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» Home » CAD » Neurology » Sleep disorders » Insomnia
Background
Insomnia is defined as trouble in maintaining or initiating sleep, as well as poor sleep quality. These symptoms persist despite the availability of appropriate sleep and circumstances, resulting in daytime dysfunction.
Insomnia has a negative impact on one’s health, quality of life, academic performance, increased risk of automobile accidents, reduce productivity at work, irritability, and increased daytime sleepiness.
Insomnia is also regarded as a risk factor for therapeutic conditions such as chronic pain syndrome, depression, cardiovascular disease, anxiety, diabetes, asthma, and obesity.
Epidemiology
Insomnia affects 10-15% of the overall population. In 2010, around 5.5 million outpatient visits for sleep disorders were recorded in the United States. Though it affects people of all ages, it is more common in peri and post-menopausal women and elderly individuals.
Anatomy
Pathophysiology
The genetic markers for sleep declination were identified from insomnia-like Drosophila flies, which exhibited characteristics comparable to human insomnia. Clock gene 3111C/C Clock and short (s-) allele of the 5-HTTLPR is linked to insomnia.
Wake-promoting compounds such as catecholamine, histamine, and orexin, as well as sleep-promoting chemicals, such as serotonin, GABA, adenosine, prostaglandin D2, and melatonin, are essential for sleep-wake regulation.
One of the proposed processes leading to insomnia is an orexin-mediated enhanced neuronal activity in the wake-promoting area and suppression of the sleep-promoting area (median and ventrolateral preoptic nuclei).
Etiology
Individuals who cannot cope with a stressful circumstance or who report being regular light sleepers are more likely to develop chronic insomnia. Insomnia is frequently associated with mental diseases such as anxiety, depression, and post-traumatic stress disorder.
Comorbid medical conditions such as chronic pain, restless legs syndrome, gastroesophageal reflux disease, immobility, and respiratory problems are linked to an increased risk of chronic insomnia.
Separation anxiety, for example, might predispose a child to sleep disorders. People who aim for perfectionism, ambition, neuroticism, poor extraversion, and a propensity for despair and concern are more prone to insomnia over time.
Insomnia is more prevalent among individuals who have experienced psychosocial stress, such as a disrupted domestic life, divorce, the loss of a spouse, or alcohol or substance misuse.
Genetics
Prognostic Factors
Clinical History
Physical Examination
Age group
Associated comorbidity
Associated activity
Acuity of presentation
Differential Diagnoses
Laboratory Studies
Imaging Studies
Procedures
Histologic Findings
Staging
Treatment Paradigm
by Stage
by Modality
Chemotherapy
Radiation Therapy
Surgical Interventions
Hormone Therapy
Immunotherapy
Hyperthermia
Photodynamic Therapy
Stem Cell Transplant
Targeted Therapy
Palliative Care
Medication
5 - 10
mg
Capsule
Orally
once a day
before bedtime, increase to 20 mg/day based on clinical symptoms
Dose Adjustments
Discontinue the drug for severe renal or hepatic failure
7.5
mg/day
Orally
at bedtime
4
weeks
Reduce the dose up to 3.75 mg according to the patient’s response
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
7.5
mg/day
Orally
at bedtime
4
weeks
Reduce the dose up to 3.75 mg according to the patient’s response
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
0.125 - 0.25
mg
Tablet
Orally
at bedtime
15 - 30
mg
Capsule
Orally
at bedtime
In the case of debilitated patients; 7.5 mg orally before bedtime
15 - 30
mg
Capsule
Orally
at bedtime
8 mg orally taken 30 minutes before bed
The Maximum Dose per day is 8 mg
Note:
Avoid taking this medication with or right after a high-fat meal
15 - 45
mg
Tablet
Orally
Once a day in the night
Initial dose: 1mg orally before bedtime
Maintenance dose: 1-3mg orally before bedtime
Maximum dose:3mg/kg
Dose Adjustments
The starting dose for those taking a CYP3A inhibitor should not exceed 1 mg. No dose adjustment is required for mild to moderate renal impairment, but those with severe hepatic impairment should start with 1 mg PO HS
Dosage adjustments may be necessary to avoid additive effects when eszopiclone is coadministered with another central nervous system (CNS) depressant
Insomnia Dosage Recommendation:
400–900 mg PO of aqueous extract up to 2 hours before bedtime
Extract from ethanol: 600 mg orally at bedtime
Root: 2-3 g orally (fresh or dried) three times a day
Hops or lemon balm combinations: 320–500 mg PO HS
a maximum of 28 days
50
mg
Orally
30 minutes before going to bed
(Off-label)
Indicated for chronic insmonia
2 to 4 mg orally as given on prescription
Dose modification
In the case of severe renal or hepatic impairment, do not take lorazepam
100 to 200 mg orally every night at bedtime; do not exceed 400 mg/day
(Off-Label)
15-45 mg orally every night
(Off-Label)
After depression- 5-20 mg orally for 8 weeks
After panic disorder- 5-10 mg for 8 weeks
(Off-Label)
After depression- 5-20 mg orally for 8 weeks
After panic disorder- 5-10 mg for 8 weeks
levomepromazine (methotrimeprazine)
10-25 mg orally as a single dose at bedtime
25 mg intramuscularly as a single dose at bedtime
6.25-250 mg/day as a continuous infusion in sterile water or normal saline through a syringe pump
6.25 mg/day as a median dose for bolus administration administered in 1-2 divided doses
Take 3-5 mg of medication orally daily before bedtime
3 - 6
mg
Orally
30 minutes before going to bed
Do not exceed 6 mg daily
10 mg orally as a single dose every night, with at least 7 hours till the scheduled time of waking.
If the dose is ineffective then increase the dose as required
The maximum dose is 20mg a day
Dose Adjustments
Renal Impairment: Dosage adjustment is not required
Hepatic Impairment:
Severe: Not recommended
Mild-to-moderate: Dosage adjustment is not required
Co-administering CYP3A4 inhibitors
Moderate: Reduce the recommended dosage of suvorexant to 5 mg orally at bedtime; if tolerated but ineffective, consider increasing the dose, but no more than 10 mg/dose.
5 mg orally not more than once each night, just before going back to bed, with a minimum of 7 hours before the scheduled time of awakening remaining
Based on the clinical response and tolerability, the dosage can be increased upto 10 mg.
1.5-2 gm of dried strobile daily
60 mg extract in combination with valerian
Take a dose of 500 mg to 1 g orally 15 to 30 minutes before sleep
Only for use up to 2 weeks and a daily dose not more than 2 g
The administration of 10-18 grams of wild jujube seed extract decocted in water taken orally every day
Administer 1 or 2 capsules orally every day at bedtime
Kava-lactones: Administer 180 to 210 mg orally every night at bedtime
(off-label):
1 to 2 mg given orally before the bedtime
1-2 milligrams Orally every night at bedtime.
Administer 500 to 1000mg orally at bedtime
The recommended dose is 2.5-5 mg at sleep time
Safety and efficacy not seen in pediatrics
Safety and efficacy not seen in pediatrics
Not recommended for pediatrics
levomepromazine (methotrimeprazine)
In children and adolescents, 0.25 mg/kg/day orally in 2-3 divided doses
0.0625-0.125 mg/kg/day to be administered as a single dose or in divided doses
Titrate the dose based on its effectiveness
0.0625 mg/kg in D5W as a 250 ml infusion slowly at 20-40 drops/minute
5 mg orally not more than once each night, just before going back to bed, with a minimum of 7 hours before the scheduled time of awakening remaining
Based on the clinical response and tolerability, the dosage can be increased up to 10 mg
Initiate with the lower dose
Dose Adjustments
Renal and hepatic impairment: Discontinue the drug for severe failure
Initiate at 3.75 mg/day orally at bedtime up to 4 weeks, increase gradually based on patient tolerance and clinical symptoms
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
Dose Adjustments
Start with a lower dose of 0.125 mg, do not exceed more than 0.25 mg per day
7.5
mg
Capsule
Orally
at bedtime
10 - 14
days
15
mg
Capsule
Orally
at bedtime
Initial dose: 1mg orally before bedtime. Do not exceed 2mg
Initial dose: 0.5-1 mg orally as required
To prevent extra sedation, do not exceed the daily dose more than 2 mg
Future Trends
References
https://www.ncbi.nlm.nih.gov/books/NBK526136/
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» Home » CAD » Neurology » Sleep disorders » Insomnia
Insomnia is defined as trouble in maintaining or initiating sleep, as well as poor sleep quality. These symptoms persist despite the availability of appropriate sleep and circumstances, resulting in daytime dysfunction.
Insomnia has a negative impact on one’s health, quality of life, academic performance, increased risk of automobile accidents, reduce productivity at work, irritability, and increased daytime sleepiness.
Insomnia is also regarded as a risk factor for therapeutic conditions such as chronic pain syndrome, depression, cardiovascular disease, anxiety, diabetes, asthma, and obesity.
Insomnia affects 10-15% of the overall population. In 2010, around 5.5 million outpatient visits for sleep disorders were recorded in the United States. Though it affects people of all ages, it is more common in peri and post-menopausal women and elderly individuals.
The genetic markers for sleep declination were identified from insomnia-like Drosophila flies, which exhibited characteristics comparable to human insomnia. Clock gene 3111C/C Clock and short (s-) allele of the 5-HTTLPR is linked to insomnia.
Wake-promoting compounds such as catecholamine, histamine, and orexin, as well as sleep-promoting chemicals, such as serotonin, GABA, adenosine, prostaglandin D2, and melatonin, are essential for sleep-wake regulation.
One of the proposed processes leading to insomnia is an orexin-mediated enhanced neuronal activity in the wake-promoting area and suppression of the sleep-promoting area (median and ventrolateral preoptic nuclei).
Individuals who cannot cope with a stressful circumstance or who report being regular light sleepers are more likely to develop chronic insomnia. Insomnia is frequently associated with mental diseases such as anxiety, depression, and post-traumatic stress disorder.
Comorbid medical conditions such as chronic pain, restless legs syndrome, gastroesophageal reflux disease, immobility, and respiratory problems are linked to an increased risk of chronic insomnia.
Separation anxiety, for example, might predispose a child to sleep disorders. People who aim for perfectionism, ambition, neuroticism, poor extraversion, and a propensity for despair and concern are more prone to insomnia over time.
Insomnia is more prevalent among individuals who have experienced psychosocial stress, such as a disrupted domestic life, divorce, the loss of a spouse, or alcohol or substance misuse.
5 - 10
mg
Capsule
Orally
once a day
before bedtime, increase to 20 mg/day based on clinical symptoms
Dose Adjustments
Discontinue the drug for severe renal or hepatic failure
7.5
mg/day
Orally
at bedtime
4
weeks
Reduce the dose up to 3.75 mg according to the patient’s response
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
7.5
mg/day
Orally
at bedtime
4
weeks
Reduce the dose up to 3.75 mg according to the patient’s response
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
0.125 - 0.25
mg
Tablet
Orally
at bedtime
15 - 30
mg
Capsule
Orally
at bedtime
In the case of debilitated patients; 7.5 mg orally before bedtime
15 - 30
mg
Capsule
Orally
at bedtime
8 mg orally taken 30 minutes before bed
The Maximum Dose per day is 8 mg
Note:
Avoid taking this medication with or right after a high-fat meal
15 - 45
mg
Tablet
Orally
Once a day in the night
Initial dose: 1mg orally before bedtime
Maintenance dose: 1-3mg orally before bedtime
Maximum dose:3mg/kg
Dose Adjustments
The starting dose for those taking a CYP3A inhibitor should not exceed 1 mg. No dose adjustment is required for mild to moderate renal impairment, but those with severe hepatic impairment should start with 1 mg PO HS
Dosage adjustments may be necessary to avoid additive effects when eszopiclone is coadministered with another central nervous system (CNS) depressant
Insomnia Dosage Recommendation:
400–900 mg PO of aqueous extract up to 2 hours before bedtime
Extract from ethanol: 600 mg orally at bedtime
Root: 2-3 g orally (fresh or dried) three times a day
Hops or lemon balm combinations: 320–500 mg PO HS
a maximum of 28 days
50
mg
Orally
30 minutes before going to bed
(Off-label)
Indicated for chronic insmonia
2 to 4 mg orally as given on prescription
Dose modification
In the case of severe renal or hepatic impairment, do not take lorazepam
100 to 200 mg orally every night at bedtime; do not exceed 400 mg/day
(Off-Label)
15-45 mg orally every night
(Off-Label)
After depression- 5-20 mg orally for 8 weeks
After panic disorder- 5-10 mg for 8 weeks
(Off-Label)
After depression- 5-20 mg orally for 8 weeks
After panic disorder- 5-10 mg for 8 weeks
levomepromazine (methotrimeprazine)
10-25 mg orally as a single dose at bedtime
25 mg intramuscularly as a single dose at bedtime
6.25-250 mg/day as a continuous infusion in sterile water or normal saline through a syringe pump
6.25 mg/day as a median dose for bolus administration administered in 1-2 divided doses
Take 3-5 mg of medication orally daily before bedtime
3 - 6
mg
Orally
30 minutes before going to bed
Do not exceed 6 mg daily
10 mg orally as a single dose every night, with at least 7 hours till the scheduled time of waking.
If the dose is ineffective then increase the dose as required
The maximum dose is 20mg a day
Dose Adjustments
Renal Impairment: Dosage adjustment is not required
Hepatic Impairment:
Severe: Not recommended
Mild-to-moderate: Dosage adjustment is not required
Co-administering CYP3A4 inhibitors
Moderate: Reduce the recommended dosage of suvorexant to 5 mg orally at bedtime; if tolerated but ineffective, consider increasing the dose, but no more than 10 mg/dose.
5 mg orally not more than once each night, just before going back to bed, with a minimum of 7 hours before the scheduled time of awakening remaining
Based on the clinical response and tolerability, the dosage can be increased upto 10 mg.
1.5-2 gm of dried strobile daily
60 mg extract in combination with valerian
Take a dose of 500 mg to 1 g orally 15 to 30 minutes before sleep
Only for use up to 2 weeks and a daily dose not more than 2 g
The administration of 10-18 grams of wild jujube seed extract decocted in water taken orally every day
Administer 1 or 2 capsules orally every day at bedtime
Kava-lactones: Administer 180 to 210 mg orally every night at bedtime
(off-label):
1 to 2 mg given orally before the bedtime
1-2 milligrams Orally every night at bedtime.
Administer 500 to 1000mg orally at bedtime
The recommended dose is 2.5-5 mg at sleep time
Safety and efficacy not seen in pediatrics
Safety and efficacy not seen in pediatrics
Not recommended for pediatrics
levomepromazine (methotrimeprazine)
In children and adolescents, 0.25 mg/kg/day orally in 2-3 divided doses
0.0625-0.125 mg/kg/day to be administered as a single dose or in divided doses
Titrate the dose based on its effectiveness
0.0625 mg/kg in D5W as a 250 ml infusion slowly at 20-40 drops/minute
5 mg orally not more than once each night, just before going back to bed, with a minimum of 7 hours before the scheduled time of awakening remaining
Based on the clinical response and tolerability, the dosage can be increased up to 10 mg
Initiate with the lower dose
Dose Adjustments
Renal and hepatic impairment: Discontinue the drug for severe failure
Initiate at 3.75 mg/day orally at bedtime up to 4 weeks, increase gradually based on patient tolerance and clinical symptoms
Dose Adjustments
Renal and hepatic impairment:
Reduce the dose to 3.75 mg
Discontinue the drug for severe failure
Dose Adjustments
Start with a lower dose of 0.125 mg, do not exceed more than 0.25 mg per day
7.5
mg
Capsule
Orally
at bedtime
10 - 14
days
15
mg
Capsule
Orally
at bedtime
Initial dose: 1mg orally before bedtime. Do not exceed 2mg
Initial dose: 0.5-1 mg orally as required
To prevent extra sedation, do not exceed the daily dose more than 2 mg
https://www.ncbi.nlm.nih.gov/books/NBK526136/
Insomnia is defined as trouble in maintaining or initiating sleep, as well as poor sleep quality. These symptoms persist despite the availability of appropriate sleep and circumstances, resulting in daytime dysfunction.
Insomnia has a negative impact on one’s health, quality of life, academic performance, increased risk of automobile accidents, reduce productivity at work, irritability, and increased daytime sleepiness.
Insomnia is also regarded as a risk factor for therapeutic conditions such as chronic pain syndrome, depression, cardiovascular disease, anxiety, diabetes, asthma, and obesity.
Insomnia affects 10-15% of the overall population. In 2010, around 5.5 million outpatient visits for sleep disorders were recorded in the United States. Though it affects people of all ages, it is more common in peri and post-menopausal women and elderly individuals.
The genetic markers for sleep declination were identified from insomnia-like Drosophila flies, which exhibited characteristics comparable to human insomnia. Clock gene 3111C/C Clock and short (s-) allele of the 5-HTTLPR is linked to insomnia.
Wake-promoting compounds such as catecholamine, histamine, and orexin, as well as sleep-promoting chemicals, such as serotonin, GABA, adenosine, prostaglandin D2, and melatonin, are essential for sleep-wake regulation.
One of the proposed processes leading to insomnia is an orexin-mediated enhanced neuronal activity in the wake-promoting area and suppression of the sleep-promoting area (median and ventrolateral preoptic nuclei).
Individuals who cannot cope with a stressful circumstance or who report being regular light sleepers are more likely to develop chronic insomnia. Insomnia is frequently associated with mental diseases such as anxiety, depression, and post-traumatic stress disorder.
Comorbid medical conditions such as chronic pain, restless legs syndrome, gastroesophageal reflux disease, immobility, and respiratory problems are linked to an increased risk of chronic insomnia.
Separation anxiety, for example, might predispose a child to sleep disorders. People who aim for perfectionism, ambition, neuroticism, poor extraversion, and a propensity for despair and concern are more prone to insomnia over time.
Insomnia is more prevalent among individuals who have experienced psychosocial stress, such as a disrupted domestic life, divorce, the loss of a spouse, or alcohol or substance misuse.
https://www.ncbi.nlm.nih.gov/books/NBK526136/
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