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Digital PharmD

Informatics in Pharmacy

Sleep Disturbances

August 13, 2018 By Dr. G, PharmD

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Lifestyle Modifications:

  • Maintain sleep schedule
  • Do not go to bed unless tired
  • Sleep long enough, but not too much
  • Optimize bedroom lighting, temp and sound
  • Develop a ritual
  • Do not stay in bed for more than 15 minutes if you can’t sleep
  • Don’t go to bed hungry.
  • Only use the bedroom for sleep
  • Avoid naps
  • Avoid stimulants
  • Avoid alcohol
  • Exercise regularly, but not close to bedtime.

BZDs used for sleep are effective and generally well tolerated. Not considered first line because of potential of dependance, decreased REM, risk of angioedema and psychosis.

BenzodiazepineOnset of ActionPeak OnsetHalf-life parent (hrs)Half-life metabolite (hrs)Comparative Oral Dose
Long Acting
FlurazepamRapid0.5-2inactive47-10030 mg
Intermediate  Acting
 TemazepamSlow 0.75-1.510-20– 30mg
Short Acting
TriazolamInt.0.75-21.6-5.5–0.5mg

Sleep aids:

MedicationSleep onsetSleep maintenanceCyp interactionsNotes
ramelteon (Rozerem)X  Melatonin agonist, hepatic concerns
Do not use with fluvoxamine
tasimelteon (Hetlioz)   Also for non-24, melatonin agonist
eszopiclone (Lunesta)X 3A4 substrateGaba agonist, Decrease dose with 3A4 inhibitors
zaleplon (Sonata)X  Gaba agonist
zolpidem (Ambien)X 3A4 substrateGaba agonist
Decrease dose in women, with 3A4 inhibitors
in older patients
-zolpidem (Edular SL tablet)X 3A4 substrate 
-zolpidem (Zolpmist SL spray)X 3A4 substrate 
-zolpidem (Ambien XR)X 3A4 substrateMust have 4-8 hours of planned sleep.
-zolpidem (Intermezzo SL tablet) X3A4 substrate 
doxepin (Silenor) X Especially good for elderly or depressed.
Do not give with MAOIs
melatoninX  Especially good for elderly.
suvorexant (Belsoma)X 3A4 / 2C9Decrease digoxin dose.
mirtazapine   Good in depression.
     
  • Depressed patients: mirtazapine, dozepin +/- trazodone
  • Older patients: doxepin, melatonin, ramelteon

Here’s a chart I copied with adverse effects of various sleeping aids, but I didn’t write down where it was from.

Filed Under: Explore, Guideline Materials and Tips, Psychiatry

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acid base acidosis acute coronary syndrome alkalosis analgesics anaphylaxis aortic dissection arrhythmia Beta-Blockers biostatistics blood pressure cardiac markers CHA2DS2-VasC cocaine COVID-19 diabetes diabetes inspidius Guidelines heart failure Heparin hypersensitivity hypertension hypovolemic shock intubation ionotropes journal club lipids LMWH medication safety morphine conversions myocardial infarction needs work NOAC NSTEMI obstructive shock pharmacoeconomics pheochromocytoma pressors reference materials right mi sedation septic shock shock STEMI Updated 2020