3/24/2016 DISCLOSURE STATEMENT PHARMACIST OBJECTIVES OVERVIEW TECHNICIAN OBJECTIVES PREVALENCE OF INSOMNIA THE WRONG SIDE OF THE BED: CHRONIC INSOMNIA

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DISCLOSURE STATEMENT I do not have any actual or potential conflict of interest in relation to this presentation THE WRONG SIDE OF THE BED: CHRONIC INSOMNIA DANIELLE ROWAN, PHARMD, MBA PGY1 PHARMACY

Causes and diagnosis Non-pharmacological treatment Pharmacological treatment: natural, OTC, and RX I. Explain impact of chronic insomnia on daily life II.

1 DISCLOSURE STATEMENT I do not have any actual or potential conflict of interest in relation to this presentation THE WRONG SIDE OF THE BED: CHRONIC INSOMNIA DANIELLE ROWAN, PHARMD, MBA PGY1 PHARMACY PRACTICE RESIDENT IOWA CITY VA HEALTH CARE SYSTEM Off-label use of medications for insomnia will be presented 2 OVERVIEW PHARMACIST OBJECTIVES Prevalence and impact Definitions Sleep architecture Causes and diagnosis Non-pharmacological treatment Pharmacological treatment: natural, OTC, and RX I. Explain impact of chronic insomnia on daily life II. Apply two principles of sleep hygiene and nonpharmacological methods to patients III. Predict the most likely side effects or consequences of agents used in insomnia IV. Compare the efficacy of pharmacologic options for insomnia V. Devise a plan to manage insomnia based upon clinical presentation and history 3 4 TECHNICIAN OBJECTIVES PREVALENCE OF INSOMNIA I. Describe the prevalence of insomnia in the US II. Recognize two medications and two disease states that can cause or contribute to insomnia III. Identify one pharmacologic and one nonpharmacologic option for insomnia IV. Contrast the efficacy and safety of OTC options for the management of chronic insomnia V. Recognize safety concerns with using natural products During the past 12 months, have you regularly had insomnia or trouble sleeping? An estimated 64% of US population experiences sleep problems at least a few nights a week 7% of adults report the use of alcohol 7% a nonprescription sleep aid 8% a prescription hypnotic 5 Trends in outpatient visits. Sleep Handbook of Nonprescription Drugs 18 th Edition. 6 1

IMPACT OF INSOMNIA Drowsy driving A CDC report of 150,000 adults across 19 states stated 4.

hrs significantly associated with CHD, stroke, and diabetes among adults over 45 years Depression and anxiety increased Obesity Drowsy driving. CDC 2013. Consequences of insomnia. Sleep Med Clin 2008.

7 SLEEP ARCHITECTURE Non-REM Stage 1: drowsiness, easily awakened, slow eye movements (5% of total sleep) Stage 2: light sleep, eye movements stop, slower brain waves with occasional bursts of rapid

Deep sleep, difficult to awaken, slow brain waves, heart and respiratory rate slowed Adapted from NIH Guide to Healthy Sleep, Aug 2011.

occurs Arms and legs are temporarily paralyzed 8 SLEEP ARCHITECTURE CHANGES WITH AGEING Carskadon MA, Dement WC (2010). Normal human sleep. In Kryger MH, Roth T, Dement WC (Eds.

2 IMPACT OF INSOMNIA Drowsy driving A CDC report of 150,000 adults across 19 states stated 4.2% reported falling asleep at the wheel in previous 30 days Slowed reaction time, impaired decision-making, less attentive Loss of productivity Cognitive impairment Chronic diseases Sleep duration 6 hrs significantly associated with CHD, stroke, and diabetes among adults over 45 years Depression and anxiety increased Obesity Drowsy driving. CDC Consequences of insomnia. Sleep Med Clin Insomnia Disorder. NEJM Professional correlates of insomnia. Sleep SLEEP ARCHITECTURE Non-REM Stage 1: drowsiness, easily awakened, slow eye movements (5% of total sleep) Stage 2: light sleep, eye movements stop, slower brain waves with occasional bursts of rapid (45-55% of total sleep) Stages 3 & 4 (Slow Wave Sleep): soon after falling asleep and in the first half of night. Deep sleep, difficult to awaken, slow brain waves, heart and respiratory rate slowed Adapted from NIH Guide to Healthy Sleep, Aug Types of Sleep REM Sleep Occurs ~ 90 minutes after falling asleep with longer, deeper periods during second half of the night Eyes move rapidly behind closed eyes Breathing, HR, BP irregular Dreaming occurs Arms and legs are temporarily paralyzed 8 SLEEP ARCHITECTURE CHANGES WITH AGEING Carskadon MA, Dement WC (2010). Normal human sleep. In Kryger MH, Roth T, Dement WC (Eds.) Principles and practice of sleep medicine (5th ed). St. Louis, MO: Elsevier. 9 Sleep Disorders and Sleep Deprivation. Institute of Medicine Committee on Sleep Medicine and Research NIH COMMON CAUSES TYPES OF INSOMNIA Medications and Substances Antidepressants Stimulants Corticosteroids Decongestants Narcotic analgesics Antihypertensives Asthma medications Alcohol Caffeine Nicotine Comorbidities Pain conditions Respiratory disease Neurological disorders Psychiatric illness Cardiovascular disease Situational Work or financial stress Jet lag or shift work Early morning awakening Difficulty falling asleep Difficulty maintaining sleep Clinical Guideline: Chronic Insomnia. J Clin Sleep Med Insomnia Disorders. NEJM

3 TYPES OF INSOMNIA Short-term/transient: symptoms present for < 3 months, but accompanied by significant concern Intermittent: on and off over a course > 1 month; can develop into chronic Chronic: symptoms occur at least 3 times/week for 1 month and are not related to an inadequate opportunity to sleep Other: symptoms of difficulty initiating or maintaining sleep but do not meet either above criteria ZZ is a 72 y/o male with a history of asthma, HTN, depression, and BPH He presents to his primary care provider stating he has had trouble falling asleep over the past 2 months He feels distracted at work and drinks 2-3 cups of coffee throughout the day to stay awake He reports being so tired by the time he arrives home he takes a nap before dinner His wife recently passed away and he has been adjusting to his new lifestyle Clinical Guideline: Chronic Insomnia. J Clin Sleep Med The international classification of sleep disorders, third edition (ICSD-3) Medication Indication Albuterol HFA inhaler 2 puffs QID prn SOB Asthma Allegra-D 24 hr 1 tablet QD prn Allergies Hydrochlorothiazide 25 mg HS HTN Lisinopril 2.5 mg QD HTN Sertraline 25 mg QPM Depression Tamsulosin 0.4 mg QD BPH Acetaminophen 650 mg BID prn Back/knee pain What might be causing or contributing to ZZ s sleep troubles? Does ZZ meet criteria for a diagnosis of insomnia? DIAGNOSIS OF INSOMNIA: AMERICAN ACADEMY OF SLEEP MEDICINE DIAGNOSIS OF INSOMNIA DISORDER: DSM V CRITERIA A complaint of: Difficultly initiating sleep Difficultly maintaining sleep Waking too early Sleep that is chronically nonrestorative or poor in quality Requires associated daytime dysfunction in addition to insomnia symptomology Occurs despite adequate opportunity and circumstances for sleep Diagnosis: clinical evaluation Differentials include medical, psychiatric, and environmental factors Daytime Dysfunction: Malaise or fatigue Attention, concentration, or memory impairment Social dysfunction or poor school performance Daytime sleepiness Motivation or energy reduction Proneness for errors or accidents Concerns or worries about sleep Predominant complaint of dissatisfaction with sleep quality or quantity, of > 1 of the following: Difficulty initiating sleep Difficulty maintaining sleep Early morning awakenings Significant impairment in social, occupational, or other areas of functioning Sleep disturbance > 3 nights/week Sleep difficulty is present for > 3 months Occurs despite adequate opportunity for sleep Clinical Guideline: Chronic Insomnia. J Clin Sleep Med Insomnia Disorder. NEJM DSM-5 Changes: Sleep-Wake Disorders. Psych Central

NHLBI Sleep Diary Sample TREATMENT GOALS Improve sleep quality and quantity Improve insomnia-related daytime impairments Avoid adverse effects from selected therapy 19 Clinical Guideline: Chronic

Annals of Internal Med. 2015. Schutte-Rodin et al. J Clin Sleep Med. 2008. Insomnia Disorder. NEJM. 2015. 22 SLEEP HYGIENE TECHNIQUES Stick to a sleep schedule, even on weekends Designate the bed for sleep and intimacy Your guide to healthy sleep.

Avoid alcoholic drinks before bed Create a sleeping environment (noise, temp, light) Avoid exercise 2-3 hours before bedtime Avoid large meals/ beverages late at night Avoid caffeine or nicotine in

CBT-I incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation 64% female; mean age 56 years Purpose To determine the efficacy

4 NHLBI Sleep Diary Sample TREATMENT GOALS Improve sleep quality and quantity Improve insomnia-related daytime impairments Avoid adverse effects from selected therapy 19 Clinical Guideline: Chronic Insomnia. J Clin Sleep Med TREATMENT SELECTION CONSIDERATIONS Age Comorbidities Psychiatric conditions History of substance abuse Type of insomnia Duration of symptoms effect profile of chosen therapy NON-PHARMA TREATMENT Cognitive behavioral therapy (CBT) Sleep restriction Light therapy Stimulus control Relaxation therapy Physical activity Sleep hygiene education 21 Trauer J et al. CBT for Chronic Insomnia. Annals of Internal Med Schutte-Rodin et al. J Clin Sleep Med Insomnia Disorder. NEJM SLEEP HYGIENE TECHNIQUES Stick to a sleep schedule, even on weekends Designate the bed for sleep and intimacy Your guide to healthy sleep. NIH Avoid alcoholic drinks before bed Create a sleeping environment (noise, temp, light) Avoid exercise 2-3 hours before bedtime Avoid large meals/ beverages late at night Avoid caffeine or nicotine in the late afternoon Avoid naps after 3 pm Cognitive Behavioral Therapy for Chronic Insomnia: A Systematic Review and Meta-Analysis Methods 20 randomized, controlled trials including 1162 participants CBT-I incorporated at least 3 of the following: cognitive therapy, stimulus control, sleep restriction, sleep hygiene, and relaxation 64% female; mean age 56 years Purpose To determine the efficacy of CBT-I, compared to control, on diary measures of overnight sleep in adults with chronic insomnia Results Sleep onset latency (SOL) Improved by min Wake after sleep onset (WASO) Improved by min Total sleep time (TST) Improved by 7.61 min Sleep efficiency (SE%) Improved by 9.91% Changes sustained at later time points (1-12 months) Some studies found improvement in sleepiness, psychomotor vigilance, mood, anxiety, beliefs and attitudes about sleep, health status, and daytime functioning Conclusions Effect sizes reported similar in magnitude to those seen in meta-analyses of hypnotic agents, though those studies are often limited by short duration and absence of long-term follow-up CBT-I is a highly effective treatment for chronic insomnia with wellmaintained responses Trauer JM, et al. Cognitive Behavioral Therapy for Chronic Insomnia. Annals of Internal Medicine 2015;163:

ZZ now presents to the pharmacy asking for something to help him sleep, stating he rarely gets > 3 hours/night ZZ tells you he is often awoken because he has to go to the bathroom but also has

5 ZZ now presents to the pharmacy asking for something to help him sleep, stating he rarely gets > 3 hours/night ZZ tells you he is often awoken because he has to go to the bathroom but also has trouble falling asleep at night. He states he is retired now and often takes nap into the afternoons. WHAT FACTORS NEED TO BE CONSIDERED WHEN SELECTING INITIAL TREATMENT? A. Type of insomnia B. Age C. Results of polysomnography D. All of the above E. A and B only WHICH OF THE FOLLOWING IS NOT A SLEEP HYGIENE RECOMMENDATION? PHARMACOLOGICAL OPTIONS A. Avoid alcohol at bedtime B. Exercise regularly before bedtime C. Create a bedtime ritual-waking at the same time D. Sleep in a quiet, cool environment Prescription Agents Benzodiazepines (BZDs) Non-benzodiazepine hypnotics Sedative antidepressants Melatonin receptor agonist Orexin receptor antagonist Over-the-Counter Agents Antihistamines Melatonin Natural products MEDICATIONS ON THE RISE BENZODIAZEPINES FDA Approved: Short Half-Life Triazolam (Halcion ) Intermediate Half-Life Estazolam (ProSom ) Temazepam (Restoril ) Long Half-Life Quazepam (Doral ) Flurazepam (Dalmane ) Off-Label: Intermediate Half-Life Alprazolam (Xanax ) Lorazepam (Ativan ) Clonazepam (Klonopin ) Long Half-Life Diazepam (Valium ) Short-Acting: difficulty initiating sleep Intermediate/Long-Acting: difficulty maintaining sleep Short Term Use: 7-14 days 29 Schutte-Rodin et al. J Clin Sleep Med Lexi-Comp. Last updated 3/1/16 American Geriatrics Society 2015 updated Beers Criteria for potentially inappropriate medication use in older adults. 2015;63(11):

BENZODIAZEPINES & SAFETY ZOLPIDEM (AMBIEN ) Benefits: Increased total sleep time,

$fractures Increased mortality with long term hypnotic use Tolerance, withdrawal,$ abuse potential Impact sleep architecture, decreasing REM sleep Time to onset: 30

abuse potential Impact sleep architecture, decreasing REM sleep Time to onset: 30

8 hours Decreases sleep latency, preserves time spent in stages 3 and 4, increases

hallucinations, anterograde amnesia Schedule IV controlled substance National

treatment of insomnia, using only for short term when insomnia is severe, disabling,

before bedtime Hepatic: 5 mg, half-life extended up to 10 hours Females & elderly: 5

BZD harm: how can it be reduced? BJCP. 2012. 31 Lexicomp. Zolpidem.

FDA notified the public about the risk of next morning impairment after use of

May also apply to men; recommend initiating at 5 mg.

(level at which impaired driving occurs) 8 hours post dosing.

gov/downloads/drugs/drugsafety/ucm335007.

minutes Duration: 4-6 hours Half-life: 1 hour Decreases time to sleep onset only;

dizziness, somnolence, CNS depression Schedule IV controlled substance Time to

sleep onset, number of awakenings, increase total sleep time, improves sleep

unpleasant taste (8-34%) Schedule IV controlled substance Adult: 5-20 mg on an empty

6 BENZODIAZEPINES & SAFETY ZOLPIDEM (AMBIEN ) Benefits: Increased total sleep time, decreased number of nighttime awakenings, decreased sleep latency Harms: Sedation with feeling of heaviness, dysphoria, disorientation Memory impairment Falls and hip fractures Increased mortality with long term hypnotic use Tolerance, withdrawal, abuse potential Impact sleep architecture, decreasing REM sleep Time to onset: 30 minutes Duration: 6-8 hours Half-life: 2.6 hours; CR 2.8 hours Decreases sleep latency, preserves time spent in stages 3 and 4, increases total sleep Abnormal behaviors and thoughts [sleep driving, eating, walking], hallucinations, anterograde amnesia Schedule IV controlled substance National Institute for Health and Clinical Excellence (NICE) urge great caution with BZD in treatment of insomnia, using only for short term when insomnia is severe, disabling, or subjecting the individual to extreme distress Adults: 10 mg daily immediately before bedtime Hepatic: 5 mg, half-life extended up to 10 hours Females & elderly: 5 mg Cost: generic $4.63/IR tab; $6.11/CR tab Lader, M. BZD harm: how can it be reduced? BJCP Lexicomp. Zolpidem. Updated 12/10/15 32 ZOLPIDEM IR VS CR ZOLPIDEM (AMBIEN ) FDA warning January 2013 FDA notified the public about the risk of next morning impairment after use of zolpidem. for women lowered to 5 mg IR and 6.25 mg ER. May also apply to men; recommend initiating at 5 mg. Study results: 15% of women and 3% of men had levels of zolpidem above 50 ng/ml (level at which impaired driving occurs) 8 hours post dosing. Conclusion: Women eliminate zolpidem more slowly. Weinling E. PK profile of zolpidem designed to improve sleep maintenance. Fundamental & Clin Pharmacology FDA ZALEPLON (SONATA ) ESZOPICLONE (LUNESTA ) Time to onset: rapid, within 30 minutes Duration: 4-6 hours Half-life: 1 hour Decreases time to sleep onset only; can be used for middle of night awakenings Comparable SE as zolpidem in headaches, dizziness, somnolence, CNS depression Schedule IV controlled substance Time to onset: rapid, 20 minutes Duration: 6-8 hours Half-life: 6 hours Reduces time to sleep onset, number of awakenings, increase total sleep time, improves sleep quality, sleep maintenance Approved for long term use (up to 6 mo) Unique: unpleasant taste (8-34%) Schedule IV controlled substance Adult: 5-20 mg on an empty stomach Hepatic: 5 mg, not recommended in severe Elderly: 5 mg, max 10 mg Cost: generic 5 mg $3.64/cap; 10 mg $3.74/cap Adults: 1 mg immediately before bed, max 3 mg FDA warning May 2014 Elderly: 1 mg, max 2 mg Cost: generic $11.60/tab regardless of strength LexiComp. Eszopiclone Updated 11/25/15 FDA Drug Safety Communication Lexicomp. Zaleplon. Updated 11/15/

7 A Polysomnographic Placebo-Controlled Evaluation of Efficacy and Safety of Eszopiclone Relative to Placebo and Zolpidem in the Treatment of Primary Insomnia. J Clin Sleep Med Study Design Multicenter, randomized, crossover study RAMELTEON (ROZEREM ) Population 65 participants years old meeting the DSM-IV criteria for primary insomnia Purpose To evaluate the PSG efficacy and safety of a range of eszopiclone doses relative to placebo in patients with primary insomnia using zolpidem 10 mg as active control Results Latency to Persistent Sleep (LPS) All active treatments reduced LPS relative to placebo, 13.1 min for 3 mg and zolpidem Sleep Efficiency (SE) Eszopiclone 2, 2.5, 3 mg and zolpidem 10 mg demonstrated significantly higher SE compared to 1 mg and placebo Adverse Zolpidem had significantly higher rates of All CNS adverse effects (23.4% vs 12.5% 3 mg) and hallucinations (4.7% vs 0) for all doses of eszopiclone Unpleasant taste more common in all doses of ezscopiclone vs zolpidem Time to onset: 30 minutes Duration: Short Half-life: 1 hour Best for sleep onset difficulties. Decreases sleep latency, also can be used in patients with COPD and sleep apnea. Unique: disturbances of reproductive hormonal regulation [dec libido, disruption of menses], angioedema, inc prolactin/dec testosterone Not a controlled substance Adult: 8 mg within 30 minutes of bedtime Hepatic: not recommended in severe Cost: brand only 8 mg tab $12.23/tab 37 LexiComp. Ramelteon Updated 12/10/15 38 SUVOREXANT (BELSOMRA ) LexiComp. Suvorexant Updated 1/27/16 Time to onset: 30 minutes, delayed with food Duration: intermediate, ~12 hours Half-life: 9-13 hrs Decreases sleep latency, increases total sleep time Unique: REM sleep effects-sleep paralysis, increased serum cholesterol, diarrhea (2%), xerostomia (2%) Schedule IV controlled substance A major substrate of CYP3A4 and minor substrate of CYP2C19 Adult: 10 mg within 30 minutes of bed, max 20 mg Hepatic: none in mild/mod; not studied in severe Cost: brand only $11.36/tab regardless of strength 39 Differential of Suvorexant and Zolpidem of Sleep Initiation and Consolidation, SWS, REM Sleep. Neuropsychopharmacology Study Design Randomized, double-blind, double-dummy, placebo-controlled, fourperiod crossover study Population 44 healthy males years old, BMI kg/m2 with sleep duration hrs/night for 3 mo Purpose To investigate a single oral dose of suvorexant 10 or 30 mg, with a positive control, zolpidem 10 mg Results Total Sleep Time (TST) Suvorexant 10 mg and 30 mg TST by 17 and 31 min vs placebo Zolpidem 10 mg TST by 11 min vs placebo Wake After Sleep Onset (WASO) Significantly reduced for 30 mg dose only Sleep Structure Suvorexant 10 mg time in stage 1 and 30 mg % of time spent in REM sleep Interval between sleep onset and first occurrence of REM sleep <15 min were observed for 10 and 30 mg suvorexant Zolpidem % time in stages 3 and 4 and the time spent in REM Adverse Frequency similar for all active groups Suvorexant 30 mg >2x as many reports of somnolence and disturbance of attention than placebo and zolpidem 40 ANTIDEPRESSANTS & ANTIPSYCHOTICS ANTIHISTAMINES Tricyclic Antidepressants (TCAs) Amitriptyline, nortriptyline, doxepin* Alpha-2 Antagonist/H1 antagonist Mirtazapine mg Serotonin Reuptake Inhibitor/Antagonist Trazodone mg Place in Therapy: due to significant SE profiles, recommended as 3 rd line when used in conjunction with treating comorbid depression/anxiety. Evidence suggests efficacy alone is weak. No one agent preferable. *FDA approved for insomnia Atypical Antipsychotics Quetiapine, olanzapine May only be suitable for patients with comorbid insomnia who may benefit from primary action of these drugs as well as from the sedating effect. Evidence for efficacy is insufficient. Diphenhydramine (Benadryl ) Doxylamine (UniSom ) Efficacy Additional mg sleep latency, sleep quality Transient mg sleep latency Transient Anticholinergic, next day sedation, mental fogginess Beers Criteria Anticholinergic, tachycardia, next day sedation Beers Criteria Avoid in BPH, glaucoma, dementia. Not as effective as BZDs Avoid in elderly, BPH, glaucoma, dementia OTC product. Metabolized via liver (2D6) Max sedation 3-6 hrs after dose OTC product May interfere with urine detection of methadone Schutte-Rodin. J Clin Sleep Med Savarses M. Subjective Hypnotic Efficacy. Arch Ital Biol. Sept Lexicomp. Updated 12/31/15 DiPiro Pharmacotherapy, 9 th Edition 42 7

8 MELATONIN NATURAL PRODUCTS An endogenous hormone capable of affecting circadian rhythm to drive increased total sleep time, sleep quality, and decrease sleep latency : 2 10 mg given 30 min to 2 hours before bed Advantages: Not a controlled substance, no dependence risk No hangover effect or tolerance Cost and availability Safety in select populations Kava Conflicting evidence in insomnia, some efficacy in insomnia associated with anxiety disorders Mild psychoactive effects Hepatotoxicity in clinical trials with only 1 month of use FDA and CDC warnings in 2002 regarding liver effects Banned from market in Germany, Canada, Switzerland Interaction with other CNS depressants, CYP 2C19 3A4, and 2C9 substrates Sour Cherry Insufficient evidence to rate effectiveness in insomnia Improved time awake after sleep onset and insomnia severity but not sleep latency Contains a small amount of melatonin (30 ml juice contains 1.4 mcg/l melatonin) but varies among varieties of cherries Valerian Possibly effective in reducing time to sleep onset and improved sleep quality, however, safety with long-term use is unknown mg Few side effects: headache, excitability (paradoxical), insomnia, tachycardia, hepatotoxicity Interaction with other CNS depressants, CYP 3A4 substrates Kava. Natural Medicines. Last Updated 2/15/15 Sour cherry. Natural Medicines. Last Updated 3/13/15. Valerian. Natural Medicines. Last Updated 2/16/15 Janet MY et al. Experiences with sedative hypnotics and risk perception. Health Expectations. June Ferraciolo-Oda. Meta-Analysis of Melatonin for Primary Sleep Disorders. PLOS One ZZ s son, ZZ Jr appreciates all the support you ve given his father and has some complaints of his own. He is 47 who reports trouble falling asleep. He has tried sleep restriction and lifestyle modifications to no avail. Which agent may be most appropriate for ZZ Jr given the following information: PMH: chronic insomnia, HTN, COPD Med list includes: Albuterol HFA 2 puffs Q4-6 hrs prn SOB Tiotropium inhale 1 capsule daily for COPD Losartan 25 mg daily for HTN BEST OPTIONS IN A. Eszopiclone (Lunesta ) 1 mg immediately at bed B. Suvorexant (Belsomra ) 20 mg 30 minutes prior to bed C. Ramelteon (Rozerem ) 8 mg 30 minutes before bed D. Temazepam 15 mg at bedtime Trouble Falling Asleep (sleep onset) Rapid onset with short-half life Zaleplon, ramelteon, triazolam Trouble Staying Asleep (sleep maintenance) Delayed onset with long half-life Zolpidem, temazepam, trazodone Middle of the night awakenings Rapid onset with short half-life Zaleplon, zolpidem CR Mixed trouble falling and staying asleep Rapid onset and longer half-life Zolpidem, eszopiclone, suvorexant 47 Schutte-Rodin. J Clin Sleep Med

9 BEST OPTIONS IN SUMMARY Elderly CBT +/- pharmacotherapy Melatonin, ramelteon, sedating antidepressant History of Substance Abuse CBT +/- pharmacotherapy Ramelteon, melatonin, sedating antidepressant, antihistamines AVOID: BZDs, BZDRAs Hepatic Dysfunction CPT +/- pharmacotherapy AVOID in severe: zaleplon, ramelteon, suvorexant While insomnia is prevalent in the US and has a significant impact on QOL, it is not often managed A thorough assessment of causes and characterization of insomnia is essential prior to treatment Non-pharmacological therapies to improve sleep habits and quality are first line according to American Academy of Sleep Medicine guidelines Patient-specific factors should be used to guide selection of therapy for chronic insomnia THE WRONG SIDE OF THE BED: CHRONIC INSOMNIA DANIELLE ROWAN, PHARMD, MBA PGY1 PHARMACY PRACTICE RESIDENT IOWA CITY VA HEALTH CARE SYSTEM 9

Insomnia: Updates in Medical Management. Michael Newnam M.D.

Insomnia: Updates in Medical Management Michael Newnam M.D. Sleep Neurobiology Delicate balance of excitatory and inhibitory neurotransmitters that control the switch between wakefulness and sleep Circadian