Hypnotics

Question 1

How do hypnotics help anxiety?

Answer 1

Because insomnia is so frequently associated with
anxiety, hypnotic drugs are used to induce sleep and decrease anxiety symptoms.

Question 2

Why are benzos a poor choice for long-term hypnotic use?

Answer 2

Despite being effective at inducing sleep, benzos reduce the quality of sleep that people get.

Question 3

Antihistamines as Hypnotics

Answer 3

Antihistamines like
doxylamine (Unisom) and diphenhydramine (Benadryl) have profound sedating
properties.

Available over-the-counter.

Antihistamines (like
benzodiazepines) mess with your sleep cycle, so while they are helpful for getting to sleep, they do not actually provide a good quality of sleep.

Antihistamines are also prone to tolerance, and after about 3 days of continued use they perform no better than placebo for sleep induction.

Question 4

Z-Drugs as Hypnotics

Answer 4

Z-drugs interact with the GABA receptor in a way similar to benzodiazepines but do not have the same chemical structure.

They are more selective for the GABA A receptor subtype (which is involved in sleep).

zolpidem (Ambien), zaleplon (Sonata), and
(es)zopiclone (Lunesta)

Z-drugs have a reduced, though certainly not absent, risk of dependence and tolerance compared to benzodiazepines.

One notable adverse effect of Z-drugs is anterograde amnesia, meaning you may forget everything that happens in the hours after you take them (which isn’t a big deal if you’re sleeping, but does give them the potential to be used as date rape drugs).

Half life can be remembered by putting in alphabetical order:

zaleplon (4 hours)
zolpidem (6 hours)
(es)zopiclone (8 hours)

Question 5

Melatonin as a Hypnotic

Answer 5

Melatonin is a naturally occurring hormone that is involved in circadian rhythms.

Levels of melatonin increase at nightfall, which chemically
signals the brain to become sleepy.

Several melatonin receptor agonists have been developed, such as ramelteon (Rozerem) and tasimelteon (Hetlioz).

Question 6

Trazodone as a Hyptonic

Answer 6

While it is most effective for insomnia related to depression, it still has soporific effects in non-depressed patients as well.

Remember to counsel on the possibility of “hangover” sedation the next day morning and the low but significant risk of priapism.

Question 7

Why should medications to treat insomnia be used sparingly?

Answer 7

Many drugs used to treat insomnia (such as benzodiazepines and antihistamines) tend to disrupt sleep architecture.

Consider referring your patients to psychotherapies (such as CBT for insomnia) which tend to be more effective than medication.

Question 8

ramelteon (Rozerem) and tasimelteon (Hetlioz)

Answer 8

Melatonin receptor agonists.