Treatment Options and Treatment Selection for Sleep Disorders

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I'd like to transition some of our discussion over to agents that are out there. We’ve got a toolbox now of different agents that are out there, and we have over-the-counter agents that people use. In fact, I think if you look at the studies up there, alcohol’s the most cited drug in America for insomnia. None of us are going to recommend that they consume that. But we’ve got over-the-counter medicines. We’ve got drugs like melatonin, and we’ve got diphenhydramine. But then we’ve got a lot of prescription drugs with the orexin drugs, the non-GABA [gamma-aminobutyric acid], the GABA agents, the melatonin-type of agents and the histaminergic agents. So, let’s talk a little bit about, in addition to efficacy and safety, what are some of the important considerations that you think of as you’re trying to decide where do I go with this patient. What tool do I pull out of my toolbox for this patient?

Debra Davis, CRNP: For me, I just don’t write prescriptions for benzodiazepines. If someone died, I’ll give you some benzodiazepines, but other than bereavement, I do not write prescriptions for benzodiazepines. They are just in my way of thinking, way too addictive. I have even at times prescribed them to patients whom someone has died very close to them. I tell them, “I’m going to prescribe you some. Don’t come back and ask for more.” And almost invariably they do. So that is definitely never my first choice. And then, of course, there are all the Z-drugs that people are so used to. The zolpidems, eszopiclone, and zaleplon, and drugs like that. Those are hypnotics and they are not without their own side effects. And so, if I were to give someone a drug such as that, it’s going to be short-term because the problem is the rebound insomnia that those cause. The other problem is the way that they work on the brain. You really can start having problems with memory, start having problems with word finding. They’re just not without the side effects that I think are not worth the drug itself.

Working with a compounding pharmacy, you mentioned melatonin. Because I had struggled with sleep, I made my own combination of melatonin, N-acetyl, holy basil, ashwagandha, and methionine. Those are all very calming herbs. And so those are something that people can use. I have to say that my favorite is the newer, the DORAS [dual orexin receptor antagonists] that we can use for sleep. I find that most of them, or 1 of them in particular that I like the best does not cause that next day hangover. And that’s 1 of the things that I’m looking for as well as side effects.

Also, there was a study done that showed that this drug in particular, the placebo showed more prevalence of falls in the elderly than did the drug itself. I think that that’s so important because often it is the elderly who can’t sleep at night. Now, why is that? Is it because they’re napping during the day or is it because they’re not tired? You really do need to get to the bottom of that. Because I do tell them, “If you are napping during the day, the body does not care. You can sleep during the day, or you can sleep at night, but you are not a baby, and you are not going to sleep both. So, you need to decide.” But with these drugs, they’re so much safer and I feel good with the patient going out the door with that prescription in their hand.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: You brought up some really good points that I want to spend a couple of minutes on, and I think you hit the nail right on the head that for so long we’ve had our zolpidems, our zaleplons, these Z-drugs. We’ve had our benzodiazepines. We have our anticholinergic agents, for instance, like trazodone which is not even approved for sleep but is the most widely prescribed sleep medicine in America. The problem is, is that these medications all have anticholinergic side effects. They’re all on the Beers Criteria of drugs not to use in our older adults. We now are seeing that evidence starting to emerge that maybe when used long-term that these are not benign drugs. While we recognize that for instance the Z-drugs might have some complex sleep behaviors associated with them, I worry a lot about the long-term implication of using these drugs.

I believe that the field of sleep medicine will change over the next decade and that we will get away from saying, “Let’s fix your sleep quick. Let’s put you on this medication and let’s get you off of it.” I believe that as we get safer drugs, I do believe that the DORAs are safer in their mechanism of action. They’re also not on the Beers Criteria and as you alluded to, not seeing falls in our older population. In fact, suvorexant, which was the first DORA on the market, is indicated to be used in patients with Alzheimer’s and dementia who also have insomnia. For me, I’m thinking about whether they are controlled and what’s the addiction potential and I also think about what’s the long-term effect of using 1 of these medications. I also have to look at what is the age of the patient whether it’s on that Beers Criteria or whether it’s not, and those factors for me all really play a role as I’m trying to choose an agent that helps people to sleep but also doesn’t harm them either short or long-term.

Debra Davis, CRNP: I’ve seen so many times people ask for certain drugs, such as zolpidem, and because of the hypnotic, put you down effect, and so many times I have seen them take this drug and I tell them, “I’m not going to refill this for you because it’s not good for you, but I am telling you nothing is going to make you sleep the way that that drug makes you sleep. Nothing is going to work like that. You do not need that.” And 1 of the things that I love about the DORAs, especially daridorexant, is the fact that there is no physical dependence and there are no withdrawal symptoms. There is no rebound insomnia. Because I promise you, if you take zolpidem, even if you take it for a week or 2, that fifteenth night that you don’t have it, you just might as well get yourself a good book because you are not going to sleep. There is a rebound of insomnia associated with those drugs that are not associated with the DORAs and that’s why I choose them as much as I can.

Wendy L. Wright, DNP, ANP-BC, FNP-BC, FAANP, FAAN, FNAP: I think that’s an awesome discussion because what a lot of people don’t realize is that the same things are seen with the benzodiazepines, that when you stop them, you will have rebound insomnia. So, I think that’s a really good point.

Transcript edited for clarity