Clinical Brief: Sleep Medications

Educational Objectives

The goal of this program is to improve insomnia. After hearing and assimilating this program, the clinician will be better able to:

1. Analyze the safety of commonly prescribed sleep medications.

Summary

Safety: the Beers criteria is an extensive list of potentially inappropriate medication use in older patients

Benzodiazepines (BZD): the least safe option (schedule 4 medications) with addictive potential; BZD decrease sleep latency; use of intermediate-acting BZD is advisable; avoid short-acting BZD (half-life, <6 hr; eg, triazolam [Halcion]), as repeated administration may increase the addictive potential; intermediate-acting BZD (half-life, 7-8 hr) include temazepam (Restoril) and lorazepam (eg, Ativan, Lorazepam Intensol, Loreev); long-acting BZD (half-life, >24 hr; eg, diazepam [Valium]) increase the risk for sedation and falls; use BZD sparingly and for no longer than 7 to 10 days

BZD receptor agonists (BZRA): include zolpidem (eg, Ambien, Edluar, Intermezzo) and eszopiclone (Lunesta); increase sleep time; a landmark trial demonstrated the safety of eszopiclone for 6 mo; adverse events of BZRA include weird sleep behaviors (eg, sleepwalking, sleep driving); in the elderly, BZRA may be used for a short duration (preferably avoided); caution against driving after the dose (<11 hr)

Trazodone: low-dose trazodone (25-100 mg) as needed at night is generally considered safe; improves sleep quality, unlike antihistamines (eg, diphenhydramine [eg, Benadryl, Nytol, Unisom]), which disrupt sleep architecture; patients feel more relaxed and refreshed after sleep

Doxepin: low-dose doxepin (Silenor), a tricyclic antidepressant with antihistaminic activity, is approved for insomnia; not as sedating as diphenhydramine but effective; has a better safety profile compared with trazodone

Melatonin: a hormone produced by the pineal gland; controls circadian rhythms; production decreases with age; supplemental melatonin is very safe; melatonin is available in low (<2 mg) and standard (>5 mg) doses; 60-mg melatonin is available over the counter; as melatonin does not have an LD50 (the dose at which the drug is lethal to 50% of users), mortality is rare; however, mortality from respiratory depression in children <2 yr of age was reported during the COVID-19 pandemic; 200-mg melatonin has been used in clinical trials by children with cancer; 5- to 20-mg melatonin for sleep is efficacious; although melatonin can be ingested 30 min before sleep, administration of melatonin 2 to 5 hr before sleep can be more effective on sleep-wake rhythm; ramelteon (Rozerem), a melatonin receptor agonist, is expensive

Miscellaneous: patients develop tolerance to the hypnotic effect of antihistamines; mirtazapine (Remeron) causes weight gain, but patients develop tolerance; alcohol is a sedative but has a rebound effect

Readings

2023 American Geriatrics Society Beers Criteria Update Expert Panel. American Geriatrics Society 2023 updated AGS Beers Criteria for potentially inappropriate medication use in older adults. J Am Geriatr Soc. 2023;71(7):2052-2081. doi:10.1111/jgs.18372. View Article; Katwala J, Kumar AK, Sejpal JJ, et al. Therapeutic rationale for low dose doxepin in insomnia patients. Asian Pac J Trop Dis. 2013;3(4):331-336. doi:10.1016/S2222-1808(13)60080-8; Krystal AD, Walsh JK, Laska E, et al. Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia. Sleep. 2003;26(7):793-799. doi:10.1093/sleep/26.7.793. View Article; Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(2):307-349. doi:10.5664/jcsm.6470.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose. Dr. Cheng's lecture includes information related to the off-label or investigational use of a therapy, product, or device.

Acknowledgements

Dr. Cheng was recorded exclusively for Audio Digest on October 24, 2024. Audio Digest thanks the speakers and presenters for their cooperation in the production of this program.

CME/CE INFO

Accreditation:

The Audio- Digest Foundation is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Audio- Digest Foundation designates this enduring material for a maximum of 0.50 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Audio Digest Foundation designates this activity for 0.50 CE contact hours.

Lecture ID:

FP730402

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 3 years from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.