Insomnia

1
Insomnia

• Key slides

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InsomniaNICE TA 77, April 2004 CKS (Prodigy),
July 2006 DTB 2004

• Insomnia difficulty initiating sleep and/or
  difficulty maintaining sleep
• Prevalence estimates vary from 10 - 48
• Higher in women, with increasing age and in those
  with concurrent physical or mental health
  conditions
• Primary insomnia
• Unknown origin or arising from sleep environment,
  irregular sleep routine, or negative conditioning
  to sleep
• Secondary insomnia
• Underlying psychological or physical condition,
  prescribed/OTC medicines, caffeine or substance
  misuse
• Important to avoid unrealistic sleep expectations
• For all people with insomnia, offer advice on
  good sleep hygiene and stimulus control
• Also consider exercise, relaxation therapies, etc.

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Non-drug approachesCKS (Prodigy), July 2006

• Sleep hygiene
• Avoid caffeine and nicotine 6 hours before bed
  time
• Avoid alcohol around bedtime (alcohol may
  encourage sleep onset but tends to fragment
  sleep)
• Avoid heavy meals before sleep (although a light
  meal may be helpful)
• Avoid exercise within 4 hours of bedtime
  (although exercise earlier in the day is
  beneficial)
• Minimise noise, light and excessive heat during
  the sleep period.
• Stimulus control measures
• Only go to bed when sleepy
• Only use the bed for sleeping and sex
• Leave the bedroom if not asleep within
  1520 minutes and go back to bed only when
  feeling sleepy again
• Get up at a fixed time in the morning, regardless
  of the amount of sleep achieved the previous
  night
• Avoid sleep during the day.

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Hypnotics for insomniaCSM, Curr Problems
Pharmacovigilance January 1988, No. 21SPCs for
zopiclone, zolpidem, zaleplon accessed from
emc.medicines.org.uk, July 2008

• Benzodiazepines should be used only if insomnia
  is severe, disabling or subjecting the patient to
  extreme distress
• Use lowest dose, for maximum of 4 weeks
• Use intermittently, if possible
• Taper off gradually
• Zopiclone, Zolpidem
• Shortterm treatment of insomniain situations
  where the insomnia is debilitating or is causing
  severe distress for the patient
• Longterm continuous use is not recommended
• Treatment duration a single course of treatment
  should not continue for longer than 4 weeks
  including any tapering off
• Zaleplon
• Treatment duration a single course of treatment
  should not continue for longer than 2 weeks.

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NICE guidance newer hypnotics (Z-drugs)NICE TA
77, April 2004

• No compelling evidence of a clinically useful
  difference between the Z-drugs and shorter-acting
  benzodiazepines from the point of view of their
  effectiveness, adverse effects, or potential for
  dependence or abuse
• The drug with the lowest purchase cost should be
  prescribed
• Switching from one of these hypnotics to another
  should only occur if a patient experiences
  adverse effects considered to be directly related
  to a specific agent. These are the only
  circumstances in which the drugs with the higher
  acquisition costs are recommended
• Patients who have not responded to one of these
  hypnotic drugs should not be prescribed any of
  the others.

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What would happen to 13 people who take sleeping
tablets for more than a week?Glass J, et al. BMJ
20053311169
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Road traffic accidents and benzodiazepines
Bandolier 1998575 (Hemmelgarn B, et al. JAMA
199727827-31)
Risks of RTA in Quebec 1990-93 Short half-life
benzos RR 0.96 (95CI 0.88 to 1.05) NS Long
half-life benzos RR 1.28 (95CI 1.12 to 1.45),
higher risk in first week
8
Hip fractures and benzodiazepinesWagner AK, et
al. Arch Intern Med 2004164156772

• Incident RR of hip fracture with BZD vs. no BZD
  use based on US claims data (194,071 person years
  of data, 1988-90)
• Any BZD exposure 1.24 (95CI 1.06 to 1.44)
• Long half-life BZD only 1.13 (0.82 to 1.55) NS
• Short half-life high potency 1.27 (1.01 to 1.59)
• Short half-life low potency 1.22 (0.89 to 1.67)
  NS
• gt1 BZD type 1.53 (0.92 to 2.53) NS
• New BZD lt16 days 2.05 (1.28 to 3.28)
• New BZD 1630 days 1.88 (1.15 to 3.07)
• Continued BZD 1.18 (1.03 to 1.35)
• Authors conclude incidence of hip fracture
  appears to be associated with benzodiazepine use.
• Note Different doses were not considered.

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Other issues

• Some GPs have misperceptions about the safety and
  efficacy of Z-drugs compared to benzodiazepines
• Siriwardena AN, et al. Br J Gen Pract
  2006569647
• Older people are not always being given
  appropriate safety warnings about taking these
  drugs
• Iliffe S, et al. Aging Ment Health 200482428
• It is difficult to withdraw from hypnotic drugs
• A letter from the GP can be effective in helping
  some to stop
• Cormack MA, et al. Br J Gen Pract 1994445-8
• CBT can be helpful
• Morgan K, et al. HTA 20048 (8)
• See CKS guidance for further information
• Published criteria for clinical audit are
  available
• Shaw E, Baker R. Journal Clin Governance
  2001945-50, NICE TA 77, April 2004

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Trends in prescribing of hypnotics in general
practice in England NHSBSA, September 2009
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Summary of key messages

• Non-drug treatments should be considered and used
  routinely in all patients
• 1988 CSM advice re benzodiazepines still stands
  and is also applicable to Z-drugs
• NICE guidance confirms that Z-drugs offer little
  or no advantage over benzodiazepines
• However overall prescribing of benzodiazepines
  and Z-drugs is not decreasing
• Long-term use of hypnotics is off-label and is
  contrary to all available evidence and guidance
• Think about auditing benzodiazepine and Z-drug
  use and changing practice
• Resources exist for managing withdrawal
• No evidence that new melatonin receptor agonists
  offer advantages over existing hypnotics.