Evaluation of single-dose hypnotic treatment before elective operation

Pharmacological profiling of zebrafish behavior using chemical and genetic classification of sleep-wake modifiers

Sleep-wake states are impaired in various neurological disorders. Impairment of sleep-wake states can be an early condition that exacerbates these disorders. Therefore, treating sleep-wake dysfunction may prevent or slow the development of these diseases. Although many gene products are likely to be involved in the sleep-wake disturbance, hypnotics and psychostimulants clinically used are limited in terms of their mode of action and are not without side effects. Therefore, there is a growing demand for developing new hypnotics and psychostimulants with high efficacy and few side effects. Toward this end, animal models are indispensable for use in genetic and chemical screens to identify sleep-wake modifiers. As a proof-of-concept study, we performed behavioral profiling of zebrafish treated with chemical and genetic sleep-wake modifiers. We were able to demonstrate that behavioral profiling of zebrafish treated with hypnotics or psychostimulants from 9 to 10 days post-fertilization was sufficient to identify drugs with specific modes of action. We were also able to identify behavioral endpoints distinguishing GABA-A modulators and hypocretin (hcrt) receptor antagonists and between sympathomimetic and non-sympathomimetic psychostimulants. This behavioral profiling can serve to identify genes related to sleep-wake disturbance associated with various neuropsychiatric diseases and novel therapeutic compounds for insomnia and excessive daytime sleep with fewer adverse side effects.

Opipramol improves subjective quality of sleep the night prior to surgery: confirmatory testing of a double-blind, randomized clinical trial

OBJECTIVE

Due to its pharmacological properties, opipramol may be useful in the context of evening premedication in anaesthesiology. This trial examines whether quality of sleep the night prior to surgery can be improved by opipramol and whether this effect is dose dependent. A second objective of this study is to examine whether the emotional state (in particular anxiety) is affected by opipramol.

METHOD

72 female patients were randomly assigned to 100 mg opipramol, 150 mg opipramol or placebo (24 patients per group) in a double-blind trial. Drug application was in the evening prior to an elective surgery. Effects were recorded the next morning by means of self-rating questionnaires regarding subjective sleep quality of the last night and patients' current subjective state. The self-rating was done by use of the Wuerzburg Sleep Questionnaire, by use of mood inventories [BSKE (EWL) and STAI-X1] and by use of the Multidimensional Somatic Symptom List. Further dependent variables were heart rate and blood pressure. Confirmatory data analysis was conducted for subjective quality of sleep.

RESULTS

100 mg opipramol as well as 150 mg opipramol significantly improved subjective quality of sleep (p < 0.001). The drug conditions did not differ in this effect. Opipramol marginally reduced anxiety (STAI-X1). The autonomic variables remained uninfluenced. There were no adverse events and no hints for interaction with anaesthesia.

CONCLUSION

Opipramol may be used as a premedication in the evening prior to surgery if the primary target is an impact on the experienced quality of sleep. For this a single dosage of 100 mg opipramol is sufficient and can be recommended.

Evaluation of zolpidem, triazolam, and placebo as hypnotic drugs the night before surgery

STUDY OBJECTIVE

To compare the hypnotic effects of a bedtime dose of zolpidem, triazolam, and placebo.

DESIGN

"Double-blind, randomized, placebo- and active-controlled, parallel-group" trial.

SETTING

Six Canadian hospitals.

PATIENTS

357 patients (aged 19 to 71 years) hospitalized the night before a surgical procedure.

INTERVENTIONS

At bedtime, each patient received either zolpidem 10 mg, triazolam 0.25 mg, or placebo, and was allowed to sleep for a maximum of 8 hours.

MEASUREMENTS

Outcome measures were subjective in nature and included a morning questionnaire, visual analog scales, and observation forms by study personnel. All continuous variables were analyzed by analysis of variance. All categorical data were compared using the Cochran-Mantel-Haenszel (CMH) test, and the percentage of patients asleep was compared using a CMH chi-square analysis. When significant overall treatment effects were observed, pairwise comparisons were undertaken. Compared with the placebo group, the following parameters were significantly (p < 0.001) different in the zolpidem and triazolam groups: sleep latency was shorter, total sleep time was longer, patients fell asleep more easily, and the number of patients awake 2 hours after drug administration was lower. There were no differences between any groups in next-morning somnolence or ability to concentrate. Both drugs were well tolerated, with adverse event incidence rates nearly identical to placebo.

CONCLUSIONS

In patients suffering from transient insomnia, a single dose of zolpidem 10 mg was as effective as triazolam 0.25 mg, and both were more effective than placebo and were well tolerated.

Hypnotic efficacy and safety of triazolam administered during the postoperative period

This study examined the hypnotic efficacy and safety of short-term use of triazolam following elective surgery. One hundred women (ages 26-69) who had received 0.125 mg of traizalam the evening before breast cancer surgery were enrolled in a randomized, double-blind study comparing triazolam to placebo. Study medication was begun on the first or second evening following surgery, depending on the patient's level of postoperative alterness, and was administered in the hospital for three consecutive evenings. The starting dose of triazolam was 0.125 mg, with the option of increasing the dose to 0.25 mg on subsequent nights if sleep response was inadequate. Relative to patients in the placebo group, patients in the triazolam group reported significantly (p < 0.05) less difficulty falling asleep, fewer nightime awakenings, better overall sleep quality, and a greater sense of restfulness. No clinically significant adverse reactions were encountered and no adverse reactions occurred more frequently in the triazolam group than in the placebo group. Results indicate that administration of traizalam is a safe and effective method of improving sleep in patients recovering from surgery.

Using triazolam to reduce dental anxiety

Triazolam, commonly prescribed to treat insomnia, also can be used to reduce dental anxiety. Despite controversial reports in the lay press, triazolam can be used safely at low doses for short periods. The authors review research concerning the drug's safety and discuss its use in dentistry.

The effectiveness of flurazepam as night sedation prior to the removal of third molars

Anxiety prior to dental treatment is a well-recognized problem. Although oral sedation has been recommended the night before appointments to reduce this anxiety, there are no well-controlled studies to support this claim. The present double-blind cross-over study investigated the effect of 30 mg of flurazepam taken the night before the removal of impacted third molars. Preoperative anxiety, visuomotor performance and sleep patterns were investigated in 20 adult patients with similarly impacted third molars. While preoperative flurazepam led to a statistically significant improvement in sleep patterns, there was no reduction in pre-operative anxiety on the morning of surgery. In addition, the flurazepam-treated group demonstrated significantly impaired visuo-motor performance 60 min after intravenous sedation compared to this group where intravenous sedation was used only preceded by placebo. Patients had a significant preference for flurazepam over placebo as a night-time sedative.

Triazolam premedication. A comparison with lorazepam and placebo in gynaecological patients

A randomised, double blind study, of 58 female patients undergoing laparoscopic investigation was carried out to compare triazolam 0.25 mg, lorazepam 2 mg, or placebo as oral premedication. Each patient was assessed by only one of the authors both pre- and postoperatively with regard to anxiolysis, sedation and rapidity of recovery. Triazolam and lorazepam were each associated with a significant reduction in anxiety compared to the initial assessment, whereas placebo had no anxiolytic effect. Sixty minutes after premedication, patients who had received triazolam were significantly more sleepy than patients given placebo or lorazepam. Two hours after the operation, the patients who had had triazolam or lorazepam were significantly more sleepy than those who received placebo. However, at 6 hours postoperatively there was no difference between triazolam and placebo, whilst those who had been given lorazepam were still significantly more sleepy than those given placebo. Triazolam appears to offer advantages over either lorazepam or placebo in patients who require rapid recovery, sedation and reduction in pre-operative anxiety.

A comparison of triazolam and diazepam as premedication agents for minor gynaecological surgery

Triazolam 0.25 mg, diazepam 10 mg and placebo were compared in a randomized double-blind trial of oral premedication in 90 patients undergoing minor gynaecological surgery. Both triazolam and diazepam produced a significant sedative effect as measured by patient self assessment linear analogue scales but only diazepam was more anxiolytic than placebo. Psychomotor performance assessed by the letter-search test at 3 and 6 hours after awakening showed a decrement in performance in patients receiving triazolam at 3 hours compared with the two other groups. Triazolam was shown to have a pronounced amnesic effect and whilst it might be used for premedication, its lack of anxiolysis coupled with a significant impairment of psychomotor performance at 3 hours after awakening, render the drug unsuitable for premedication in the short stay patient.

A double-blind group comparative study using the new anti-depressant Org 3770, placebo and diazepam in patients with expected insomnia and anxiety before elective gynaecological surgery

Two hundred and fifty female patients about to undergo elective gynaecological surgery, were randomly allocated to a single oral dose of either 5, 15, 30 mg Org 3770, placebo, or 10 mg diazepam the evening before operation. Assessment of sleep quality next morning using self-rated questionnaires showed that both Org 3770 and diazepam were significantly better than placebo in enhancing sleep. In addition, a dose-response effect was seen with Org 3770, 15 mg seeming optimal. Assessment of presurgery anxiety, again using self-rated questionnaires, showed that 15 mg Org 3770, and 10 mg diazepam were significantly more effective than placebo at reducing anxiety. None of the medications produced any troublesome side effects nor did they have an effect on blood pressure.

Experience with triazolam as a preoperative sedative for outpatient surgery under local anesthesia

Triazolam, a new benzodiazepine hypnotic agent with an ultra-short duration of action, was given preoperatively to 251 outpatients who underwent plastic surgical procedures under local anesthesia. Satisfactory sedation was obtained in 96% of the patients, all of whom received intravenous diazepam primarily for its amnesic action. There were no untoward results attributed to triazolam and no residual effects postoperatively. Triazolam may be preferable over other benzodiazepine sedative-hypnotic agents used for outpatient surgery because of its rapid onset and short half-life.

Comparison of quazepam, flunitrazepam and placebo as single-dose hypnotics before surgery

The hypnotic effect and tolerance of quazepam (Sch 16134) 15 and 30 mg, flunitrazepam 1 and 2 mg and placebo were evaluated in a one-night, randomized, double-blind, parallel group study of 100 hospitalized patients, who were to undergo a planned operation on the following day. All active drugs were rated as superior to placebo by the physician. Subjectively, quazepam 30 mg and flunitrazepam 1 and 2 mg were superior to placebo. Hangover effects were not distinguishable from placebo. Vigilance and ataxia tests were not altered by any of the drugs.

Triazolam: a review of its pharmacological properties and therapeutic efficacy in patients with insomnia

Triazolam is a triazolobenzodiazepine with hypnotic properties, advocated for use in acute or chronic insomnia, situational insomnia in hospitalised patients, and insomnia associated with other disease states. As triazolam has a relatively short half-life of about 2 to 3 hours in healthy subjects and has only 1 short acting active metabolite, alpha-hydroxytriazolam, it would seem more suitable as an hypnotic than longer acting drugs such as flurazepam, nitrazepam or flunitrazepam, particularly when residual sedative effects on the day after ingestion are undesirable. Thus, with usual hypnotic doses of triazolam (0.25 or 0.5 mg) impairment of psychomotor and cognitive function is generally not carried over into the day after ingestion, although at doses of 1 mg or greater, residual effects may appear. In short term comparative studies triazolam was clearly superior to a placebo, and was at lest as effective as flurazepam, or other benzodiazepines such as nitrazepam or diazepam, in hastening sleep onset, reducing nocturnal awakenings, and increasing sleep duration. In other studies it was often superior to chloral hydrate, methyprylone or quinalbarbitone (secobarbital). In a small number of patients with chronic insomnia receiving extended treatment with triazolam in a clinical setting or in some sleep laboratory studies, no evidence of tolerance occurred; however, some evidence of reduced effect with repeated administration has been reported in one sleep laboratory study. Thus, a definitive statement about the likelihood of tolerance occurring on repeated administration is difficult to make at this time.