Midazolam: sleep and performance studies in middle age

Distinct effects of orexin receptor antagonist and GABAA agonist on sleep and physical/cognitive functions after forced awakening

The majority of patients with insomnia are treated with hypnotic agents. In the present study, we evaluated the side-effect profile of an orexin receptor antagonist and γ-aminobutyric acid A (GABA_A) receptor agonist on physical/cognitive functions upon forced awakening. This double-blind, randomized, placebo-controlled, cross-over study was conducted on 30 healthy male subjects. Fifteen minutes before bedtime, the subjects took a pill of suvorexant (20 mg), brotizolam (0.25 mg), or placebo and were forced awake 90 min thereafter. Physical- and cognitive-function tests were performed before taking the pill, after forced awakening, and the next morning. Polysomnographic recordings revealed that the efficacies of the hypnotic agents in prolonging total sleep time (∼30 min) and increasing sleep efficiency (∼6%) were comparable. When the subjects were allowed to go back to sleep after the forced awakening, the sleep latency was shorter under the influence of hypnotic agents (∼2 min) compared to the placebo trial (24 min), and the rapid eye movement latency was significantly shorter under suvorexant (98.8, 81.7, and 48.8 min for placebo, brotizolam, and suvorexant, respectively). Although brotizolam significantly impaired the overall physical/cognitive performance (sum of z score) compared with placebo upon forced awakening, there was no significant difference in the total z score of performance between suvorexant and placebo. Notably, the score for static balance with the eyes open was higher under suvorexant compared to brotizolam administration. The energy expenditure was lower under suvorexant and brotizolam compared with the placebo. The effect size of brotizolam (d = 0.24) to reduce the energy expenditure was larger than that of suvorexant (d < 0.01).

Ceiling and floor effects in sleep research

Ceiling and floor effects dictate that the efficacy of sleep-promoting stimuli should be proportional to the degree of pre-stimulus sleep impairment. This review addressed CF effects in polysomnographic research involving hypnotic drugs and exercise. Correlations of placebo/baseline levels of sleep with changes in sleep following hypnotic or exercise treatment were assessed across both literatures. CF effects were further addressed by comparing sleep-promoting effects of hypnotics vs exercise, after ANCOVA control for substantial baseline differences reported in studies of these stimuli. Significant correlations between placebo-baseline levels and sleep changes were observed following both hypnotic and exercise stimuli. Indeed, approximately 60% of the variance in improvement in sleep latency (SOL), wakefulness after sleep onset (WASO) and total sleep time (TST) following hypnotic treatment was associated with differences in baseline levels. ANCOVAs revealed significantly greater decreases in SOL and WASO following hypnotics compared with exercise. However, no significant difference between stimuli was found for TST, and exercise elicited a significantly greater increase in slow wave sleep. Similar results were found when a comparison between hypnotics and exercise was limited to good sleepers. The results show powerful CF influences on sleep responses to hypnotics and exercise and suggest a need for comparing these treatments in poor sleepers.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

Effects of drugs on sleep

Many commonly prescribed medications and substances of abuse can have significant effects on sleep and wakefulness. Chronic use or abuse of certain drugs may lead to the development of substance-related sleep disorders. Primary sleep disorders, such as apnea, periodic movement disorders, and parasomnias, may be exacerbated by various drugs. This article summarizes the effects of widely used medications and recreational drugs on sleep.

Midazolam daytime residual effect evaluated by the Multiple Sleep Latency Test

Daytime sleepiness after ingestion of midazolam as a hypnotic was quantitatively studied employing the Multiple Sleep Latency Test (MSLT). We evaluated 20 healthy volunteers, 10 of which received a single oral dose of midazolam (15 mg, one tablet) and 10 of which received placebo, in a double-blind design. Tablets were administered at 2200 h, bedtime. On the following day, all subjects were submitted to a clinical evaluation, a subjective checklist and the MSLT. The mean age was 34.7 +/- 8.9 years in the midazolam and 38.0 +/- 10.6 years in the placebo groups (n.s.). Sex and weight distributions were similar in both groups (n.s.). Clinical evaluation and subjective symptom checklist did not make evident significant differences between midazolam and placebo groups (n.s.). The MSLT was performed at 0900, 1100, 1300, 1500 and 1700 h. Mean sleep latencies were 12.0, 12.7, 8.0, 13.5, 17.0 min in the midazolam group; mean sleep latencies were 13.8, 9.0, 6.9, 9.5, 13.6 min in the placebo group (n.s.). In the single dose, double-blind design here evaluated, midazolam did not show differences in relation to placebo on the following day, detectable by the MSLT.

Drug effects on REM sleep and on endogenous depression

In earlier work REM sleep deprivation (RSD) by arousals improved endogenous depression. This suggested that drugs producing a similar RSD would have antidepressant activity. The arousal RSD was large, persisted for weeks, and was followed by a REM rebound. We call RSD with these properties arousal-type RSD. The present study reviewed literature from 1962 to 1989 on drug REM sleep effects to examine the hypothesis that drugs producing arousal-type RSD improve endogenous depression. The literature reviewed concerned the REM sleep effects of amine precursors, antidepressants, antihistamines, antipsychotics, barbiturates, benzodiazepines, other hypnotics, drugs affecting cholinergic and noradrenergic neurotransmission, ethanol, lithium and narcotics. Four hundred and sixty-eight relevant papers were read and 215 contributed information that could be used in the review. The findings indicated that all drugs producing arousal-type RSD improved endogenous depression. Four drugs that improved endogenous depression did not produce arousal-type RSD.

Midazolam: the first water-soluble benzodiazepine. Pharmacology, pharmacokinetics and efficacy in insomnia and anesthesia

Midazolam is a 1,4-benzodiazepine derivative with a unique chemical structure: depending on environmental pH, the drug can produce highly water-soluble salts (pH less than 4) or exist in lipophilic diazepine ring-closed form (pH greater than 4). This characteristic contributes to rapid onset of action and to good local tolerance after parenteral administration. After both oral and parenteral administration, midazolam has a fast absorption rate and is rapidly excreted, with a half-life of only about 2 hours. A reasonably good correlation has been found between plasma levels and clinical effects, indicating a fast but brief response. As a hypnotic, midazolam is mainly indicated in insomniac patients with difficulties in falling asleep or having a pathologic sleep pattern during the first half of the night. No marked hangover effects are present the next morning. In anesthesiology, midazolam appears to be a useful, short-acting, sedative-anxiolytic and amnesic premedicant after both oral and parenteral administration. In minor surgery, however, the slow, unpredictable onset and variable duration of action, as compared with thiopental, may inhibit its routine use as an induction agent, especially in young patients, without heavy premedication. In major surgery, midazolam is an alternative to thiopental for induction of anesthesia in spite of its slow, variable induction time. Its advantages include good cardiovascular stability, transient and mild respiratory depression, low frequency of venous irritation, production of anterograde amnesia and short duration of action in comparison with other benzodiazepines.

Midazolam. A review of its pharmacological properties and therapeutic use

Midazolam is a short-acting water-soluble benzodiazepine (at pH less than 4), a member of a new class of imidazobenzodiazepine derivatives. At physiological pH the drug becomes much more lipid soluble. Water solubility minimises pain on injection and venous thrombosis compared with diazepam administered in organic solvent. Midazolam is a hypnotic-sedative drug with anxiolytic and marked amnestic properties. To date it has been used mostly by the intravenous route, for sedation in dentistry and endoscopic procedures and as an adjunct to local anaesthetic techniques. It has proved less reliable than thiopentone, but preferable to diazepam, as an intravenous induction agent and is unlikely to replace the other well established drugs. However, due to the cardiorespiratory stability following its administration, midazolam is useful for anaesthetic induction in poor-risk, elderly and cardiac patients. The short elimination half-life (1.5-3.5h) and the absence of clinically important long acting metabolites make midazolam suitable for long term infusion as a sedative and amnestic for intensive care, but clinical trials have yet to be completed. Thus, a combination of properties make midazolam a useful addition to the benzodiazepine group.

Efficacy and safety of midazolam and vesparax in treatment of sleep disorders

In a double-blind parallel study in which a placebo phase preceded and followed the double-blind verum phase, midazolam 15 mg and Vesparax (150 mg secobarbital, 50 mg brallobarbital, 50 mg hydroxyzine) were administered to 30 female patients aged 20-76 years, suffering from insomnia secondary to neuromuscular disease. Both products were shown to be efficient hypnotics maintaining a constant level of effect. Midazolam proved to be better tolerated and, in contrast to Vesparax, did not cause hangover, nor did rebound phenomena ensue after its withdrawal.

Midazolam and triazolam in out-patients: a double-blind comparison of hypnotic efficacy

The hypnotic efficacy and the effect on the condition after morning awakening of midazolam 15 mg and of triazolam 0.5 mg were studied in a multicentre, double-blind cross-over study in 198 out-patients with sleeping difficulties of various origin. The subjects received each drug for two consecutive nights, and completed a questionnaire each day on awakening. Both midazolam and triazolam significantly shortened the sleep-onset latency, reduced the number of awakenings, and increased the total sleep time. The state on awakening was also significantly improved after both compounds for several self-rated items. There was a difference only with regard to the patients' feeling of being under drug influence, which was reported as being significantly more marked after triazolam. In conclusion, both compounds were effective and well tolerated in the doses used, only a few side-effects being reported.