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continuing education Management of Insomnia By Ariane Conrad, PharmD U pon successful completion of this article, the pharmacist should be able to: 1. Describe the characteristics and signifi- cance of insomnia. 2. identify the goals of therapy for the man- agement of insomnia. 3. Describe the non-pharmacological techniques recom- mended for the management of insomnia. 4. Describe the medications and their typical dosages, due, at least in part, to underreporting of symptoms to their physicians. insomnia has been estimated to be associated with high health care utilization costs. Direct and indirect costs of chronic insomnia were estimated to be $10 billion annually in 2005. As insomnia is often associated with complaints due to another disease state, it is difficult to separate the costs as- sociated with insomnia alone. However, it has been clinically significant or commonly encountered side ef- shown that people with insomnia have higher rates fects and drug interactions. of psychiatric illness, drug and alcohol abuse, and 5. Provide counseling points to provide to patients about cardiac morbidity, which can lead to an increase in therapy for insomnia. overall utilization of health care resources. INTRODUCTION INSOMNIA DESCRIPTION insomnia is the most common sleep complaint among insomnia is a disorder characterized by any of the Americans. Poor sleep quality and quantity can impact following symptoms: difficulty initiating sleep, dif- daytime functioning, and these effects extend beyond the ficulty maintaining sleep, waking too early, or inability patient. Work and personal obligations may suffer when sleep to achieve restorative sleep with associated func- is disrupted. According to the 2008 Sleep in America Poll, tional impairment during the day. insomnia is classi- 65 percent of the survey respondents reported having sleep fied as primary (idiopathic) or secondary (comorbid). problems at least a few nights a week within the past month, Primary insomnia is a diagnosis that is made after with 44 percent having all other potential causes have been excluded. Useful Web Sites problems every night or al- Secondary insomnia is attributable to another medi- most every night. the most cal condition or the adverse effects of medications. ■ www.aasmnet.org common complaints were insomnia is further classified as acute or chronic Web site for the American Academy of waking up unrefreshed (49 based on the duration of symptoms. Acute insomnia Sleep Medicine. It contains patient-cen- percent), waking during the generally lasts fewer than 30 days, and can usu- tered information and provides links to other sites for more information on sleep night (42 percent), waking ally be associated with an acute life stress or crisis, and sleep disorders. up too early and being un- environmental factors, acute illness, or medications. ■ www.sleepfoundation.org able to go back to sleep (29 chronic insomnia lasts for more than 30 days and Web site for the National Sleep Founda- percent), and difficulty fall- is commonly associated with chronic medical and tion. It contains patient-centered informa- ing asleep (26 percent). in- psychiatric conditions. Most patients will develop tion regarding sleep topics along with terestingly, only 15 percent chronic intermittent insomnia, experiencing sleep information about treatment options for of the survey respondents problems for several nights followed by a problem- sleep disorders. The site also provides in- reported having been diag- free period before the symptoms return. formation geared toward educating health nosed with a sleep disorder the prevalence of chronic insomnia has been professionals about sleep disorders. by a physician. this is likely reported to be higher in women and older adults. 44 america’s Pharmacist | September 2009 www.americaspharmacist.net table 1: international classification of Sleep Disorders Alcohol abuse, nicotine use, and the use of Diagnostic criteria certain medications are also associated with an increased prevalence of insomnia. other A. A complaint of difficulty initiating sleep, difficulty maintaining sleep, or waking up too early, or sleep that is chronically risk factors identified include psychiatric illness, nonrestorative or poor in quality medical comorbidities, impaired social relation- B. The above sleep difficulty occurs despite adequate opportunity and circumstances to sleep ships, chronic stress, lower socioeconomic C. At least one of the following forms of daytime impairment related status, separation from a spouse or significant to the nighttime sleep difficulty is reported by the patient: other, and unemployment. 1. Fatigue or malaise 2. Attention, concentration, or memory impairment 3. Social or vocational dysfunction or poor school EVALUATION performance 4. Mood disturbance or irritability there are several classification systems avail- 5. Daytime sleepiness able to diagnose insomnia. Many clinicians 6. Motivation, energy, or initiative reduction use the international classification of Sleep 7. Proneness for errors/accidents at work or while driving 8. Tension, headaches, or gastrointestinal symptoms in Disorders general criteria for insomnia to make response to sleep loss the diagnosis. (See table 1.) A comprehen- 9. Concerns or worries about sleep sive sleep history should be obtained before insomnia can be diagnosed. this sleep his- tory should cover specific insomnia complaints, concentration and memory. this will often interfere with the pre-sleep conditions, sleep-wake patterns, any ability to perform daily activities, which may affect inter- other sleep-related symptoms, and any daytime personal relationships and work productivity. Many people consequences. comorbid medical conditions suffering from chronic insomnia will experience increased and medication usage must be evaluated in absenteeism from work, increased risk of psychiatric disor- detail to identify any possible contributing fac- ders, impaired cognition, and an overall negative quality of tors. (See tables 2 and 3.) Physical examination life. they have also been shown to have higher rates of drug and laboratory testing are not necessary to make and alcohol abuse and cardiac morbidity. People suffering the diagnosis of insomnia. However, this type of from sleep deprivation have been shown to be at an in- evaluation should be performed to identify any creased risk of driving accidents and decreased productivity secondary causes for insomnia such as obstruc- at work. According to the Sleep in America Poll, 32 percent of tive sleep apnea and thyroid dysfunction. all of the respondents reported that they have driven drowsy A thorough evaluation of the patient’s cur- at least once per month. Among those, 36 percent stated that rent symptoms, along with any reported daytime they have fallen asleep while driving, and 2 percent of those consequences due to lack of quality sleep, is have had an accident or near accident while driving. When necessary to determine if treatment is necessary. asked about sleepiness at work, 29 percent of respondents A sleep diary may also be a helpful tool when stated that they have fallen asleep or become very sleepy at evaluating insomnia symptoms. A one to two week work. Sixty-five percent of those respondents reported having sleep diary should include information regarding experienced at least one of the following attributes at work bedtime, total sleep time, time to sleep onset, due to their sleepiness: impatience with others, boredom at number of nighttime awakenings, daytime naps, work, difficulty concentrating, lower than expected productiv- use of medications, and the patient’s subjective ity, lack of organization at work, avoidance of interactions with feeling in the morning. Bed partner interviews, at others, repeating job duties because of mistakes, and failure home sleep logs, and self-administered question- to complete assigned tasks. naires may also provide beneficial information. OVERVIEW OF MANAGEMENT CONSEQUENCES OF INSOMNIA goals of therapy for the management of insomnia are to insomnia is usually associated with sleepiness, improve sleep quality and quantity, to improve daytime func- fatigue, mood disturbances, and difficulties with tion, and to cause minimal adverse effects due to medica- www.americaspharmacist.net September 2009 | america’s Pharmacist 45 table 2: common causes for Secondary insomnia Stimulus Control Therapy Stimulus control therapy teaches patients to elimi- Alcohol Use Anxiety nate distractions from the bedroom and to associ- Chronic Obstructive Pulmonary Disease (COPD) ate the bedroom with only sleep and sex. Behav- Congestive Heart Failure (CHF) iors such as reading or television watching should Diabetes Mellitus Dementia be avoided in the bedroom. Stimulus control also Depression involves only going to bed when sleepy, leaving the Fibromyalgia Gastroesophageal Reflux Disease (GERD) bedroom if not asleep within 20 minutes, maintain- Hyperthyroidism ing a regular wake-up schedule regardless of sleep Medications (See Table 3) duration, and avoiding naps. this therapy is not Menopause Obstructive Sleep Apnea recommended for patients with restricted mobility, Pain and/or those at increased risk for falls. Panic Disorder Pregnancy Restless Leg Syndrome Sleep Restriction Therapy Seizure Disorder Sleep restriction therapy requires setting limits on Stroke Urinary Incontinence the time in bed with the goal of maximizing sleep efficiency. Patients are asked to keep sleep diaries in order to estimate their total sleep time and to tions. Eliminating insomnia, unfortunately, is not usually the then restrict their time in bed based on this time endpoint goal. Appropriate management of any existing frame. the time spent in bed must not be less comorbidity may relieve the symptoms of insomnia. Howev- than five hours and the morning wake time should er, treatment strategies must be individualized for the patient be consistent throughout the therapy. using this despite the cause. non-pharmacological interventions are method, patients should gradually be able to recommended as initial therapy in the treatment of chronic increase the amount of time that is spent in bed insomnia. these treatments should be utilized prior to initiat- because they are able to make bedtime earlier by ing medication therapy. When pharmacotherapy becomes 15-minute increments as long as sleep efficiency necessary, the choice of a specific agent should be based (total sleep time divided by time spent in bed then on the following: (1) symptoms present, (2) treatment goals, multiplied by 100) is 90 percent or better. Sleep (3) past treatment response, (4) patient preference, (5) restriction therapy should be avoided in patients cost, (6) medication availability, (7) comorbid conditions, (8) with epilepsy, bipolar disorder, or sleepwalking medication interactions, and (9) side effects. Food and Drug problems because this therapy may worsen these Administration (FDA)-approved pharmacotherapy options disorders. Also, patients should be warned that this are provided in table 4. therapy might result in increased daytime sleepi- ness and make activities requiring high cognitive Non-pharmacological Therapies functioning unsafe. Sleep Hygiene Education Sleep hygiene education teaches patients behaviors that Cognitive Behavior Therapy will improve sleep quality. good sleep hygiene behaviors cognitive behavior therapy is instituted to cor- include avoiding caffeine, alcohol, and nicotine, maintaining rect some of the misconceptions about sleep. regular exercise, avoiding heavy exercise within two hours this form of therapy focuses on identifying, of bedtime, maintaining a regular sleep-wake cycle, avoid- challenging, then replacing the attitudes regard- ing naps, and maintaining a dark bedroom. these types of ing sleep and the effect of sleep loss. Examples behaviors promoted for patient use should be customized of concepts reviewed with patients include the based on the specific needs of the patient. Regardless reinforcing that patients require seven to eight of the cause of insomnia, most patients can benefit from hours of sleep per night, discussing the normal behaviors to improve sleep habits. changes in sleep associated with aging, and 46 america’s Pharmacist | September 2009 www.americaspharmacist.net easing exaggerated concerns about the impact substances, so there is a potential for addiction and physical of insomnia. these techniques are believed to dependence. therefore, therapy with these agents should be be the standard of care when combined with tapered off gradually to avoid withdrawal symptoms, especially sleep restriction therapy and stimulus control. after sustained use (use more than 10 days). Benzodiazepines (except temazepam) are substrates Relaxation Therapy of cYP 3A4. inhibitors of this system, such as Azole Relaxation therapy is most beneficial for pa- antifungals, Macrolide antibiotics, and grapefruit juice can tients with high muscular tension and cognitive increase benzodiazepine toxicity. inducers of this system, arousal throughout the day and night. Several such as carbamazepine and St. John’s Wort, can decrease techniques are employed in order to deacti- their effectiveness. Alcohol and other central nervous sys- vate this hyperactivity. Examples of relaxation tem depressants can increase the risk of the cnS depres- techniques include imagery training, meditation, sion seen with benzodiazepines. Benzodiazepines should and progressive muscle relaxation. Patients be used with caution in patients with sleep apnea, depres- can perform most of these therapies after initial sion, psychosis, respiratory disease, and hepatic or renal professional training and regular practice. impairment. Benzodiazepines therapy is contraindicated in pregnant patients (pregnancy category X) and patients with Pharmacological Therapies narrow angle glaucoma. Benzodiazepines Benzodiazepines have historically been the first line table 3: Medications causing Secondary insomnia agents used for the treatment of insomnia, but they Albuterol have lost favor due to their side effect profile and Antidepressants (Selective Serotonin Reuptake inhibitors, Serotonin norepinephrine Reuptake inhibitors, Monoamine oxidase inhibitors) problems with dependence and tolerability. these Beta-blockers agents work by enhancing the inhibitory effect of (- caffeine aminobutyric acid-A (gABA-A) on neuronal excitabil- corticosteroids Decongestants (phenylephrine, pseudoephedrine) ity, resulting in cnS depression. they are effective Diuretics for decreasing the time to sleep onset and prolong- HMg-coA Reductase inhibitors narcotic Analgesics ing sleep duration. However, it has been shown nicotine that their efficacy declines when used for more Stimulants (methylphenidate, amphetamine derivatives, cocaine) than 30 days. the only benzodiazepines FDA ap- theophylline proved for the short-term treatment of insomnia are ProSom (estazolam), Dalmane (flurazepam), Doral Non-Benzodiazepine Hypnotic (quazepam), Restoril (temazepam), and Halcion the newer non-benzodiazepine hypnotics, Ambien (zolpidem), (triazolam). there is little difference in the effective- Sonata (zaleplon), and Lunesta (eszopiclone), have become ness of these agents, so no one drug is considered widely used as alternatives to benzodiazepine therapy. these preferable to the others. the primary considerations agents interact with the benzodiazepine gABA-A receptor in a in choosing an agent are the onset of action and the similar manner as benzodiazepines, but these molecules are half-life. the potential side effects of this drug class structurally different. non-benzodiazepine gABA-A receptor include impaired daytime performance, rebound agonists have been marketed as having a better safety profile insomnia, rebound anxiety (triazolam) dizziness, than the older benzodiazepine agents. Specifically, they have and impaired memory. there is also data showing been touted as causing less rebound insomnia and having an increased risk of falls and hip fractures in elderly less potential for abuse. However, like the benzodiazepines, patients treated with benzodiazepines. Agents they are schedule iV controlled substances and have been with longer half-lives will have an increased risk of associated with causing withdrawal symptoms, physical affecting daytime performance and causing dizzi- dependence, and tolerance resulting in the potential for abuse, ness when compared to those with shorter half- especially after chronic therapy. the longer acting agents may lives. All of these agents are schedule iV controlled also cause daytime performance impairment. www.americaspharmacist.net September 2009 | america’s Pharmacist 47 table 4: FDA-Approved Pharmacotherapy options Drug Recommended Onset (Hr) Half-life (Hr) Notes Dose Benzodiazepines Estazolam 0.5–2 mg 1 10–24 • Short-term use only • can be drug of choice for elderly when therapy is indicated due to lack of active metabolites Flurazepam 15–30 mg 0.25–0.3 2–113 • Short-term use only • Avoid in elderly due to production of long-acting metabolite Quazepam 7.5–15 mg 2 73 • Short-term use only • Avoid in elderly due to production of long-acting metabolite temazepam 15–30 mg 2–3 10–12 • Short-term use only • can be drug of choice for elderly when therapy is indicated due to lack of active metabolites triazolam 0.125–0.5 mg 0.25–0.5 2–6 • Short-term use only • take while in bed due to rapid onset • Avoid in elderly due to high incidence of cnS adverse effects • can cause rebound anxiety Non-benzodiazepine GABA-A Receptor Agonists Zolpidem 5–10 mg 0.5 3 • Short-term use only • can be drug of choice in elderly if therapy is indicated • take immediately before bedtime if patient can devote 7–8 hours to sleep Zolpidem cR 6.25–12.5 mg 0.5 3 • can be used long-term if indicated • take immediately before bedtime if patient can devote 7–8 hours to sleep Zaleplon 5–20 mg Rapid 1 • Short-term use only (7–10 days) • take immediately before bedtime • Dose can be repeated if necessary Eszopiclone 1–3 mg Rapid 6 • can be used long-term if indicated • take immediately before bedtime if patient can devote 8 hours to sleep Melatonin Receptor Agonists Ramelteon 8 mg 0.5 1–3 • can be used long-term if indicated • take within 30 min of bedtime Barbiturates Secobarbital 100–200 mg 0.25–0.5 15–40 • Short-term use only • Avoid in elderly due to long half-life and addictive potential All of these agents work to decrease the time to sleep on- onset. An extended release formulation is approved set, and the major difference between agents is their duration for the treatment of insomnia due to difficulty with of action. Zolpidem and eszopiclone have longer half-lives, sleep onset with difficulty with sleep maintenance. so these agents are useful for sleep maintenance in addition this formulation is allowed for long-term use, and to improving sleep onset problems. they also should only be can be prescribed for more than 30 days. Eszopi- taken when there is time for a full night’s sleep (seven to eight clone is approved for the treatment of insomnia hours). Zolpidem is approved for the short-term treatment of and its use is also approved for more than 30 days. insomnia where the primary complaint is difficulty with sleep Zaleplon is FDA approved for the short-term (seven 48 america’s Pharmacist | September 2009 www.americaspharmacist.net table 4: FDA-Approved Pharmacotherapy options—Continued Drug Recommended Onset (Hr) Half-life (Hr) Notes Dose Antihistamines Diphenhydramine 50 mg 1–3 2–10 • Short-term use only for infrequent insomnia • Associated with significant sedative and anticholinergic properties • Avoid in elderly Doxylamine 25 mg 0.5 10–12 • Short-term use only for infrequent insomnia • Associated with significant sedative and anticholinergic properties • Avoid in elderly to 10 days) treatment of insomnia, but it has been ing properties by helping to maintain the circadian rhythm to shown to be effective for up to five weeks in clinical support the normal sleep-wake cycle. this agent does not trials. Zaleplon has a rapid onset of action and a have any effect on gABA receptors or receptors that bind short half-life, so it is very beneficial for patients with neuropeptides, cytokines, serotonin, dopamine, noradrena- problems going to sleep without causing issues line, acetylcholine, or opiates. clinically, this contributes to such as daytime drowsiness. However, it is not use- the lack of dependence, tolerance, withdrawal symptoms, ful for increasing sleep time or decreasing the num- motor and cognitive deficits, and rebound insomnia noted ber of awakenings at night. the main advantage with ramelteon. the most common side effects associated of this agent is that it can be taken in the middle of with this agent include somnolence, dizziness, fatigue, head- the night if the patient wakes up at least four hours ache, nausea, and exacerbated insomnia. before planning to rise. Ramelteon is a major substrate of cYP1A2 and a mi- these agents are all substrates of cYP3A4 nor substrate of cYP2c9 and cYP3A4. concurrent use to some extent. therefore, usage with potent of strong cYP1A2 inhibitors (such as fluvoxamine) may cYP3A4 inhibitors can increase toxicity, while result in increased serum concentrations of ramelteon; cYP3A4 inducers may decrease effectiveness. therefore, they should not be used together. Medica- Alcohol and other cnS depressants should be tions that inhibit cYP3A4 or cYP2c9 can also increase avoided due to the added risk of cnS depres- the risk of toxicity, while those that induce these systems sion. the non-benzodiazepine gABA-A receptor may diminish the effect of ramelteon. Patients should be agonists should be used with caution in patients instructed not to take ramelteon with or immediately after with sleep apnea, respiratory disease, and severe any high-fat meals or snacks, as this causes a delay in hepatic dysfunction. All of these agents have a absorption and beneficial effects. Because of the rapid pregnancy category rating of c so they should not onset of action, ramelteon should be taken immediately be used in pregnant patients unless the benefits before bedtime or while in bed. this agent should be clearly outweigh the potential risk to the fetus. used with caution in patients with moderate hepatic impairment, and it should be avoided in severe hepatic Melatonin Receptor Agonists impairment. Dosage adjustments are unnecessary for Rozerem (ramelteon) is the only FDA approved elderly patients or those with renal impairment. Ramelt- therapy for insomnia that available by prescrip- eon has a pregnancy category rating of c and is not tion only and is not a controlled substance. it is recommended for use in pregnant patients unless the indicated for the treatment of insomnia charac- benefits of therapy justify the potential risk to the fetus. terized by difficulty with sleep onset. Ramelteon is a melatonin receptor agonist with high affinity Barbiturates for melatonin Mt1 and Mt2 receptors. Activity at Barbiturates are not currently recommended for the treat- these receptors is believed to have sleep promot- ment of insomnia because there are several disadvantages www.americaspharmacist.net September 2009 | america’s Pharmacist 49 to their use: a narrow therapeutic index, lethal in case of an Melatonin supplementation taken in the afternoon overdose, quick tolerance development, high abuse poten- or early evening has been shown to promote sleep, tial, and many drug interactions. Amytal (amobarbital) and but it has little effect if taken at bedtime. However, it Seconal (secobarbital) are the only barbiturates that are may be of some benefit to patients with sleep prob- FDA approved for the short-term treatment of insomnia. lems due to jet lag or shift work. Valerian root may However, these agents should not be recommended as improve the quality of sleep, but its effectiveness is therapy options. these agents are schedule ii controlled not established. therefore, this agent is not recom- substances and have a pregnancy category rating of D. mended as therapy. Melatonin and valerian use is generally discouraged due to issues with standard- Non-FDA Approved Agents: Antidepressants and ization of ingredients and dose variability due to the Antipsychotics lack of FDA regulation. the most commonly prescribed antidepressants for the treatment of insomnia are Desyrel (trazodone), Remeron FDA Warnings for Pharmacological Treatment (mirtazapine), Elavil (amitriptyline), and Sinequan (doxepin). in March 2007, the FDA requested labeling changes these agents do not have an indication for insomnia, and for several medications used in the treatment of in- there is no real evidence supporting their use for insomnia somnia. the agents included in this request were as that is not associated with depression. trazodone is the most follows: Ambien/Ambien cR (zolpidem), Butisol (bu- commonly prescribed antidepressant, and it continues to be tabarbital), carbrital (pentobarbital and carbromal), one of the most frequently prescribed agents for the treat- Dalmane (flurazepam), Doral (quazepam), Halcion ment of insomnia. these agents are most valuable in patients (triazolam), Lunesta (eszopiclone), Placidyl (ethchor- with comorbid depression suffering from chronic insomnia. vynol), Prosom (estazolam), Restoril (temazepam), Antipsychotic agents such as Seroquel (quetiap- Rozerem (ramelteon), Seconal (secobarbital), and ine) have been used for insomnia, but there is no data Sonata (zaleplon). the revised product labels in- supporting this indication unless there is an associated clude warnings about severe allergic reactions, such psychiatric disorder. as anaphylaxis and angioedema. Also included in the warning are complex sleep behaviors, such Non-prescription Agents as sleep-driving, making and eating food, sleep- Benadryl (diphenhydramine) and unisom (doxylamine) are walking, having sex and making phone calls while first generation histamine (H1) antagonists approved as over sleeping. the patient may have little or no memory the counter sleep aids for the short-term treatment of insom- of these activities because they are not fully awake. nia. use of first generation antihistamines should be limited to All of these agents are considered to have these those with infrequent symptoms of insomnia. these agents risks, but there may be differences in the frequency are not recommended for chronic insomnia due to tolerance of these risks depending on the agent. issues and lack of efficacy and safety data. caution should be used when recommending these agents to patients with co- Combination Therapy morbid conditions, such as glaucoma BPH, or patients at risk the data showing that the combination of be- of falling, such as the elderly. these agents have a pregnancy havioral therapy and medication therapy is more category rating of B, so they may be cautiously used in preg- effective than behavioral therapy alone is limited. nant patients. common side effects include anticholinergic Most of the data supports the use of behavior side effects (orthostatic hypotension magnifying the risk of falls therapy alone over medication therapy, especially for the elderly), daytime sedation, and cognitive impairment. for the treatment of chronic insomnia. there has Melatonin and valerian root are both commercially mar- been evidence to show a clear advantage or keted herbal products used as sleep agents. Endogenous disadvantage to using combination therapy. in melatonin is a hormone produced by the pineal gland. its re- general, combination therapy is reserved for those lease normally rises in the evening and falls during the morning patients achieving inadequate results after contin- hours. Peak values are associated with maximum sleep quality. ued non-pharmacological therapy modifications. 50 america’s Pharmacist | September 2009 www.americaspharmacist.net CONCLUSION with the ability to sleep, such as irregular sleep schedule, Psychological and behavior interventions are exercise before bed, alcohol, caffeine, and nicotine. considered to be effective and are recommended When counseling patients, it should be explained as first line treatment of chronic insomnia. Stimulus that medications are only effective for a short time frame control therapy, relaxation therapy, and cognitive and overuse can actually make the insomnia worsen. behavior therapy are recommended as standard of Pharmacists should review some of the common and care and should be implemented for most patients. unique side effects associated with their insomnia When initial therapy has been ineffective, pharmaco- prescription therapy. Also, pharmacists are in the unique therapy may be considered. Short-acting benzodi- position to help educate patients regarding the appropri- azepines or non-benzodiazepine gABA-A receptor ateness of therapy with non-prescription agents. agonists are recommended as first line agents. tri- azolam and zaleplon are best indicated for patients with sleep onset due to their short onset of action Ariane Conrad, PharmD, is assistant professor of clinical pharmacy at and half-life. Quazepam, zolpidem, and eszopiclone the Xavier University of Louisiana College of Pharmacy in New Orleans. are better for patients with problems with sleep maintenance due to their longer half-life. the lowest effective dosage should be used to minimize issues Editor’s Note: to obtain the complete list of references used in the article, contact chris Linville at ncPA (703-838-2680) with side effects, especially in elderly patients. or at firstname.lastname@example.org. Benzodiazepines and non-benzodiazepine gABA-A receptor agonists may need to be avoided in patients with a history of drug or alcohol abuse, as these agents have the potential for abuse. Ramelteon may be considered first for in- CONTINUING EDUCATION QUIZ somnia in the elderly and in patients with a history Select the correct answer. of drug abuse. other sedating medications, such as antidepressants and antipsychotic agents, are 1. Which of the following is not a risk factor for the only recommended when used to treat a concomi- development of insomnia? tant illness. non-prescription antihistamines, herbal a. tobacco use agents and barbiturates are generally not recom- b. Age under 30 years mended due to safety and efficacy concerns. the c. Female sex FDA recommends that pharmacotherapy use for d. Psychiatric illness insomnia is limited to one month. Longer use (up to one year) may be considered if the patient is not 2. Which of the following is not a goal of therapy for the experiencing any side effects from therapy. management of insomnia? a. improve daytime function PATIENT COUNSELING b. improve sleep quality For any therapy to be successful, the patient c. Reduce adverse effects associated with therapy must be properly educated regarding the therapy d. Eliminate insomnia options available. Patients should be educated regarding the advantages and disadvantages 3. Which of the following factors should be considered associated with the non-pharmacological and when choosing therapy for the treatment of chronic pharmacological therapies. Furthermore, they insomnia? should be involved in the decision making process a. Patient preference which will facilitate effectiveness and compliance. b. Presenting symptoms Patients should also be encouraged to avoid some c. comorbidities of the behaviors and substances that may interfere d. All of the above www.americaspharmacist.net September 2009 | america’s Pharmacist 51 4. Which non-pharmacological therapies is considered 10. Which of the following non-pharmacological standard care for the treatment of insomnia? therapies is not appropriate for patients a. cognitive behavior therapy diagnosed with epilepsy? b. Sleep hygiene therapy a. Relaxation therapy c. Sleep restriction therapy b. Sleep restriction d. All of the above c. Sleep hygiene d. Stimulus control 5. Which of the following drugs is not recommended for the management of insomnia in elderly patients? 11. Which of the following patient a. temazepam characteristics would be a contraindication for b. Estazolam therapy with benzodiazepines? c. Flurazepam a. Age more than 65 years d. All of the above b. chronic renal insufficiency c. Pregnancy 6. Which of the following medications has been associated d. Severe hepatic dysfunction with causing high rates of rebound anxiety? a. triazolam 12. Which of the following benzodiazepines b. Zolpidem is considered an appropriate choice for c. Diphenhydramine insomnia therapy for an elderly patient when a d. Ramelteon benzodiazepine is desired? a. triazolam 7. JM is a 40-year-old female taking quazepam for the b. Estazolam treatment of her insomnia. Which of the following antibiotics c. Lorazepam should not be prescribed for this patient? d. Diazepam a. ciprofloxacin b. Fluconazole 13. Which of the following patient c. Penicillin characteristics would be a contraindication for d. Sulfamethoxazole/trimethoprim therapy with ramelteon? a. Age more than 65 years 8. All of the following medications are Food and Drug b. chronic renal insufficiency Administration approved for the treatment of insomnia c. Pregnancy EXcEPt: d. Severe hepatic dysfunction a. trazodone b. Ramelteon 14. Which of the following medications is c. triazolam considered to be a secondary cause of d. Eszopiclone insomnia? a. Acetaminophen 9. Which of the following insomnia symptoms is most likely b. Ramipril to respond to therapy with zaleplon? c. Decongestants a. Waking too early d. carbamazepine b. Difficulty initiating sleep c. Difficulty maintaining sleep 15. Each of the following is considered to be a d. All of the above medical cause for insomnia except: a. chronic obstructive pulmonary disease (coPD) b. Allergic rhinitis c. Diabetes d. obstructive sleep apnea 52 america’s Pharmacist | September 2009 www.americaspharmacist.net 16. Which of the following insomnia symptoms Management of Insomnia is most likely to respond to therapy with Sept. 1, 2009 (expires Sept. 1, 2012) flurazepam? FREE ONLINE C.E. Pharmacists now have online access to ncPA’s a. Waking too early c.E. programs through Powered by cEcity. By taking this test on- b. Difficulty initiating sleep line—go to the continuing Education section of the ncPA Web site (www.ncpanet.org) by clicking on “Professional Development” under c. Difficulty maintaining sleep the Education heading you will receive immediate online test results and certificates of completion at no charge. d. All of the above To earn continuing education credit: ACPE Program 207-000-09-009-H01-P 17. Which of the following statements regarding A score of 70 percent is required to successfully complete the c.E. quiz. antidepressant use for insomnia therapy is tRuE? if a passing score is not achieved, one free reexamination is permitted. a. Antidepressants have been proven to be ef- Statements of credit for mail-in exams will be available online for you to print out approximately three weeks after the date of the program fective therapy options for insomnia. (transcript Web site: www.cecerts.oRg). if you do not have access to a b. Antidepressants are approved for short-term computer, check this box and we will make other arrangements to send treatment of insomnia. you a statement of credit: q c. Antidepressants are only appropriate for use Record your quiz answers and the following information on this form. in patients with comorbid depression and q ncPA Member License ncPA Member no. ____________________ State __________ no. _____________________ insomnia. q nonmember State __________ no. _____________________ d. Antidepressants should be recommended as All fields below are required. Mail this form and $7 for manual processing to: first line therapy for chronic insomnia. ncPA c.E. Processing ctr.; 405 glenn Drive, Suite 4; Sterling, VA. 20164 _____________________________________________________________________________________ Last 4 digits of SSn MM-DD of birth 18. AJ is a 70-year-old patient presenting to the _____________________________________________________________________________________ name pharmacy complaining of insomnia symptoms _____________________________________________________________________________________ lasting for seven days. He has a history of Pharmacy name _____________________________________________________________________________________ hypertension and diabetes. Which of the Address _____________________________________________________________________________________ following would be appropriate to recommend city State ZiP _____________________________________________________________________________________ for this patient? Phone number (store or home) a. Doxylamine _____________________________________________________________________________________ Store e-mail (if avail.) Date quiz taken b. Diphenhydramine Quiz: Shade in your choice c. Valerian root a b c d e a b c d e d. none of the above 1. q q q q q 11. q q q q q 2. q q q q q 12. q q q q q 3. q q q q q 13. q q q q q 19. Which of the following medications does 4. q q q q q 14. q q q q q not have a FDA-mandated warning attached to 5. q q q q q 15. q q q q q its labeling? 6. q q q q q 16. q q q q q a. Zolpidem 7. q q q q q 17. q q q q q b. Secobarbital 8. q q q q q 18. q q q q q 9. q q q q q 19. q q q q q c. Doxylamine 10. q q q q q 20. q q q q q d. triazolam Quiz: Circle your choice 21. is this program used to meet your mandatory c.E. requirements? 20. Each of the following medications must be a. yes b. no taken immediately before bedtime due to their 22. type of pharmacist: a. owner b. manager c. employee rapid onset of action EXcEPt: 23. Age group: a. 21–30 b. 31–40 c. 41–50 d. 51–60 e. over 60 a. triazolam 24. Did this article achieve its stated objectives? a. yes b. no 25. How much of this program can you apply in practice? b. temazepam a. all b. some c. very little d. none c. Ramelteon How long did it take you to complete both the reading and the quiz? ______ minutes d. Zaleplon NCPA® is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. NCPA has assigned two contact hours (0.2 CEU) of continuing education credit to this article. Eligibility to receive continuing education www.americaspharmacist.net May 2007 | america’s Pharmacist 53 credit for this article expires three years from the month published.
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