Abstract
Despite the risks associated with hypnotics and their recent increased use in Saudi Arabia, there are no specific national guidelines for using these medicines to treat insomnia nor are there any data on how these medicines are currently prescribed. There is the potential, however, that some physicians might be adhering to the United States guidelines. The current audit study was aimed to assess the current practice in treating insomnia with hypnotics in Saudi Arabia, and to evaluate its agreement with the US guidelines. The audit was conducted using data collected between April 2012 and March 2017 at King Fahad Central Hospital (KFCH; Jazan), of patients who were either prescribed benzodiazepines (BZDs) or Z-drugs or diagnosed with insomnia. The audit criteria followed two US guidelines for the management of insomnia in adults. Data included documented diagnosis, use of CBT-I (Cognitive Behavioral Therapy for Insomnia), use of BZDs and Z-drugs including treatment regimen, and whether physicians prescribed anti-histamines for insomnia. The data were analyzed using STATA 14 after transcription to a MS XL file. Of the 504 records reviewed, 379 patients (75%) were prescribed BZDs or Z-drugs; only 182 (48%) of them had clearly documented indications for their use. Three hundred and seven patients (60%) were diagnosed with insomnia; none of them received CBT-I as initial treatment. No patients on long-term use of hypnotics were reviewed by their physicians after they began using the medication. More than 43% of patients were prescribed anti-histamines for insomnia. No records met all (or even six) of the seven criteria. KFCH physicians do not follow US guidelines. Therefore, the Ministry of Health (MOH) should improve its administrative systems including documentation, and instead of using international guidelines that are seldom followed, physicians should be trained in prescribing hypnotics and national guidelines need to be developed.
Highlights
Studies show that while benzodiazepines (BZDs) and Z-drugs are associated with a high risk of patient misuse, and cause addiction, dependence, falls, accidents, cognitive impairment and withdrawal symptoms, the therapeutic benefits outweigh the disadvantages if the drugs are prescribed appropriately [1,2]
The national guidelines for insomnia management in the US and UK begin with sleep hygiene, non-pharmacological remedies such as cognitive behavioural therapy for insomnia (CBT-I), and only after these treatments have been attempted, is the short-term use of hypnotic medicines considered for patients with severe insomnia [3,6,7]
All standards and consensus recommendations related to the use of BZDs or Z-drugs and/or the management of primary insomnia from the guidelines were incorporated into the criteria to develop a data collection tool (Table 1) to be applied in the Kingdom of Saudi Arabia (KSA)
Summary
Studies show that while benzodiazepines (BZDs) and Z-drugs (eszopiclone, zolpidem and zaleplon) are associated with a high risk of patient misuse, and cause addiction, dependence, falls, accidents, cognitive impairment and withdrawal symptoms, the therapeutic benefits outweigh the disadvantages if the drugs are prescribed appropriately [1,2]. Pharmacy 2019, 7, 15 and other countries, the known risks have led to clinical guidelines to help physicians prescribe the medicines safely, and to minimize the risk of addiction [3,4,5,6,7]. While these guidelines contain attributes specific to the countries where they are applied, there are recommendations common to all, among which is the importance of using the smallest dosage possible to induce a therapeutic effect. Prescribing hypnotics for long-term use might indicate that physicians do not adhere to the guidelines
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