Pharmacotherapy For Insomnia Research Articles

Overview of the Therapeutic Management of Insomnia with Zolpidem

Benzodiazepine hypnotic agents were the mainstream pharmacotherapy for insomnia from the 1960s to the 1980s, but their safety profile proved to be not quite as perfect as originally expected with regard to daytime performance and cognition, and above all the risk of dependence. These risks are substantially diminished in the non-benzodiazepine hypnotic agents developed and marketed during the past two decades, but the fears engendered by certain benzodiazepines still greatly influence the attitude of both physicians and the general public to the treatment of insomnia. For this reason, as well as in the interests of matching the pharmacotherapy of insomnia more closely to the often fluctuating nature of this disorder, the possibility of the discontinuous or 'as needed' use of hypnotic drugs has attracted increasing attention in recent years. Current recommendations strongly favour the use of hypnotic drugs for a limited period of time. However, some insomniac patients need sleep medication for longer periods in spite of a non-pharmacological approach, whereas other patients become dependent on drugs as a result of rebound insomnia, withdrawal symptoms, or the recurrence of insomnia. The pharmacological properties of zolpidem make it feasible for non-nightly use. A double-blind, randomized, parallel-group study of continuous treatment with either zolpidem or estazolam, followed by an observation of the discontinuation of drug treatments combined with the non-pharmacological management of primary insomnia, showed a carry-over benefit for zolpidem treatment.

Tolerability of hypnosedatives in older patients.

Sleep disturbances are common and prevalence rates increase with age. Especially in the elderly, somatic diseases and medications with adverse effects relating to sleep are frequent reasons for disturbed and nonrefreshing sleep. It should be emphasised that these reasons must be excluded before symptomatic therapy is started. In some cases the use of hypnosedatives may be included as part of the treatment of a somatic disease and may cause sleep disturbances. Pharmacotherapy is one of the main approaches in the management of primary insomnia and should be part of a broader treatment strategy including nonpharmacological methods. This article focuses on the tolerability of frequently prescribed hypnosedatives in the elderly with primary insomnia and addresses the primary care physician. In general, recommendations for the pharmacotherapy of insomnia in elderly patients include using a reduced dosage. For some substances (e.g. zolpidem, zopiclone, zaleplon, temazepam and triazolam) the recommended dosage is half that recommended for younger patients. The properties of the selected hypnosedative should be taken into consideration and matched with the type of sleep disturbance experienced by the patient. Ultrashort-acting drugs may be useful when initiating sleep is the main problem, whereas short- and intermediate-acting substances are recommended for maintaining sleep. Possible interactions with pre-existing medication must also be taken into consideration. Some agents such as antipsychotics, antidepressants, melatonin and herbal agents may be used in specific indications. However, only a few of these substances have proven tolerability in the elderly and further investigations are recommended.

GUEST EDITORIAL: Rational pharmacotherapy for insomnia: time for a new paradigm.

Any interesting debate must have two sides well-defended by facts, realities, and even emotion. The debate over the pharmacological treatment of insomnia is no exception. Milton Kramer has argued that long-term treatment of insomnia with benzodiazepine receptor agonist (BzRA) hypnotics is more effective than often acknowledged, less toxic than often feared, and greatly appreciated by many insomnia sufferers (1). Daniel Kripke, in a previous article as well as in his response to Kramer, cites convincing data that long-term use of BzRA drugs has minimal therapeutic effects at the cost of significant adverse effects (2, 3). The debate is framed in quasi-religious terms: should we avoid the “pharmacologic Calvinism” that denies effective treatment to those with insomnia? Or should we rather fear the “hypnotic Bacchanalianism” that promotes an ineffective and potentially dangerous “treatment”, albeit one that feels good? Is there a middle ground for the well-intentioned clinician and researcher? I believe the answer is yes. In fact, even Kramer and Kripke agree on several key points regarding the type of information that will help us gain a better perspective on this debate. Between the paths of Calvin and Bacchus, I would like to propose a new paradigm that I will call “rational pharmacotherapy for insomnia”.

Pharmacotherapy of insomnia: practice and prospects.

Insomnia is a complex complaint which is often multifactorial in origin. Pharmacotherapy can only be an adjunct in the treatment of insomnia and hypnotics should be given on an intermittent basis for short periods of time. An overview is presented of the currently available hypnotics, of which benzodiazepines are still the most widely prescribed. New drugs which bind to specific receptor subtypes or which are partial benzodiazepine receptor agonists might overcome the disadvantages associated with chronic benzodiazepine use, but more long-term investigations are needed.

Sedative-Hypnotics and the Treatment of Insomnia

Insomnia is a common complaint that can lead to inappropriate prescribing of sedative-hypnotics. For some patients. insomnia is a symptom of a significant medical problem and should be addressed by treating the primary disorder. Insomnia can also occur as a adverse reaction to prescription drugs or social drugs, such as caffeine or alcohol. Benzodiazepines have become the sedative- hypnotic of choice; however, their limitations are legion. They should be avoided in patients at risk for cognitive impairment, disequilibrium and falls, or respiratory depression. Using the lowest possible dose and tapering when using short-acting benzodiazepines may decrease the occurrence of adverse effects. Non-drug therapy can be an adjunct or alternative to pharmacotherapy of insomnia. It requires an investment in patient education and counseling, but may lead to better sleep habits over time.