1
|
Ahmad M, Kelly J, Montano CB, Kumar D, Perdomo C, Malhotra M, Amchin J, Moline M. Transitioning insomnia patients from zolpidem to lemborexant: A multicenter, open-label study evaluating a next-dose transition approach to insomnia pharmacotherapy. Sleep Med X 2024; 7:100098. [PMID: 38312371 PMCID: PMC10835435 DOI: 10.1016/j.sleepx.2023.100098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/18/2023] [Indexed: 02/06/2024] Open
Abstract
Objective Few clinical studies have assessed real-world abrupt transitioning between insomnia medications. This study assessed strategies for directly transitioning patients from zolpidem tartrate (ZOL) immediate/extended release to the dual orexin receptor antagonist, lemborexant (LEM). Methods This randomized, open-label, multicenter study (Study 312; E2006-A001-312) enrolled 53 adults age ≥18 years with insomnia disorder and ≥1-month history of intermittent (3-4 nights/week) or frequent (≥5 nights/week) ZOL use. Subjects recorded their ZOL use in a 3-week Pretreatment Phase, followed by a 2-week Treatment Phase (TRT; Titration) during which ZOL was discontinued. Intermittent ZOL users transitioned to LEM 5 mg (LEM5), Cohort 1, and frequent ZOL users were randomized 1:1 to LEM5, Cohort 2A, or LEM 10 mg (LEM10), Cohort 2B. One dose adjustment was permitted during the TRT. Subjects completing the TRT could continue LEM in the 12-week Extension Phase (EXT). The primary outcome was proportion of subjects who successfully transitioned and remained on LEM at the end of the TRT. Results Most subjects (43 [81.1 %]) successfully transitioned to LEM (9 [90 %], 17 [81.0 %], and 17 [77.3 %] in Cohorts 1, 2A, and 2B, respectively). By the end of the EXT, 66.7 % in Cohort 1 and 60.0 % in Cohort 2A up-titrated to LEM10, whereas 41.2 % in Cohort 2B down-titrated to LEM5; 61.0 % were receiving LEM10 at study end. At the end of the TRT, more subjects taking LEM reported that it helped them return to sleep after waking, compared with those taking ZOL (71.7 % vs. 49.1 %). There were no important differences between treatments regarding how subjects reported feeling as they fell asleep. Most of the treatment-emergent adverse events with LEM were mild in severity. Conclusions Most subjects transitioned successfully to LEM from ZOL (intermittent or frequent use). LEM was well tolerated.
Collapse
Affiliation(s)
- Maha Ahmad
- Clinilabs Drug Development Corporation, New York, NY, USA
| | - James Kelly
- Clinilabs Drug Development Corporation, New York, NY, USA
| | | | | | | | | | | | | |
Collapse
|
2
|
Bramoweth AD, Hough CE, McQuillan AD, Spitznogle BL, Thorpe CT, Lickel JJ, Boudreaux-Kelly M, Hamm ME, Germain A. Reduction of Sleep Medications via a Combined Digital Insomnia and Pharmacist-Led Deprescribing Intervention: Protocol for a Feasibility Trial. JMIR Res Protoc 2023; 12:e47636. [PMID: 37471122 PMCID: PMC10401195 DOI: 10.2196/47636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 06/16/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023] Open
Abstract
BACKGROUND Chronic insomnia is one of the most common health problems among veterans and negatively impacts their health, function, and quality of life. Although cognitive behavioral therapy for insomnia (CBT-I) is the first-line recommended treatment, sedative-hypnotic medications remain the most common. Sedative-hypnotics, however, have mixed effectiveness, are frequently prescribed longer than recommended, and are associated with numerous risks and adverse effects that negatively impact veteran function. Meeting the treatment needs of veterans impacted by insomnia requires delivering gold standard behavioral care, like CBT-I, and the reduction of sedative-hypnotics through innovative methods. OBJECTIVE The objective of this feasibility clinical trial is to test a digital CBT-I approach combined with deprescribing to improve the success of sedative-hypnotic reduction among veterans. The intervention combines Noctem Health Clinician Operated Assistive Sleep Technology (COAST), an effective and efficient, scalable, and adaptable digital platform to deliver CBT-I, with clinical pharmacy practitioner (CPP)-led deprescribing of sedative-hypnotic medications. METHODS In this nonrandomized single-group clinical trial, 50 veterans will be recruited and enrolled to receive CBT-I delivered via Noctem COAST and CPP-led deprescribing for up to 12 weeks. Assessments will occur at baseline, posttreatment, and 3-month follow-up. The aims are to (1) assess the feasibility of recruiting veterans with chronic sedative-hypnotic use to participate in the combined intervention, (2) evaluate veterans' acceptability and usability of the COAST platform, and (3) measure changes in veterans' sleep, sedative-hypnotic use, and function at baseline, posttreatment, and 3-month follow-up. RESULTS The institutional review board approved the study in October 2021 and the trial was initiated in May 2022. Recruitment and data collection began in September 2022 and is anticipated to be completed in April 2024. Aim 1 will be measured by tracking the response to a mail-centric recruitment approach using electronic medical records to identify potentially eligible veterans based on sedative-hypnotic use. Aim 2 will be measured using the Post-Study System Usability Questionnaire, assessing overall usability as well as system usefulness, information quality, and interface quality. Aim 3 will use the Insomnia Severity Index and sleep diaries to measure change in insomnia outcomes, the Patient-Reported Outcome Measurement Information System Profile to measure change in physical function, anxiety, depression, fatigue, sleep disturbance, participation in social roles, pain, cognitive function, and self-reported sedative-hypnotic use to measure change in dose and frequency of use. CONCLUSIONS Findings will inform the utility of a combined digital CBT-I and CPP-led deprescribing intervention and the development of an adequately powered clinical trial to test the effectiveness in a diverse sample of veterans. Further, findings will help inform potential new approaches to deliver care and improve access to care for veterans with insomnia, many of whom use sedative-hypnotics that may be ineffective and increase the risk for negative outcomes. TRIAL REGISTRATION ClinicalTrials.gov NCT05027438; https://classic.clinicaltrials.gov/ct2/show/NCT05027438. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/47636.
Collapse
Affiliation(s)
- Adam D Bramoweth
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Caroline E Hough
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | - Amanda D McQuillan
- Pharmacy Services, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
| | | | - Carolyn T Thorpe
- Center for Health Equity Research and Promotion, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, United States
| | - James J Lickel
- Behavioral Health, William S Middleton Memorial Veterans' Hospital, Madison, WI, United States
| | | | - Megan E Hamm
- Mental Illness Research, Education and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, United States
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Anne Germain
- Noctem Health Inc, Pittsburgh, PA, United States
| |
Collapse
|
3
|
Landy MSH, Newman L, Carney AE, Donkin V, Nicholls J, Krol SA, Farvolden P. Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia: A Case Report. Clin Case Stud 2023. [DOI: 10.1177/15346501221145944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Despite its well-documented efficacy, few clinicians are trained to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), and it remains an inaccessible treatment. Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia (TAI-CBT-I) holds promise for overcoming barriers to accessing this evidence-based treatment. However, to date, there have been no case reports published that describe how to deliver TAI-CBT-I. This case report fills in this gap by illustrating the application and utility of such a treatment on an asynchronous platform. We report on a course of TAI-CBT-I for a 34-year-old Caribbean Canadian male who presented with chronic insomnia characterized by difficulty falling and staying asleep, night awakenings, and reduced helpfulness from medication. Self-report measures of sleep, depression, functioning and ability, and therapist satisfaction were administered throughout treatment, post-discharge, and at follow-up. Improvement was noted across all measures. This case report demonstrates that TAI-CBT-I can be an effective treatment for chronic insomnia and showcases how to deliver it.
Collapse
Affiliation(s)
| | | | - Alison E. Carney
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
| | - Victoria Donkin
- Department of Psychology, Toronto Metropolitan University, Toronto, ON, Canada
- Centre for Addiction and Mental Health, Toronto, ON, Canada
| | - Jocelyn Nicholls
- Canadian Mental Health Association, York Region and South Simcoe, Toronto, ON, Canada
| | | | | |
Collapse
|
4
|
Chudow M, Paradiso V, Silva N, Collette J. Evaluation of the Impact of Prior-to-Admission Sleep Aid Prescribing Practices on Sleep and Delirium in the Intensive Care Unit. Ann Pharmacother 2021; 56:679-684. [PMID: 34486435 DOI: 10.1177/10600280211042632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Sleep disruptions in the intensive care unit (ICU) may lead to complications such as delirium. There is limited evidence addressing how sleep aid use before and during ICU admission affects outcomes. OBJECTIVE The purpose of this study is to evaluate the impact of prior-to-admission sleep aid prescribing practices in the ICU on delirium and sleep outcomes. METHODS A retrospective review was conducted of adult patients admitted to any ICU from January to June 2018 receiving a sleep aid prior to admission. Patients were categorized based on sleep aid continuation, discontinuation, or alteration during the ICU admission. The primary end point was the incidence of delirium. Secondary end points included the incidence of sleep-wake cycle disturbances, delirium scores, and ICU length of stay. RESULTS A total of 291 patients were included with 109 in the continued group, 121 in the discontinued group, and 61 in the altered group. There was a similar incidence of delirium at 24 hours (P = 0.71), 48 hours (P = 0.60), 72 hours (P = 0.25), and 5 days (P = 0.48) after ICU admission. There was also no statistical difference in sleep-wake cycle disturbances or delirium scores at any time point. ICU length of stay was similar between the groups. CONCLUSION AND RELEVANCE The incidence of delirium and sleep-wake cycle disturbances was not affected by differences in prior-to-admission sleep aid prescribing patterns during ICU admission.
Collapse
Affiliation(s)
- Melissa Chudow
- University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Vittorio Paradiso
- University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Nicole Silva
- University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| | - Jillian Collette
- University of South Florida Taneja College of Pharmacy, Tampa, FL, USA
| |
Collapse
|
5
|
Tang HYJ, McCurry SM, Pike KC, Riegel B, Vitiello MV. Open-loop Audio-Visual Stimulation for sleep promotion in older adults with comorbid insomnia and osteoarthritis pain: results of a pilot randomized controlled trial. Sleep Med 2021; 82:37-42. [PMID: 33878522 DOI: 10.1016/j.sleep.2021.03.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2020] [Revised: 03/14/2021] [Accepted: 03/26/2021] [Indexed: 10/21/2022]
Abstract
Osteoarthritis is commonly comorbid with insomnia in older adults. While cognitivebehavioral therapy for insomnia is the recommended first-line treatment for insomnia, alternative efficacious non-pharmacological options are needed. This study examined sleep and pain in 30 community-dwelling older adults with comorbid insomnia and osteoarthritis pain randomized to two weeks of 30 min of bedtime active (n = 15, mean age 66.7 ± 5.2) or placebo control (n = 15, mean age 68.9 ± 5.0) Audiovisual Stimulation (AVS). After AVS use, improvements in sleep, pain, and depression were reported for both groups but between-group comparisons were non-significant. A posthoc analysis examined the effects of AVS in the 11 subjects who reported sleep latency complaints (≥30 min). No significant group differences were found for this small sleep latency subsample; however, the pre-post effect sizes (ES) of active AVS versus placebo were greatly increased for the subsample relative to the total sample for sleep (ES = 0.41 versus 0.18 for the Insomnia Severity Index, and 0.60 versus 0.03 for the Pittsburgh Sleep Quality Index, respectively). A similar enhanced effect pattern was found for pain (ES = 0.41 versus 0.15 for the Brief Pain Inventory). Study findings suggest that the 30-min AVS program may have potential to improve sleep in older adults with sleep onset but not sleep maintenance difficulty. Despite study limitations of a small sample size and lack of follow-up, results offer valuable insights into the functionality of AVS treatment. Future research should focus on subjects with sleep onset complaints, who are most likely to receive benefit from this treatment modality.
Collapse
Affiliation(s)
- Hsin-Yi Jean Tang
- Department of Biobehavioral Nursing and Health Informatics, School of Nursing, University of Washington, Seattle, WA, United States.
| | - Susan M McCurry
- Department of Child, Family and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, United States
| | - Kenneth C Pike
- Department of Child, Family and Population Health Nursing, School of Nursing, University of Washington, Seattle, WA, United States
| | - Barbara Riegel
- Department of Biobehavioral Health Sciences, School of Nursing, University of Pennsylvania, Philadelphia, PA, United States
| | - Michael V Vitiello
- Department of Psychiatry and Behavioral Sciences, School of Medicine, University of Washington, Seattle, WA, United States
| |
Collapse
|
6
|
Rosenberg R, Citrome L, Drake CL. Advances in the Treatment of Chronic Insomnia: A Narrative Review of New Nonpharmacologic and Pharmacologic Therapies. Neuropsychiatr Dis Treat 2021; 17:2549-2566. [PMID: 34393484 PMCID: PMC8354724 DOI: 10.2147/ndt.s297504] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 07/16/2021] [Indexed: 12/13/2022] Open
Abstract
Chronic insomnia disorder, which affects 6-10% of the population, is diagnostically characterized by ongoing difficulties with initiating or maintaining sleep occurring at least three times per week, persisting for at least 3 months, and associated with daytime impairment. While chronic insomnia is often considered a condition primarily related to impaired sleep, the disorder can also adversely affect domains of physical and mental health, quality of life, and daytime function, which highlights the importance of treating the multidimensional sleep disorder. Owing to misperceptions about the safety and effectiveness of treatment options, many individuals with insomnia may not seek professional treatment, and alternatively use ineffective home remedies or over-the-counter medications to improve sleep. Some physicians may even believe that insomnia is remediated by simply having the patient "get more sleep". Unfortunately, treatment of insomnia is not always that simple. The disorder's complex underlying pathophysiology warrants consideration of different nonpharmacologic and pharmacologic treatment options. Indeed, recent insights gained from research into the pathophysiology of insomnia have facilitated development of newer treatment approaches with more efficacious outcomes. This narrative review provides a summary of the diagnostic criteria and pathophysiology of insomnia and its subtypes. Further, this review emphasizes new and emerging nonpharmacologic and pharmacologic treatments for chronic insomnia, including recent enhancements in approaches to cognitive behavioral therapy for insomnia (CBT-I) and the new dual orexin receptor antagonist (DORA) pharmacologics. These advances in treatment have expanded the treatment options and are likely to result in improved outcomes in patients with chronic insomnia.
Collapse
Affiliation(s)
| | - Leslie Citrome
- Department of Psychiatry and Behavioral Sciences, New York Medical College, Valhalla, NY, USA
| | - Christopher L Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, MI, USA
| |
Collapse
|