Over-the-Counter Agents for the Treatment of Occasional Disturbed Sleep or Transient Insomnia: A Systematic Review of Efficacy and Safety

The use of prolonged-release melatonin in circadian medicine: a systematic review

INTRODUCTION

Melatonin, a hormone produced by the pineal gland, regulates the sleep-wake cycle and is effective in restoring biological rhythms. Prolonged-release melatonin (PRM) is designed to mimic the natural physiological pattern of melatonin release. In circadian medicine, PRM can be used to treat sleep and circadian rhythm disorders, as well as numerous organic diseases associated with sleep disorders.

EVIDENCE ACQUISITION

This systematic review analyzed 62 studies and adhered to the PRISMA guidelines, examining the effectiveness of PRM in organic pathologies and mental disorders.

EVIDENCE SYNTHESIS

The main evidence concerns primary insomnia in subjects over the age of 55, showing significant improvements in sleep quality. In neurodevelopmental disorders, there is evidence of a positive impact on sleep quality and quality of life for patients and their caregivers. PRM shows efficacy in the treatment of sleep disorders in mood disorders, schizophrenia, and neurocognitive disorders, but requires further confirmation. The additional use of PRM is supported for the withdrawal of chronic benzodiazepine therapies. The tolerability and safety of PRM are excellent, with ample evidence supporting the absence of tolerance and dependence.

CONCLUSIONS

Overall, PRM in circadian medicine is an effective chronopharmaceutical for restoring the sleep-wake rhythm in patients with insomnia disorder. This efficacy may also extend to sleep disorders associated with mood, neurodevelopmental and neurocognitive disorders, suggesting a further potential role in insomnia associated with various organic diseases.

Insomnia: A Current Review

Insomnia is a prevalent sleep disorder with pervasive effects on quality of life. The deleterious effects of insomnia are largely preventable with appropriate therapeutic interventions. Pharmacotherapy should be initiated in patients with inadequate response to CBT-I and tailored to comorbidities. Referral to a sleep medicine specialist should be considered in patients with a suboptimal response.

Complementary and alternative treatments for insomnia disorder: a systematic umbrella review

Insomnia is a common disorder and cognitive behavioural therapy for insomnia (CBT-I) is recommended as first-line treatment. However, CBT-I is not widely distributed and infrequently available while medication is not indicated for long-term use. To close this evident gap in supply, alternative treatments could be utilised. High-quality research on this topic is scarce, and there is currently no comprehensive publication on the effectiveness of alternative treatments. To address this pressing question, we systematically summarised the existing research on alternative treatments for insomnia. A comprehensive search of systematic reviews and (network) meta-analyses of randomised controlled trials investigating the efficacy of alternative treatments compared to waiting-list control or placebo in adults with insomnia disorder with or without comorbidities was conducted in PubMed, MEDLINE, PsycInfo, and PsycArticles on December 6, 2022, yielding 391 records. Finally, 15 eligible studies were included. Evidence on acupuncture, exogenous melatonin, mind-body interventions and exercise, repetitive transcranial magnetic stimulation (rTMS), valerian, and light exposure was found. Acupuncture, rTMS and mind-body exercises significantly improved sleep quality and insomnia severity but effects on objectively assessed outcomes were inconclusive. Melatonin led to a reduction in both self-reported and objectively assessed sleep onset latency. Light exposure and valerian did not significantly improve sleep outcomes. Overall, the quality of studies was rated as low. Results indicate that alternative treatments are effective mostly on subjective outcomes. However, evidence on the efficacy of some intervention types is sparse and there is a need for high-quality original studies. Future research could investigate whether combining different alternative treatment aspects with CBT-I improves individual treatment.

Efficacy and safety of pharmacotherapy in chronic insomnia: A review of clinical guidelines and case reports

Introduction

Chronic insomnia affects 5% to 10% of the US population, increasing the demand for treatment options and the corresponding research to prove their validity.1 This review compares recommendations from 3 clinical guidelines and summarizes hypnotic medications, including their newly reported side effects not mentioned in the guidelines. In addition, we aim to provide an overview of what pharmacotherapies are available for prescribers and patients.

Methods

A literature search was conducted for articles published prior to January 10, 2022, and case reports and clinical studies were retrieved from PubMed and Google Scholar.

Results

Definitive conclusions cannot be drawn regarding the safety and efficacy of medications reviewed; however, trends are apparent. All 3 guidelines included in this review remarked most treatment recommendations as weak except for cognitive behavioral therapy for insomnia, which is effective but not readily available. Furthermore, based on the 15 case reports and 13 clinical studies presented in this review, many of the medications used for treatment of insomnia present safety concerns.

Discussion

Benzodiazepines and benzodiazepine receptor agonists are commonly used hypnotic agents with the "Z-drugs" having robust data establishing their efficacy for the short-term treatment of chronic insomnia. However, significant adverse effects related to the central nervous system (CNS), including developing tolerance, addiction, CNS depression, and amnesia, remain barriers to their long-term use. In comparison, newer agents present more favorable side-effect profiles although with less established efficacy. Additionally, off-label agents, including antidepressants, antihistamines, and natural supplements, are discussed due to their prominent use.

Improving sleep health management in primary care: A potential role for community nurses?

AIMS

To explore community nurses sleep health practices and their perspectives on improving sleep health care provision.

DESIGN

An exploratory study utilizing the qualitative description methodology.

METHODS

Semi-structured interviews were conducted with community nurses from May 2019 - October 2021. Interviews were audio-recorded, transcribed, and subjected to an inductive thematic analysis using a constructivist-interpretive paradigm.

RESULTS

Twenty-three Australian community nurses were interviewed. Participants frequently encountered sleep disturbances/disorders in their patients. Data analysis yielded three main themes: (1) Sleep health in the community serviced, (2) sleep health awareness and management, and (3) community nurses' A to Z of improving sleep health. The most common sleep disorder presentations were insomnia and sleep apnea. Although most community sleep apnea cases were appropriately managed, insomnia was often mismanaged. Participants described their sleep health knowledge as deficient, with the majority advocating for increased sleep-related education tailored to their profession. Other important factors needed for improving sleep health provision were standardized patient treatment/referral pathways, increased interprofessional collaboration, and sufficient time for patient consults.

CONCLUSION

Community nurses service a patient population that requires increased sleep health care. However, they are currently underequipped to do so, leading to suboptimal treatment provision. Providing community nurses with the appropriate resources, such as increased sleep-related education and standardized treatment frameworks, could enable them to better manage sleep disturbance/disorder presentations, such as insomnia.

IMPACT

Little is known about how community nurses care for patients with sleep disturbance/sleep disorders. This study found that contemporary sleep health care was lacking due to knowledge deficits, competing challenges, and a need for standardized care pathways. These findings can inform the development of targeted education/training and standardized guidelines for community nurses providing sleep health care to patients as well as the design of future practice models of care provision.

PATIENT OR PUBLIC CONTRIBUTION

Previous research by authors has involved extensive engagement with patients and health professionals, such as community pharmacists, general practitioners, and naturopaths who play a role in sleep health in the primary health care sector. These previous research projects built a significant understanding of the patient and health practitioner experience and have provided the background to the concept and design of this study.

Prevalence and Risk Factors of Insomnia and Sleep-aid Use in Emergency Physicians in Japan: Secondary Analysis of a Nationwide Survey

INTRODUCTION

Emergency physicians (EP) are suspected to have a high prevalence of insomnia and sleep-aid use. Most prior studies about sleep-aid use in EPs have been limited by low response rates. In this study our aim was to investigate the prevalence of insomnia and sleep-aid use among early-career Japanese EPs and assess the factors associated with insomnia and sleep-aid use.

METHODS

We collected anonymous, voluntary, survey-based data regarding chronic insomnia and sleep-aid use from board-eligible EPs taking the initial Japanese Association of Acute Medicine board certification exam in 2019 and 2020. We describe the prevalence of insomnia and sleep-aid use and analyzed demographic and job-related factors using multivariable logistic regression analysis.

RESULTS

The response rate was 89.71% (732 of 816). The prevalence of chronic insomnia and sleep-aid use was 24.89% (95% CI 21.78-28.29%) and 23.77% (95% CI 20.69-27.15%), respectively. Factors associated with chronic insomnia were long working hours (odds ratio [OR] 1.02, 1.01-1.03, per one-hour/week), and "stress factor" (OR 1.46, 1.13-1.90). Factors associated with sleep-aid use were male gender (OR 1.71, 1.03-2.86), unmarried status (OR 2.38, 1.39-4.10), and "stress factor" (OR 1.48, 1.13-1.94). The "stress factor" was mostly influenced by stressors in dealing with patients/families and co-workers, concern about medical malpractice, and fatigue.

CONCLUSIONS

Early-career EPs in Japan have a high prevalence of chronic insomnia and sleep-aid use. Long working hours and stress were associated with chronic insomnia, while male gender, unmarried status, and stress were associated with the use of sleep aids.

Exploring the Prevalence and Patterns of Use of Sleep Aids and Stimulants Among Emergency Physicians and EMS Providers in Saudi Arabia

Purpose

This study explores the prevalence and patterns of the use of pharmacologic sleep aids and stimulants among Saudi Arabia’s emergency physicians (EPs) and emergency medical services (EMS) providers.

Patients and Methods

We adopted a descriptive, cross-sectional design. To collect data on the types and frequencies of sleep aids and stimulants used, we distributed a semi-structured, anonymous, web-based questionnaire to registered EPs, paramedics, and emergency medicine technicians (EMTs) in the Saudi Commission for Health Specialties. An internal consistency analysis showed good reliability (Cronbach’s alpha=0.667) of the questionnaire. A subscale analysis confirmed the results—alpha values were 0.720 and 0.618 for the use of sleep aids and stimulants, respectively.

Results

Males and females represented 81.8% and 18.2%, respectively, of the valid sample of 669 participants. Respondents aged 25–34, 35–44, and 45–55 years represented 51.9%, 32.7%, and 10.2% of the sample, respectively. Results showed that a majority of the respondents (67.1%) used stimulants. Caffeine was the most common stimulant; caffeine and energy drinks were used by 65.9% and 17.2% of the respondents, respectively. Caffeine, energy drinks, nicotine, and ephedrine were used by 65.9%, 17.2%, 18.5%, and 17.3% of the respondents, respectively. The respondents who used at least one sleeping aid and those using only one and two sleeping aids accounted for 36.6%, 15.6%, and 9.7%, respectively. The most common sleeping aids antihistamines and marijuana were used on most days by 13.4% and 13.3% of the respondents, respectively. The average monthly number of night shifts (P = 0.025) significantly influenced sleep aid use. Respondents working in night shifts for 3–5 months or more than 7 days were more likely to use sleeping aids.

Conclusion

Future research should enhance health workers’ knowledge of the efficacy and safety of these medications and guide strategies to organize and reduce night shift work.

Sleep medication use and incident dementia in a nationally representative sample of older adults in the US

BACKGROUND

Sleep difficulties are common among older adults, and clinical management of sleep difficulties commonly includes sleep medication (pharmacological and non-pharmacological). Our research examines sleep medication use and incident dementia over 8 years using nationally representative data from older adults ages 65 years and older in the United States.

METHODS

We used data collected from the National Health and Aging Trends Study (NHATS), a nationally-representative longitudinal study of Medicare beneficiaries. Routine sleep medication use (pharmacological and non-pharmacological) was defined as use "most nights" or "every night." Participants were screened for dementia with validated instruments that assessed memory, orientation, and executive function. We conduct prospective analyses to examine the relationship between routine sleep medication use and incident dementia using Cox proportional hazards modeling and estimated survival curves. Analyses controlled for age, sex, marital status, education, and chronic conditions.

RESULTS

Among respondents at baseline (n = 6373), most participants (21%) were age 70-74 years of age. Participants were 59% female and the sample comprised non-Hispanic White (71%). At baseline, 15% of our study sample reported using sleep medication routinely, which is representative of 4.6 million older adults in the US. Covariate adjusted proportional hazard models revealed that routinely using sleep medication was associated with incident dementia (HR = 1.30, 95%CI: 1.10 to 1.53, p < 0.01).

CONCLUSIONS

Our study observed, in a nationally representative study of older adults in the US across 8 years of data that 15% of older adults report routinely using sleep medication, yet routine use of sleeping medication was associated with incident dementia across the follow-up interval. Future research may examine behavioral approaches to improving sleep among older adults.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

Comparative effectiveness and safety of pharmacological and non-pharmacological interventions for insomnia: an overview of reviews

BACKGROUND

This review aimed to assess the existing evidence regarding the clinical effectiveness and safety of pharmacological and non-pharmacological interventions in adults with insomnia and identify where research or policy development is needed.

METHODS

MEDLINE, Embase, PsycINFO, The Cochrane Library, and PubMed were searched from inception until June 14, 2017, along with relevant gray literature sites. Two reviewers independently screened titles/abstracts and full-text articles, and a single reviewer with an independent verifier completed charting, data abstraction, and quality appraisal.

RESULTS

A total of 64 systematic reviews (35 with meta-analysis) were included after screening 5024 titles and abstracts and 525 full-text articles. Eight of the included reviews were rated as high quality using the Assessment of Multiple Systematic Reviews 2 (AMSTAR2) tool, and over half of the included articles (n = 40) were rated as low or critically low quality. Consistent evidence of effectiveness across multiple outcomes based on more than one high- or moderate quality review with meta-analysis was found for zolpidem, suvorexant, doxepin, melatonin, and cognitive behavioral therapy (CBT), and evidence of effectiveness across multiple outcomes based on one high-quality review with meta-analysis was found for temazepam, triazolam, zopiclone, trazodone, and behavioral interventions. These interventions were mostly evaluated in the short term (< 16 weeks), and there was very little harms data available for the pharmacological interventions making it difficult to evaluate their risk-benefit ratio.

CONCLUSIONS

Assuming non-pharmacological interventions are preferable from a safety perspective CBT can be considered an effective first-line therapy for adults with insomnia followed by other behavioral interventions. Short courses of pharmacological interventions can be supplements to CBT or behavioral therapy; however, no evidence regarding the appropriate duration of pharmacological therapy is available from these reviews.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42017072527.

[Acute insomnia: natural course and correction modalities]

The review describes general patterns of the development of acute (short-term) insomnia, its occurrence and course with the risk of transition to chronic insomnia. Main approaches for pharmacological and psychotherapeutic correction of acute insomnia needed to prevent chronification are indicated. The author suggests an algorithm for the treatment of acute insomnia taking into account its staging.

A combination of Eschscholtzia californica Cham. and Valeriana officinalis L. extracts for adjustment insomnia: A prospective observational study

Eschscholtzia californica Cham. and Valeriana officinalis L. have long been used for the management of sleep disorders and anxiety. Use of a fixed combination of these two plant extracts (Phytostandard® d’Eschscholtzia et de Valériane, PiLeJe Laboratoire, France) was investigated in an observational study. Adults with adjustment insomnia according to the criteria of the International Classification of Sleep Disorders and with an insomnia severity index (ISI) score >7 enrolled by GPs took a maximum of four tablets of the eschscholtzia and valerian combination every night for four weeks. Within one month, ISI score decreased by approximately 30% (from 16.09 ± 3.67 at inclusion (V1) to 11.32 ± 4.78 at 4 weeks (V2); p < 0.0001). Night sleep duration significantly increased between the first and the fourth week of supplement intake, sleep efficiency increasing from 78.4% ± 12.5 to 84.6% ± 10.2 (p = 0.002). There was no improvement in sleep latency. The number of awakenings decreased by approximately 25% and their total duration by approximately 25 min. Anxiety score significantly decreased by 50% from 13.9 ± 7.3 at V1 to 6.7 ± 6.3 at V2 (p < 0.0001). The supplement was well tolerated. These results suggest that the tested combination of eschscholtzia and valerian extracts could be beneficial for the management of insomnia in adults and deserves further investigation.

Treating psychiatric symptoms and disorders with non-psychotropic medications

A few drugs prescribed in internal medicine, ie, non-psychotropic drugs, can be used to treat certain neuropsychiatric disorders. For most of these situations, the level of evidence remains low. But when sufficient data becomes available, these molecules are then included in official guidelines for the treatment of neuropsychiatric disorders. In this article we review interesting drugs which may be relevant from an evidence-based medicine point of view, and could become part of psychiatric practice in the future.
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Medicated or not medicated hypnotic substance use: strategies in sleep disorders among patients of community pharmacy

The principal outcome was to identify which hypnotics substances, medicated (benzodiazepines, antihistamine, antidepressant…) or not medicated (herbal medicine, homeopathy, melatonin…), were consumed by community pharmacy patients who reported taking something for sleep disorder, and which factors can influence the consumption of medicated substance rather than nonmedicated substance. Data were collected via a network of 73 partner pharmacies around Nantes, France. Patients who reported taking a substance to sleep completed a questionnaire that collected data relative to the different substances consumed by that person for sleep, and the desired effect. Substances were classified in Hypnotic Drug Substances and nonmedicated hypnotic substances. A logistical regression was done in order to highlight the factors associated with the consumption of Hypnotic Drug Substance rather than nonmedicated hypnotic substances. Six hundred and forty-seven patients were included, with an average age of 58 years and 74% female. The principal strategy employed to combat sleep disorder was the consumption of Hypnotic Drug Substance (54%), followed by herbal medicine (32%) and homeopathy (19%). The factors positively associated with the consumption of a Hypnotic Drug Substance are age, living alone, being out of work, or in the process of looking for a job and being a parent. In our survey, the use of Hypnotic Drug Substance to help patients with sleep is far from systematic. On the other hand, among patients who consume HDS, misuse is still significant, particularly in terms of the duration of consumption.

A Phase I Study of the Pharmacokinetics and Pharmacodynamics of Intranasal Doxylamine in Subjects with Chronic Intermittent Sleep Impairment

Introduction

Doxylamine tablets are approved as an over-the-counter sleep aid. We developed a doxylamine succinate intranasal metered-dose delivery system with the expectation of a more rapid onset of action with reduced side-effect potential compared with the oral tablet.

Methods

This phase I study randomized 24 adults with chronic intermittent sleep impairment to receive either single doses of intranasal doxylamine succinate 3.2, 6.3, or 12.7 mg or doxylamine succinate 25-mg oral tablet. Doxylamine pharmacokinetics were assessed using noncompartmental methods; pharmacodynamics were evaluated using the Karolinska Sleepiness Scale (KSS) and numerous psychomotor tests. Adverse events (AEs) were monitored.

Results

None of the intranasal dose levels produced a mean maximum plasma concentration (C_max) above the 50 ng/mL target level or a time to maximum concentration shorter than that of the oral tablet. At the highest intranasal dose, C_max and area under the doxylamine concentration–time curve were approximately 25% of the values achieved with the oral dose. Variation in most pharmacokinetic parameters was higher with intranasal compared with oral dosing. A relationship between plasma doxylamine concentration and KSS change from baseline was evident for the 25-mg tablet and, to a lesser extent, for the 12.7-mg intranasal dose. Changes from baseline in psychomotor parameters did not show a relationship to intranasal dose, and did not distinguish between intranasal versus oral dosing. The most common AEs with intranasal dosing were nasal congestion, nasal dryness, and frontal headache.

Conclusion

The nasal spray did not increase doxylamine absorption or systemic bioavailability compared with the oral tablet.

Managing sleep problems using non-prescription medications and the role of community pharmacists: older adults' perspectives

OBJECTIVES

To examine older adults' perspectives regarding managing sleep problems through selection and use of non-prescription sleep aids, and the role of pharmacists.

METHODS

Telephone interviews were conducted from May to June 2015 with 116 individuals aged ≥60 years in Pittsburgh, Pennsylvania. Participants reported in a previous survey to have used at least one non-prescription sleep aid in the past 30 days and were willing to participate in a follow-up interview. Interview guides were designed to elicit perspectives of sleep problems, selection and use of non-prescription sleep aids, and consultation with healthcare professionals. Interview transcripts underwent content analysis.

KEY FINDINGS

Four themes emerged as follows: experiences with sleep problems, selection of non-prescription sleep aids, non-prescription sleep aid use and interactions with healthcare professionals. Over half of participants reported using a non-prescription sleep aid for >1 year, were satisfied with its use and perceived it improved sleep quality. Participants commonly used an antihistamine-only sleep aid; 36% of participants self-recommended their sleep aid; and 16% of participants consulted healthcare professionals. Few participants read medication dosage labels (22%), side effects or warnings (19%), and many reported they disregarded directions. Participants did not typically consult pharmacists about sleep problems (65%) but perceived that they could assist with medication concerns.

CONCLUSIONS

Although most participants had favourable perceptions of non-prescription sleep aids, older adults may be inappropriately using non-prescription sleep aids to self-manage sleep problems by frequently disregarding medication labels and directions for safe use. Also, few older adults are discussing their sleep aid selection and use with pharmacists.