Insomnia (2.17.15) (EXAM 2)

Who should not use diphenhydramine?

- Older men with prostatic hyperplasia and difficulty urinating -Patients with cardiovascular disease -Patients with dementia

What are the treatment goals of insomnia?

-improve the patient's presenting symptoms, quality of life, and functioning

What can insomnia be caused by?

-medical or psychiatric conditions -mental stress or excitement -certain daytime and bedtime habits

What can diphenhydramine cause?

-morning grogginess or excessive sedation -dry mouth -blurred vision -constipation -difficulty urinating (particularly in older men).

For patients with transient or short-term insomnia but NO underlying medical conditions that cause insomnia what should you suggest?

-reestablish normal sleep cycle with good sleep hygiene practices -can do this WITH OR WITHOUT a nonprescription sleep aid.

What is a nonpharmacologic therapy for insomnia?

-sleep hygiene measures are recommended for all patients with insomnia. -in many patients, these measures should be tried before drug therapy -encourage them to try 1-2 at a time

Patients with insomnia are significantly more likely to report being unable to do what because they are too sleepy?

-work efficiently -exercise -eat healthfully -engage in leisure activities

What are the objectives for self-treatment of insomnia?

1. improve the duration and quality of sleep 2. reduce fatigue and drowsiness during the day 3. improve daytime function 4. minimize adverse effects of treatment

What are 3 complementary therapies that are commonly used for insomnia?

1. melatonin 2. valerian 3, kava

What are 6 exclusions for self-treatment for insomnia?

1.* <12 years of age 2. >or= 65 years of age* 2. *pregnancy* 3. frequent nocturnal awakenings or early morning awakenings 4. chronic insomnia (>3weeks) 5. sleep disturbance secondary to psychiatric or general medical disorders.

Advise patients with self-treatable symptoms that if symptoms worsen or do not improve __ days, they should contact their health care provider

10

DO NOT take diphenhydramine longer than __ days.

10

Refer children younger than __ years, pregnant women, and adults older than __ years with insomnia to their health care provider.

12 : 65

Compared with placebo, diphenhydramine improved sleep efficiency for __ weeks in patients with mild insomnia.

2

If insomnia worsens or continues beyond __ weeks while doing nondrug measures, seek medical attention.

2

After __-__ nights of improved sleep, skip taking the medication for one night to see if insomnia is relieved.

2-3

Although the usual diphenhydramine dosage is 50 mg nightly, some individuals benefit from a __ mg dosage.

25

Maximum sedation with diphenhydramine occurs between ___ and ___ hours after a dose

3 and 6

Do NOT take more than __ mg of diphenhydramine each night

50

The average adult requires 8 hours of sleep nightly, the typical American gets __ hours.

6.7

Diphenhydramine should be used for no more than _-__ consecutive nights because insomnia may be a symptom of an undiagnosed medical or psychiatric illness that requires further evaluation.

7-10

________ toxicity can result from excessive antihistamine dosages.

Anticholinergic

Counsel patients on the adverse effects of diphenhydramine and other sleep aids, particularly drowsiness and the additive _______ effects of alcohol and other sedating drugs.

CNS depressant

In patients on multiple medications, particularly older patients, diphenhydramine may reduce the clearance of drugs metabolized by _______, such as venlafaxine, codeine, or propranolol. These potential interactions should be carefully monitored.

CYP2D6 (Diphenhydramine, an inhibitor of the hepatic enzyme CYP2D6)

____________ anticholinergic toxicity is one of the primary presenting features of antihistamine excess.

Central nervous system (CNS)

When should you take diphenhydramine?

Establish a regular bedtime and take diphenhydramine 30-60 minutes before you want to go to sleep

_______, in both low and high quantities, initially improves sleep in people who do not abuse alcohol, but sleep disturbances occur in the second half of the night at high doses.

Ethanol

________ affect sleep through their affinity for blocking histamine1 and muscarinic receptors.

Ethanolamines

Why shouldn't you take diphenhydramine longer than 10 days?

Longer use will cause tolerance to the medication's sleep-inducing effects but not necessarily to its side effects, and you may have an underlying disorder that is causing insomnia

________ may be effective in short-term treatment of delayed sleep phase syndrome (i.e., a sleep pattern characterized by a delayed onset of sleep by 2 or more hours from normal, resulting in a later bedtime and wake time). (evidence of efficacy is conflicting and limited

Melatonin

Can you take diphenhydramine while breast-feeding

NO, Diphenhydramine may pass into breast milk and may harm a nursing baby. Antihistamines may also slow breast milk production. Do not use this medicine without medical advice if you are breast-feeding a baby.

Alcohol is present in some nonprescription combination cold products, such as _____ Liquid, which contains 10% alcohol by volume. Data are limited regarding the efficacy and safety of these products as hypnotics

NyQuil

Insomnia is one of the most common patient complaints, ranking third behind headache and the common cold. What is Insomnia?

Occurs when a person has trouble falling or staying asleep, wakes up too early and cannot return to sleep, or does not feel refreshed after sleeping.

______ quickly develops after the initial beneficial effects, often leading to the use of higher doses

Tolerance

________ has limited benefit in insomnia compared with placebo.

Valerian

When is insomnia considered chronic?

When it happens almost nightly for at least 1 month

Patients with other sleep disorders, such as sleep apnea, narcolepsy, and restless legs syndrome, also seek nonprescription sleep aids. BUT because of potentially significant adverse clinical effects, patients with these disorders should see who?

a sleep specialist

What can happen when alcohol use ceases in someone who chronically drinks?

a worsening of sleep

Use of _____ to induce sleep is common in patients with chronic insomnia and is associated with hazardous drinking behavior

alcohol

Why should you NOT take diphenhydramine with alcohol?

alcohol can increase the effects of the medication on the central nervous system. Alcohol also disrupts the sleep cycle.

Additive sedation or _________ effects occur when diphenhydramine is used in combination with other medications that have these properties.

anticholinergic

What is the primary adverse effects of diphenhydramine and doxylamine?

anticholinergic (dry mouth and throat, constipation, blurred vision, urinary retention, and tinnitus)

Patients exhibiting excessive anticholinergic effects can be .....

anxious, excited, delirious, hallucinating, or stuporous.

Significant morbidity is associated with obstructive sleep apnea, including increased mortality from ________ death.

cardiovascular

In general, diphenhydramine is not as effective as benzodiazepine hypnotics and should not be recommended for a _______ sleep disturbance

chronic

The efficacy of diphenhydramine in patients with ______ insomnia is poor!

chronic

Only a small of patients with a sleep disorder actually tell their medical provider. The combination of frequent misuse of hypnotics and availability of nonprescription agents makes insomnia a disorder of significant _______.

concern

Advise patients about the different dosage forms of sleep aids so they can select a product that is best suited for them. Advise patients that _______ is the only antihistamine recommended as a sleep aid for OCCASIONAL insomnia.

diphenhydramine

When the FDA issued its final monograph on nonprescription sleep aids in 1989, __________ was the ONLY sleep aid deemed to be safe and effective.

diphenydramine

Refer patients with chronic insomnia or sleep disturbance caused by an underlying _______ for medical evaluation.

disorder

Individuals with heavy or continuous alcohol use usually experience restless sleep, often awaken within 2-4 hours, and have reduced total sleep duration. People who chronically drink alcohol usually have a marked _________ of the sleep cycle.

disorganization

Although the safety and efficacy of _________ have not been fully established, FDA has allowed the drug to remain on the market.

doxylamine

Diphenhydramine and ________ are members of the ethanolamine group of antihistamines.

doxylamine

Counsel patients with insomnia on nondrug measures such as what?

good sleep hygiene

Kava (Piper methysticum) has been used in insomnia and has been associated with severe _________. Therefore, kava should not be recommended as a sleep aid.

hepatotoxicity

_______ is difficulty getting enough sleep or trouble sleeping without interruption.

insomnia

A report on the safety and effectiveness of melatonin found that, for most sleep disorders, its benefits are ________.

limited

Consult your health care provider before taking diphenhydramine with other ________

medications.

Counsel patients that nonprescription sleep aids can cause what?

next-day sedation

Complaints of insomnia in _____ patients should be carefully evaluated.

older

Patients with sleep disorders should be encouraged to do what before starting drug medications?

practice good sleep hygiene measures. (for some patients these measures alone will resolve insomnia)

Advise patients to discuss the potential risks and benefits of complementary therapies with their health care provider before _______ an agent.

selecting

Combination products containing diphenhydramine and acetaminophen, ibuprofen, or aspirin are available, although no published studies establish whether these products are of additive benefit in inducing ______ in patients who complain of insomnia caused by pain.

sleep

Clinical trials have used 400-900 mg of the valerian root extract. Continuous nightly use for several days or weeks is required for effect, so valerian is not useful for acute insomnia. Patients using large dosages of valerian over several years can experience severe benzodiazepine-like withdrawal symptoms and cardiac complications. Therefore valerian should be ______ tapered after extended use.

slowly

What is the primary indication for diphenhydramine?

symptomatic management of transient and short-term sleep difficulty, particularly in individuals who complain of occasional problems falling asleep.

If use of a nonprescription sleep aid is appropriate for insomnia, the dosage guidelines and recommended duration should be reviewed with who?

the patient

Taking more than one product (i.e., prescription, nonprescription, and dietary supplements) concomitantly to treat insomnia should be discouraged; why?

this approach increases the risk of adverse effects

Advise patients not to take other oral medications that contain diphenhydramine with a nonprescription sleep aid that also contains diphenhydramine OR _____ products that contain diphenhydramine.

topical