Management of insomnia: treatments and mechanismsi

Off-label low dose amitriptyline for insomnia disorder: Patient-reported outcomes

PURPOSE

Low dose amitriptyline is prescribed off-label to improve sleep maintenance in patients with insomnia disorder. Data on treatment outcomes are limited. We aimed to assess patient-reported treatment effect and side effects of low dose amitriptyline for insomnia in routine care data.

METHODS

Cross-sectional study: Seven hundred fifty-two consecutive patients with insomnia disorder having sleep maintenance problems were treated in an outpatient sleep clinic with low dose amitriptyline (10-20 mg based on self-titration). Treatment was intended to improve sleep maintenance. Before the planned follow-up consultation (approximately 6 weeks after start treatment) patients completed an online treatment evaluation questionnaire. Treatment (dose, adherence), sleep, fatigue, satisfaction and side effects were assessed by multiple-choice questions with room for free-text elaboration.

RESULTS

53.7% of the patients reported to use amitriptyline up to 10 mg/day, 42.9% used a self-increased dose of mostly 20 mg/day, while 3.5% had discontinued treatment. 73.9% of the total study population reported improvement of sleep maintenance, 31.3% improved sleep onset, 35.2% improved daytime fatigue, and 45.8% reported to be (very) satisfied with treatment results. 66.1% reported at least one side effect. The reported side effects were generally the already known side effects of amitriptyline.

CONCLUSION

These patient-reported outcomes support the clinical observations that low dose amitriptyline improves sleep maintenance on the short term and that it is generally well tolerated. This further justifies randomized controlled trials in patients with insomnia disorder and sleep maintenance problems to assess the effectiveness and safety of low dose amitriptyline on the short and long term.

Efficacy and safety of Z-substances in the management of insomnia in older adults: a systematic review for the development of recommendations to reduce potentially inappropriate prescribing

BACKGROUND

Z-drugs are usually prescribed as first line pharmacological therapy for insomnia. However, the benefits and risks of Z-drugs may differ for older adults. This systematic review investigated the available evidence on the efficacy and safety of Z-drugs in the management of insomnia in older adults.

METHODS

The Cochrane database of Systematic Reviews, the Cochrane Central Register of Controlled Trials, PubMed/MEDLINE and EMBASE were searched for systematic reviews, meta-analyses, controlled interventional and observational studies using a pre-formulated search term. The target population was older adults (≥65 years old) with insomnia. Studies were included if they reported efficacy and/or safety outcomes of the use of Z-drugs for the management of insomnia compared to placebo, usual or no treatment, or other pharmacological agents.

RESULTS

Eighteen studies were included (8 interventional and 10 observational studies). In short-term interventional studies, Z-drugs were similarly or better efficacious in improving both sleep and daytime parameters than placebo or other pharmacological treatments, while showing good results on measures of safety. However, in longer-term observational studies, Z-drugs significantly increased the risk for falls and fractures in comparison to no treatment or melatonin agonists.

CONCLUSIONS

Analyzing the evidence from short-term interventional studies, Z-drugs appear effective and safe for treatment of insomnia in older adults, but they may have unfavorable side effects when used for longer periods of time. We, therefore, recommend discontinuing Z-drugs, principally because of the high risk for falls and fractures. Nonetheless, quality and quantity of evidence are low. Due to the scarcity of data, especially concerning drug dependence after longer periods of treatment and due to the significantly increased risk for falls and fractures, further studies are needed to evaluate the benefit-risk profile of Z-drugs use in older patients, particularly for long-term use.

Treatment of Major Depressive Disorder in Japanese Patients with Cancer: A Matched Cohort Study Using Employer-Based Health Insurance Claims Data

BACKGROUND AND OBJECTIVE

Patients with cancer are at high risk of major depressive disorder (MDD), but little is known about their MDD treatment. We investigated the use of antidepressants and other drugs for MDD after cancer diagnosis, and patient characteristics associated with their use.

METHODS

Adults with a new cancer diagnosis were matched to cancer-free patients using a Japanese employee health insurance database (JMDC); this exploratory analysis included only cohort patients diagnosed with MDD between 6 months before and 12 months after the cancer diagnosis index month. Initial prescription frequencies of antidepressants and other MDD medications were compared between cancer and cancer-free groups and analyzed according to age, sex, and hospital characteristics.

RESULTS

Compared with the cancer-free group (n = 4097), significantly fewer patients in the cancer group (n = 1199) were prescribed antidepressants {622 (51.9%) [95% CI 49.0-54.7] vs 2385 (58.2%) [95% CI 56.7-59.7]}, particularly selective serotonin reuptake inhibitors. In contrast, prescription of other medications, especially antipsychotics and anxiolytics (tandospirone, hydroxyzine), was more frequent in the cancer group than in the cancer-free group. In the cancer group, women were prescribed antidepressants (mostly selective serotonin reuptake inhibitors) and other medications (mostly benzodiazepines) more than men. Antidepressant prescription decreased with age; patients aged < 40 years had the highest selective serotonin reuptake inhibitor and the lowest conventional antidepressant prescription rate compared with patients aged 40-64 years and ≥ 65 years. Lower selective serotonin reuptake inhibitor and benzodiazepine prescription rates were seen in large (≥ 100 beds) hospitals and in hospitals where patients received their cancer diagnosis.

CONCLUSIONS

These results suggest Japanese patients with cancer may be undertreated for MDD compared with cancer-free patients. However, when prescribed, medications may be chosen according to patient needs, including avoiding adverse effects and drug-drug interactions.

Non-drug and drug alternatives to benzodiazepines for insomnia in primary care: Study among GPs and pharmacies in a Southwest region of France

OBJECTIVES

Benzodiazepines and related drugs are the most commonly prescribed drugs in the treatment of insomnia, and referral to psychotherapy is rare when recommended as first-line treatment for chronic insomnia. The frequency of referral to psychologists, of use of alternative drugs to benzodiazepines, either prescribed by general practitioners (GPs) or dispensed by community pharmacies, is unknown in France. We aimed to describe the non-pharmacological approaches recommended, such as cognitive behavioral therapies (CBT), and the drugs, including alternatives drugs to benzodiazepines, used by GPs and community pharmacies for patients complaining of insomnia.

METHODS

A cross-sectional study was conducted during 3 months in 2015 on the management of individual GPs' patients and pharmacies' customers consecutively consulting for insomnia in the Midi-Pyrénées region of southwest France. Participating GPs and pharmacists completed a form, for each patient, on their management (drugs, sleeping advices, referral to psychotherapy).

RESULTS

Fifty-five GPs included 263 patients and 43 community pharmacies included 354 customers in the study. Among patients, 193 (73,4%) had already used benzodiazepine. Thirty-eight patients (14.4%) and 2 customers (0.5%) were recommended non-drug therapies (mostly CBT). Benzodiazepines were prescribed 188 times (69.1% of the prescriptions) by GPs. Alternative drugs prescribed were mostly antihistamines (n=26; 9.6%) and antidepressants (n=17; 6.3%). Antihistamines were the most commonly dispensed drugs by pharmacists (n=149; 39.4%).

CONCLUSIONS

While non-pharmacological treatments, such as CBT, are safe and widely recommended, benzodiazepines and antihistamines remain widely used despite the lack of long term benefit and the risk of adverse drug reactions.

Drugs for Insomnia beyond Benzodiazepines: Pharmacology, Clinical Applications, and Discovery

Although the GABAergic benzodiazepines (BZDs) and Z-drugs (zolpidem, zopiclone, and zaleplon) are FDA-approved for insomnia disorders with a strong evidence base, they have many side effects, including cognitive impairment, tolerance, rebound insomnia upon discontinuation, car accidents/falls, abuse, and dependence liability. Consequently, the clinical use of off-label drugs and novel drugs that do not target the GABAergic system is increasing. The purpose of this review is to analyze the neurobiological and clinical evidence of pharmacological treatments of insomnia, excluding the BZDs and Z-drugs. We analyzed the melatonergic agonist drugs, agomelatine, prolonged-release melatonin, ramelteon, and tasimelteon; the dual orexin receptor antagonist suvorexant; the modulators of the α₂δ subunit of voltage-sensitive calcium channels, gabapentin and pregabalin; the H₁ antagonist, low-dose doxepin; and the histamine and serotonin receptor antagonists, amitriptyline, mirtazapine, trazodone, olanzapine, and quetiapine. The pharmacology and mechanism of action of these treatments and the evidence-base for the use of these drugs in clinical practice is outlined along with novel pipelines. There is evidence to recommend suvorexant and low-dose doxepin for sleep maintenance insomnia; there is also sufficient evidence to recommend ramelteon for sleep onset insomnia. Although there is limited evidence for the use of the quetiapine, trazodone, mirtazapine, amitriptyline, pregabalin, gabapentin, agomelatine, and olanzapine as treatments for insomnia disorder, these drugs may improve sleep while successfully treating comorbid disorders, with a different side effect profile than the BZDs and Z-drugs. The unique mechanism of action of each drug allows for a more personalized and targeted medical management of insomnia.

Sleep in older adults: normative changes, sleep disorders, and treatment options

Approximately 5% of older adults meet criteria for clinically significant insomnia disorders and 20% for sleep apnea syndromes. It is important to distinguish age-appropriate changes in sleep from clinically significant insomnia, with the latter having associated daytime impairments. Non-pharmacologic therapies, such as cognitive-behavioral therapy for insomnia, can be highly effective with sustained benefit. Pharmacologic therapies are also available, but may be associated with psychomotor effects. A high index of suspicion is crucial for effective diagnosis of sleep apnea because symptoms commonly noted in younger patients, such as obesity or loud snoring, may not be present in older patients.

Real-world, open-label study to evaluate the effectiveness of mirtazapine on sleep quality in outpatients with major depressive disorder

INTRODUCTION

The objective of this study was to evaluate the effect of mirtazapine on sleep quality in real-world outpatients with major depressive disorder (MDD).

METHODS

Demographic characteristics of MDD outpatients were collected and the Pittsburgh Sleep Quality Index (PSQI) was assessed before and after treatment.

RESULTS

In 3,924 MDD outpatients after treatment, sleep efficiency was significantly higher (P < 0.001), global PSQI score was significantly lower (P < 0.01), the reduction rates of sleep latency (P < 0.01) and global PSQI score (P < 0.001) were notably higher, and the proportion of using sleep medications (P < 0.05) was significantly lower in the mirtazapine group. In 3,455 MDD outpatients with insomnia after treatment, the reduction of sleep latency (P < 0.001), the prolongation of sleep duration (P < 0.001), and the increase in habitual sleep efficiency (P < 0.001) were more obvious, the reduction rates of sleep latency (P < 0.05) and global PSQI score (P < 0.001) were significantly higher, and the proportion of using sleep medications (P < 0.001) was significantly lower in the mirtazapine group. In 469 MDD outpatients without insomnia after treatment, the reduction of sleep latency (P < 0.05), the increase in sleep duration (P < 0.001) and habitual sleep efficiency (P < 0.001), and the reduction rate of global PSQI score (P < 0.05) were significantly greater in the mirtazapine group.

DISCUSSION

This real-world study suggests that mirtazapine improves sleep quality of MDD outpatients, and decreases the concomitant use of sleep medications.

GPs' management strategies for patients with insomnia: a survey and qualitative interview study

BACKGROUND

Patients frequently experience sleep problems and present to primary care. However, information is limited regarding the management strategies that GPs employ.

AIM

To gain an understanding of current GP management strategies for insomnia.

DESIGN AND SETTING

A postal questionnaire survey and qualitative interviews with GPs in the south of England.

METHOD

A postal survey of 296 GPs and qualitative interviews were carried out with 23 of the GPs.

RESULTS

The survey response rate was 56% (166/296). GPs look for signs of depression and anxiety in patients and if present treat these first. 'Sleep hygiene' advice is provided by 88% (147/166) of GPs but often seems insufficient and they feel under pressure to prescribe. Benzodiazepines and Z drugs are prescribed, often reluctantly, for short periods, because of known problems with dependence and tolerance. Many GPs prescribe low-dose amitriptyline for insomnia although it is not licensed for this indication. For insomnia 95% (157/166) of survey responders 'ever prescribe' amitriptyline, with 31% (52/166) stating they do so commonly. Most GPs perceived amitriptyline to be effective and a longer-term option for those with ongoing sleep problems. GPs report a lack of knowledge and confidence in the provision and use of psychological therapies, such as cognitive behavioural therapy (CBT), in the management of insomnia.

CONCLUSION

GPs often find 'sleep hygiene' advice is insufficient for managing insomnia and report frequently prescribing medication, including amitriptyline (off licence), which is often based on perceived patient pressure for a prescription. Patients are rarely offered psychological therapies such as CBT for insomnia, despite evidence suggesting its potential effectiveness.

Controversies in the use of second generation antipsychotics as sleep agent

A growing number of patients present in clinics with complaints of insomnia. Over the past century, great advances have been made in our knowledge of mechanisms of sleep and wakefulness. Understanding sleep neurochemistry has led to better management of different types of insomnias with a variety of non-pharmacological and pharmacological treatments. Unfortunately, the increasing development and availability of second generation antipsychotics (SGA) have prompted their frequent use exclusively for insomnia. However, to date, no large randomized-controlled or placebo-controlled studies have shown the utility of SGAs in the realm of treating insomnia. Many clinicians use SGAs as "off-label" for sleep induction and maintenance, but this practice needs to be readdressed given their potential risks and the current lack of evidence base. This review will highlight the neurochemistry related to sleep, the mechanisms of action by which SGA may have some benefit in treating insomnia, and the risks associated with their utilization.

Biochemical basis of circadian rhythms and diseases: With emphasis on post-traumatic stress disorder

Circadian rhythms affect several processes in the body physiology. This commentary revisits the topic of 'metabolic basis of diseases' with a view to shed light on how cellular energy requirements feed-forward to a sequential signaling of hormonal response, blood glucose metabolism, antioxidant activities, and pathophysiology. Attempt is made to explain how diseases that may not appear to be closely related, such as bone metabolism and vasculopathy, have an increase in oxidative damage as a common underlying biochemistry. Importantly, this article identifies oxidative damage as an outcome of sleep disturbance and hypothesize that sleep complaint is not merely one of many resulting symptoms of PTSD, but a core feature that arise from trauma and gives rise to the stress biochemistry, which in turn manifests symptomatically. Further, we suggest that the current non-pharmacologic and pharmacologic therapeutic options attenuate oxidative stress. Implication for clinical diagnosis and evaluations is also suggested.

Sleep in dementia and caregiving--assessment and treatment implications: a review

BACKGROUND

The increasing prevalence of dementia will precipitate a significant burden in terms of the costs of caring for people with dementia over the next 30 years; sleep disturbances in dementia are an important factor contributing to this burden.

METHODS

We reviewed sleep disturbances in people with dementia and their carers and describe the various diagnostic, assessment and treatment strategies available to physicians in the management of this clinically significant problem.

RESULTS

Sleep disturbances in people with dementia and their carers (i) are highly prevalent; (ii) impact significantly on quality of life of both people with dementia and their carers; (iii) increase the rate of cognitive decline; and (iv) accelerate the breakdown of community-based care. The training of physicians in the assessment and treatment of sleep disturbances in dementia and caregiving is scant despite a wide range of assessment strategies and treatment approaches, which comprise both pharmacological (including hypnotic/sedative medications) and non-pharmacological approaches (including: environmental; psychobehavioral; exercise and activity; and multi-component interventions). Specific diagnostic criteria for sleep disturbances in people with dementia and their carers remain lacking despite established criteria for general insomnia. Further to this, proposed changes to diagnostic criteria for DSM-V do not include a specific focus for the diagnosis and management of sleep disturbances in people with dementia or their carers.

CONCLUSIONS

This review suggests that the improved training of physicians to meet the needs of these vulnerable groups of older people is a priority, especially in the context of a rapidly increasing demand for accurate, early diagnosis and efficient management of sleep disturbance in these groups.

Zolpidem-induced changes in activity, metabolism, and anxiety in rats

Gamma aminobutyric acid (GABA)-A receptor modulators constitute the majority of clinically relevant sedative-hypnotics. Zolpidem (Ambien) is a nonbenzodiazepine GABA-A receptor modulator that binds with high affinity to GABA-A receptors expressing alpha-1 subunits. The present study examined the effects of a new approach to the oral administration of zolpidem on locomotor activity, body weight, food intake, relative food intake, feed efficiency, anxiety, and visceral adiposity in rats. Effects of withdrawal associated with cessation of the drug were also recorded. A daily chronically administered oral 10 mg/kg dose of zolpidem caused a decrease in locomotor activity, an increase in food intake and relative food intake, and a more positive feed efficiency during the drug-administration period. Anxiety and visceral adiposity also increased in animals receiving the drug. During withdrawal of zolpidem, there was a decrease in body weight, food intake, relative food intake, and anxiety, as well as a negative feed efficiency. These results suggest that zolpidem can modulate locomotor activity, metabolism, and anxiety-related behavior. A highly positive feed efficiency and increased visceral adiposity associated with zolpidem intake were unique findings of this study.

Long-term misuse of zopiclone in an alcohol dependent woman with a history of anorexia nervosa: a case report

INTRODUCTION

The Z-drugs, zaleplon, zopiclone and zolpidem, are short-acting hypnotics which act at the same receptor as the benzodiazepines, but seemingly without the potential for misuse and the development of dependence of the older benzodiazepines. However, with increased prescribing of Z-drugs, reports of misuse and possible dependence began to appear in the literature, particularly in people with a history of substance misuse and comorbid psychiatric illness. Here we report the case of a woman with a history of chronic zopiclone use and anorexia nervosa, admitted for alcohol detoxification.

CASE PRESENTATION

A 31-year old Caucasian British woman with a history of long-term zopiclone use and anorexia nervosa was admitted as an inpatient for a ten-day alcohol detoxification. Her weekly (four days out of seven) intake of alcohol was 180 units and her daily intake of zopiclone, 30 mg. Apart from a short period five years ago, she had been taking zopiclone for 13 years at daily doses of up to 90 mg. She admitted to using 'on top' of her prescribed medication, purchasing extra tablets from friends or receiving them gratis from her partner. After detoxification from alcohol and zopiclone, she was prescribed diazepam which she found ineffectual and voiced her intention of returning to zopiclone on leaving the hospital.

CONCLUSION

Zopiclone is generally regarded as safer than benzodiazepines, however, this particular individual, who was using high doses of zopiclone over many years, may provide further evidence of a risk of dependency when this drug is prescribed for substance users with a comorbid psychiatric illness.

Critical appraisal of ramelteon in the treatment of insomnia

Ramelteon is the first member of a novel class of hypnotics and acts as a selective melatonin receptor agonist. In 2005, ramelteon was approved by the US Food and Drug Administration for the treatment of insomnia characterized by sleep onset problems. Its unique mechanism of action made it a promising candidate compared with the widely used hypnotics that act on the benzodiazepine receptor complex. Several studies have examined its efficacy and safety as a hypnotic agent. The primary efficacy of ramelteon was found to lie in a decrease in latency to persistent sleep, as measured by polysomnographic tests. Other sleep-related measures, such as total sleep time and number of nightly awakenings, show less pronounced improvement when treated with ramelteon. In addition, no rebound insomnia or abuse potential was observed in clinical studies. Although additional studies are necessary, current data on the acute and next-morning effects of ramelteon did not indicate cognitive or psychomotor impairment. Overall, ramelteon is safe and well tolerated, although some questions remain regarding its long-term efficacy and safety. These issues and possibilities for use in other patient groups should be addressed in future research.