Insomnia and Drowsiness

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Insomnia and Drowsiness

• Prepared by Lindsey Brown
• Winter Term 2006

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A disorder not a disease

• Diverse etiologies patient complaints
• Very subjective
• ½ of US population experienced insomnia in the
  past year
• 30 of patients have symptoms nightly

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Questions?
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Chief complaint?

• Specific complaint of insomnia?
• How is it affecting their daily activities?

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Duration and Frequency?

• Transient lt 1 week
• Short term 1-3 weeks
• Chronic gt 3 weeks

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Medical History?

• Current Medical Problem or Conditions?
• Current Medications (Rx or OTC)?
• Allergies or Sensitivities?

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Good Sleep Hygiene
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• Regular sleep pattern
• Comfortable surroundings
• Relax
• Exercise
• Break the cycle of daytime naps
• Avoid overeating close to bedtime
• Monitor caffeine and nicotine use
• Alcohol not a good sedative
• Avoid sleep anxiety

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Diphenhydramine

• The only FDA approved OTC sleep aid
• Patient specific dosing (25-50mg QHS)
• Duration of sedation 3 - 6 hours
• Next morning hang-over tolerance are common

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What to be aware of

• Anticholinergic SEs
• Contraindications BPH, difficulty urinating
• narrow closed angle glaucoma, CVD, dementia
• Do not use more than 7-10 days

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Melatonin

• Endogenous hormone produced by pineal gland
• Shifts circadian rhythm, body temp, and
• alertness
• 0.3- 1 mg taken 1-2 hours prior to bedtime

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Drowsiness Case Study

• 23 yo male comes to your pharmacy and states
  that he was up all weekend studying for finals,
  and is worried he cant stay alert to take the
  tests he studied so hard for. He is looking for
  an OTC stimulant to help stay awake for his 3
  days of exams.

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What do you need to know?
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• Medical or psychiatric problems
• Current medications
• Caffeine consumption
• Sleep patterns
• Lifestyle

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Caffeine

• Not a substitute for good sleep patterns
• Most frequently used stimulant in the world
• Good sleep hygiene, lifestyle modifications, and
  referral should come 1st

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If Caffeine is used

• Xanthine derivative that antagonizes the
  receptors of Adenosine
• Tolerance and withdrawal are common
• Usual Dose 100 -200mg Q3-4H PRN, NTE 600mg/day
• Special considerations

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Ginseng

• Herbal product that inhibits thromboxane
• Weak antiplatelet effects, increased risk of
  bleeding
• May exacerbate psychiatric symptoms
• Hypoglycemic effects
• Usual Dose 100-300mg BID

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Musculoskeletal Injuries

• Sprains, Strains and Pains

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Musculoskeletal and connective tissue injuries
are the 3rd and 5th leading cause of lost work
days in men women in the US, respectively..
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Patient Assessment

• There are no wrong answers

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P,Q,R,S,T

• Precipitating factors
• Quality of pain
• Region or location
• Severity (changes in daily activities)
• Timing

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Exclusions for self-treatment

• Pain with N/V
• Weakness in any limb
• Visually deformed joint or abnormal joint
  movement
• Joint pain with systemic symptoms
• Pelvic or abdominal pain
• Pain that is increasing or changing
• Flouroquinolone use
• Duration gt2 weeks

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Tendonitis, Bursitis, Strains, and Sprains

• P protect
• R rest
• I ice (10-30 min TID-QID or at max Q2H)
• C compress
• E elevate
• NSAIDS
• 2 theories early vs. withhold

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Counterirritants

• Paradoxical pain-relieving effect achieved by
  producing a less severe pain to counter a more
  intense one
• Psychological component placebo effect

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Rubefacients

• MOA vasodilation producing reactive hyperemia
  redness
• Methyl salicylate most widely used

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Cooling Sensation

• Dose Dependent MOA
• Stimulates nerves that perceive cold while
  depressing nerves that perceive pain, this is
  followed by a sensation of warmth
• Menthol
• Camphor

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Vasodilation

• MOA
• Marked power of diffusion which leads to elevated
  skin temperature at very low concentrations
• Mediated by PG biosynthesis
• SEs drop in BP, pulse, and syncope
• Methyl Nicotinate

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Incite Irritation

• MOA depletes sensory neurons of Substance P,
  which will cause burning pain and redness
• Capsicum only counterirritant for chronic pain
• Apply TID-QID for long-term use

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Unproven Effectiveness

• MOA absorbed through the skin and results in
  synovial fluid salicylate concentrations slightly
  lower than oral ASA.
• Contraindications renal insufficiency, liver
  disease, hypothrombinemia, vitamin K deficiency,
  scheduled for surgery, chronic alcohol users
• Trolamine Salicylate

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Osteoarthritis

• Affects ½ of US population gt 70 yo
• General Treatment Approach
• APAP NTE 4000mg/ day
• Glucosamine 1500mg QD

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Dont Forget

• Warm-up and Cool down

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References

• Berardi R, McDermott J, et al. HandBook of
  NonPrescription Drugs. 14th Ed. 2004.
• Engle J, Stovitz S. Partners in Self-Care
  Self-Treatment Options for Common Sports and
  Physical Activity Injuries. 2004 12 1-18.