Insomnia strikes 30%-40% of American adults annually and 10% have insomnia that is chronic or severe.
Behavioral therapy is the first step recommended by some experts. But for patients whose primary insomnia has lasted for more than 4 weeks, drug therapy is the most common treatment. Drug therapy works faster; behavioral therapy produces more durable results. Combining the two may work even better but not dramatically so.
The benzodiazepine receptor agonists (BRAs) are considered the top drug class. The other drugs listed here are alternatives that can be used for selected patients or after several BRAs have proved ineffective or are not tolerated.
Primary insomnia is diagnosed mainly by exclusion. Insomnia can be secondary to several physical and psychological conditions that must be ruled out before starting drug therapy Experts have five rules for treating patients with drugs for insomnia: Use the lowest effective dose, limit drug use to 2-4 days a week, use drug therapy for a maximum of 4 weeks, discontinue the drug gradually and watch for rebound insomnia.
BRAs are not recommended for pregnant or breast-feeding women. Patients with hepatic or renal insufficiency may have an increased risk of sedative side effects from drugs in this class. The dose of BRAs should be halved for elderly patients. Among the non-BRAs, amitriptyline should not be used in women who are pregnant or breast-feeding. Doxepin and the listed antihistamines also should be avoided in breastfeeding women.
The class of hypnotic agents is largely composed of benzodiazepine receptor agonists. BRAs differ in their elimination half-lives. Some experts say that the drugs with short half-lives--zaleplon, zolpidem, and triazolam--are best for patients who have trouble falling asleep, while the intermediate half-life BRAs--estazolam, oxazepam, and temazepam--are best for patients who have trouble staying asleep. The BRAs with longer half-lives-clonazepam, flurazepam, and quazepam--are considered by some experts to be best used when daytime anxiolytic activity is desirable; in addition, these drugs may cause less rebound insomnia. But other experts say that the efficacy of all BRAs is similar. Rule out sleep apnea before prescribing a BRA because it may depress respiration.
COPYRIGHT 2000 International Medical News Group
COPYRIGHT 2001 Gale Group