Insomnia: Therapeutic Approach

, MD, , MD, , Department of Psychiatry and Behavioral Medicine, University of Louisville School of Medicine, Louisville, Ky

South Med J. 2001;94(9) 

In This Article

Guidelines for Sedation

When a medicinal strategy is chosen, consider potential side effects, interactions, underlying conditions, and drug dependency risk factors. Sedative prescribing includes precautions for decreased alertness or impaired psychomotor function. Although food in the stomach generally slows drug absorption times, most of these medicines are not significantly affected by taking them with meals. Short-term use of the lowest effective dose should be used to minimize side effects, rebound insomnia, tolerance, and habituation.[9,26] Rebound insomnia refers to problems with sleep induced by abrupt discontinuance of long-term sedative administrations; intermittent use and dosage tapering minimize discontinuance difficulties.[1] A trial period without medication is advised periodically for anyone taking them for long periods.

Choosing from among the wide array of available medicines depends on the pharmacokinetic properties of the agent and the specific needs of the patient (eg, life-style or interacting drugs). Co-prescribing medications with sedative properties or concurrent use of alcohol will result in additive, synergistic effects; however, in practical clinical use, there are few other drug-to-drug interactions of significance, with the exception of alprazolam and triazolam, which are increased in concentration by cytochrome P-450 3A 3/4 enzyme inhibitors (eg, erythromycin or ketoconazole). Sedatives should be avoided in people prone to substance abuse, because of a risk for addiction.[5,7] Use of such agents in this population may be more acceptable during hospitalization for an acute illness than in outpatient applications. Patients with respiratory disorders, such as chronic obstructive pulmonary disease (COPD), should not receive medicinals that cause respiratory depression.[25,30,33,34] Firemen, ambulance workers, and others who must be rapidly awakened and alert early or unpredictably should not use sleep-enhancing drugs.[30]

Consider age when choosing among pharmaceuticals.[29] In older patients, only half the usual adult dose is initially prescribed.[20,26] More care must be taken when prescribing to persons with renal or hepatic insufficiency. Decreased clearance of drugs and their metabolites may lead to accumulation, sedation, and/or cognitive impairment.[30,34] Appropriate dosing diminishes unwanted effects.

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