frontal area prevalence of this (kappa?) activity in the fibromyalgia group.

The evaluation of a nonsteroidal anti-inflammatory drug (tenoxicam) in the treatment of sleep disturbance in osteoarthritic patients

The effects of a nocturnal nonsteroidal anti-inflammatory drug (tenoxicam) on twelve male osteoarthritic patients were investigated in a randomised, double-blind, placebo-controlled, cross-over study. Tenoxicam produced no significant changes in any of the areas evaluated which included electroencephalographic (EEG) sleep, subjective sleep, pain and early morning stiffness. The selection of patients may have contributed to this unexpected result. There was no evidence to suggest that tenoxicam caused any unwanted side-effects or affected early morning psychomotor performance. The use of the sleep EEG as an objective pain measure is discussed.

Differential effects of acetylsalicylic acid and acetaminophen on sleep abnormalities in a rat chronic pain model

We studied the effects of two non-steroidal anti-inflammatory analgesics (NSAIAs), acetylsalicylic acid (ASA) and acetaminophen, on sleep patterns in rats with adjuvant-induced arthritis. We found that in the normal rat both NSAIAs reduced non-rapid eye movement (NREM) sleep. In arthritic rats ASA and acetaminophen had opposite effects on sleep. ASA increased wakefulness and decreased all sleep stages and acetaminophen decreased wakefulness and increased NREM sleep and paradoxical sleep during the light hours (the hours of maximal sleep in the normal rat). When the effects of severity of arthritis were factored out, both drugs still had large and significant effects on sleep and wakefulness. Thus, two prostaglandin synthetase inhibitors showed differential effects on sleep and wakefulness in the normal rat and in rats experiencing chronic pain. Although ASA is important in the treatment of pain in rheumatic diseases, it may contribute to abnormal sleep patterns.