NURS 6630 Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult

NURS 6630 Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult

Insomnia
31-year-old Male

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

Decision Point One

Select what you should do:

Zolpidem: 10 mg daily at bedtime

Trazodone: 50–100 mg daily at bedtime

Hydroxyzine: 50 mg daily at bedtime

Decision Point One

Zolpidem: 10 mg daily at bedtime

RESULTS OF DECISION POINT ONE

Patient returns to clinic in 2 weeks.
Patient states the medication “knocked him out” but felt he slept well.NURS 6630 Pharmacologic Approaches to the Treatment of Insomnia
NURS 6630 Pharmacologic Approaches to the Treatment of Insomnia

His new girlfriend was concerned as he woke up in the middle of the night and cooked breakfast, yet the patient has no recollection of the occurrence.
Patient states that the medication helps him sleep especially well when taken with a beer right before bedtime. Patient denies auditory/visual hallucinations and is future oriented.
Decision Point Two

Decrease zolpidem to 5 mg daily at bedtime

RESULTS OF DECISION POINT TWO

Patient returns to clinic in 2 weeks.
Patient states his episodes of “nighttime activity” has greatly decreased.
His girlfriend told him that one time in the 2 weeks he got up and was getting ready to go for a drive.
Patient denies auditory/visual hallucinations and is future oriented.
Patient states that he likes the way the zolpidem helps him sleep and “is good with continuing to take it if most of the time I sleep through the night undisturbed.”
Decision Point Three

Maintain dose. Patient to return in 4 weeks for follow up appointment

Guidance to Student

Zolpidem is a medication that has a host of negative side effects. It should not be the first choice of therapy due to these side effects. Caution must be exercised if prescribing this medication to a patient. The patient should be instructed not to mix the medication with alcohol or any other medication unless first speaking with their provider.

In this case, the patient is experiencing complex sleep behavior. It is prudent as the patient’s healthcare provider to discontinue this medication and prescribe something different.

Trazodone is a selective serotonin reuptake inhibitor that is a much safer choice. In adults you will want to start with 50mg at bedtime and titrate up as needed.

Decision Point One

Trazodone: 50–100 mg daily at bedtime

RESULTS OF DECISION POINT ONE

Patient returns to clinic in 2 weeks
Patient states medication works well but gives him an unpleasant side effect of a prolonged erection of the penis, approximately 15 minutes after waking
Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two

Explain that priapism is a side effect of trazodone that should diminish over time. Continue dose

RESULTS OF DECISION POINT TWO

Patient returns to clinic in 2 weeks
Patient states priapism has diminished over time
Patient denies auditory/visual hallucinations and is future oriented
Patient states trazodone is effective at 50 mg dose but sometimes wakes up following day with next-day drowsiness
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three

Discontinue trazodone. Initiate therapy with sonata 10 mg nightly at bedtime. Follow up in 4 weeks

Guidance to Student

Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. It would not be prudent to prescribe sonata as it carries with it the risk of complex sleep behaviors. Hydroxyzine is an antihistamine with strong sedative properties. However, many patients complain of anticholinergic adverse effects the following morning, such as Xerostomia and Xerophthalmia.

The patient is presenting with excessive somnolence. It would be prudent to reduce the dose of trazodone by 50% and reassess in 4 weeks.

Decision Point One

Hydroxyzine: 50 mg daily at bedtime

RESULTS OF DECISION POINT ONE

Patient returns to clinic in 2 weeks
Patient states medication helps with sleep but leaves a similar next-day feeling to what the patient experienced with diphenhydramine
Patient also states his mouth and eyes are extremely dry in the morning
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Two

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Discontinue hydroxyzine. Initiate therapy with temazepam 15 mg daily at bedtime

RESULTS OF DECISION POINT TWO

Patient returns to clinic in 2 weeks
Patient states temazepam really helps with sleep and makes him feel great when he washes it down with a beer
Patient denies auditory/visual hallucinations and is future oriented
Decision Point Three

Discontinue temazepam. Initiate therapy with trazodone 50–100 mg nightly at bedtime. Follow up in 4 weeks

Guidance to Student

The mixture of alcohol and benzodiazepines is one that can result in respiratory depression and death. It would be prudent to discontinue any benzodiazepines your patient is on if you are aware, or even have a suspicion, that the patient consumes alcohol. The mixture of hypnotics and alcohol can also cause respiratory depression and death. Trazodone is a selective serotonin reuptake inhibitor that has a low side effect profile. Alcohol counseling should also be discussed with the patient to rule out any issues.

Learning Resources

Required Readings (click to expand/reduce)

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Fernandez-Mendoza, J., & Vgontzas, A. N. (2013). Insomnia and its impact on physical and mental health. Current Psychiatry Reports, 15(12), 418. https://doi.org/10.1007/s11920-012-0418-8

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

Morgenthaler, T. I., Kapur, V. K., Brown, T. M., Swick, T. J., Alessi, C., Aurora, R. N., Boehlecke, B., Chesson, A. L., Friedman, L., Maganti, R., Owens, J., Pancer, J., & Zak, R. (2007). Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. SLEEP, 30(12), 1705–1711. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_Narcolepsy.pdf

Morgenthaler, T. I., Owens, J., Alessi, C., Boehlecke, B, Brown, T. M., Coleman, J., Friedman, L., Kapur, V. K., Lee-Chiong, T., Pancer, J., & Swick, T. J. (2006). Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. SLEEP, 29(1), 1277–1281. https://j2vjt3dnbra3ps7ll1clb4q2-wpengine.netdna-ssl.com/wp-content/uploads/2017/07/PP_NightWakingsChildren.pdf

Sateia, M. J., Buysse, D. J., Krystal, A. D., Neubauer, D. N., & Heald, J. L. (2017). Clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults: An American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine, 13(2), 307–349. https://jcsm.aasm.org/doi/pdf/10.5664/jcsm.6470

Winkleman, J. W. (2015). Insomnia disorder. The New England Journal of Medicine, 373(15), 1437–1444. https://doi.org/10.1056/NEJMcp1412740

Medication Resources (click to expand/reduce)

U.S. Food & Drug Administration. (n.d.). Drugs@FDA: FDA-approved drugs. https://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

alprazolam
amitriptyline
amoxapine
amphetamine
desipramine
diazepam
doxepin
eszopiclone
flunitrazepam
flurazepam
hydroxyzine
imipramine
lemborexant
lorazepam
melatonin
methylphenedate
modafinil
armodafinil
carnitine
clomipramine
clonazepam
nortriptyline
pitolisant
ramelteon
sodium oxybate
solriamfetol
SSRI’s
temazepam
trazodone
triazolam
trimipramine
wellbutrin
zaleplon
zolpidem