Week 8: Therapy for Patients With Sleep/Wake Disorders
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Therapy for Patients With Sleep/Wake Disorders
For this discussion, the case of a young adult male patient with a history of insomnia has been used. The patient is 31 years old and presents with insomnia as the chief complaint. He reports that the lack of sleep has been getting worse over the past 6 months. According to him, sleeping problems have never created a great concern as he is used to them. However, it has been worse ever since the death of his fiancé, as he struggles to fall and stay asleep. This has greatly compromised his quality of life as his job performance has reduced. He also claims that due to poor sleep at night, he sometimes falls asleep at the workplace. He confirms that he has been taking diphenhydramine to help him sleep in the past, but is unhappy with the way it makes him feel the next morning. His previous physician reports that the patient has a history of opiate abuse following his ankle fracture in a skiing accident that led to the use of hydrocodone/APAP (acetaminophen) for the management of pain. He has however not used analgesics for the past 4 years. The patient however confirms to be taking alcohol to help with his sleeping. Mental status examination results reveal that the patient current healthcare need is only insomnia.
Several patient factors affect their pharmacokinetic and pharmacodynamic processes hence must be considered when making decisions concerning which drug to prescribe to the patient. For this patient, some of such factors include his male gender, adult age, diagnosis of insomnia, previous use of diphenhydramine, substance use history of opiate abuse, and use of alcohol. The purpose of this paper is thus to consider the above patient factors and determine the most effective choice of drugs for the management of the patient’s insomnia, and necessary medication adjustments based on the treatment outcomes.
Decision Point One
Selected Decision and Rationale
Based on the patient-specific factors, the initial decision was to administer trazodone 50mg orally at bedtime. Despite trazodone being approved by the FDA for the management of depression, evidence demonstrates that its off-label use in the management of insomnia has surpassed its antidepressant indications (Bollu & Kaur, 2019). Trazodone mode of action is associated with the inhibition of serotonin reuptake, antagonizing serotonin, antagonizing alpha1 (α1) adrenergic receptors, and inhibitor of serotonin reuptake transporter (Levenson et al., 2015; Medalie & Cifu, 2017). It is effective for patients with diphenhydramine withdrawal (Krystal et al., 2019: Bollu & Kaur, 2019). The drug is also rapidly absorbed from the GI when administered orally with a short onset of action of between 1 to 2 hours, hence appropriate in helping the patient fall asleep easily (Sateia et al., 2017). Its half-life is also short promoting its safety profile as a result of reduced toxicity risks (Zhand & Milin, 2018).
It was not necessary to consider zolpidem as the medication can only be prescribed in case there is no other better option for the management of the patient’s insomnia, as the drug has increased risks of adverse events such as hallucination and amnesia (Krystal et al., 2019; Palagini et al., 2020). Hydroxyzine on the other hand could also not be selected given that it is an antihistamine just like diphenhydramine (Levenson et al., 2015). As such, it will lead to similar side effects to the ones that made the patient stop using the drug, to begin with (Sateia et al., 2017).
Expected Outcome
The patient’s insomnia should be getting better with the use of trazodone for the following four weeks. He should be able to easily fall asleep and stay asleep (Bollu & Kaur, 2019). Achievement of 50% remission of symptoms within the first four weeks, is demonstrated as a positive response to the medication (Levenson et al., 2015).
Ethical Considerations
When deciding on which medication to prescribe to the patient, the PMHNP must demonstrate a high level of critical thinking with the patient’s interest at hand (Krystal et al., 2019). Ethical guidelines recommend all healthcare professionals uphold the patient’s autonomy and promote their health while preventing harm (Sateia et al., 2017; Medalie & Cifu, 2017).
Decision Point Two
Selected Decision and Rationale
During the second visit, it was necessary to reduce the dose of trazodone from 50mg to 25mg at bedtime. The patient displayed positive outcomes with the use of this medication which demonstrates great effectiveness in the management of insomnia (Levenson et al., 2015). However, he reported unpleasant side effects such as prolonged erection which undermines his tolerance to the medication at that dose (Zhand & Milin, 2018). Since the benefits outweigh the side effects, reducing the dose helps reduce the plasma concentration of the drug which in turn helps reduce the risks of side effects (Bollu & Kaur, 2019). Consequently, studies show that side effects of trazodone such as prolonged erection are normally self-limiting and can disappear at low doses or with continuous use of the drug (Sateia et al., 2017; Medalie & Cifu, 2017).
Explaining to the patient the side effects and the possibility of resolving them on their own over time without making any changes to the treatment regimen was not appropriate. This would otherwise affect the patient’s compliance with the medication by skipping doses to avoid the side effects (Krystal et al., 2019; Zhand & Milin, 2018). On the other hand, it was also not necessary to stop using trazodone and replace it with suvorexant as the medication has already displayed great effectiveness in the management of patients’ insomnia (Palagini et al., 2020). Suvorexant is also associated with adverse events like unusual dreams which will further compromise the patient’s condition (Bollu & Kaur, 2019).
Expected Outcome
The side effects of prolonged erection in the morning after using trazodone are expected to diminish within the following four weeks (Bollu & Kaur, 2019). The patient should continue experiencing further improvements in the symptoms of insomnia (Levenson et al., 2015). No additional side effects are expected (Sateia et al., 2017).
Ethical Considerations
The PMHNP must inform the patient about the side effects, why they occurred, and how to solve them (Krystal et al., 2019; Palagini et al., 2020). This will help promote the patient their engagement in making decisions concerning their health as required by legal and ethical guidelines (Zhand & Milin, 2018).
Decision Point Three
Selected Decision and Rationale
The final decision was to advise the patient to continue using trazodone at the same dose, consider sleep hygiene for the next four weeks, and report for follow-up evaluation. This decision was based on the reported positive outcome of the drug by the patient at a dose of 25mg (Bollu & Kaur, 2019). Studies show that at the right dose, trazodone is effective in managing insomnia, with reduced risks of side effects (Bollu & Kaur, 2019; De Crescenzo et al., 2022). However, since the patient reports that the dose is sometimes low to help him sleep through the night, it was necessary to consider non-pharmacological interventions such as sleep hygiene (Krystal et al., 2019). Previous evidence demonstrated that use of medication and sleep hygiene at the same time help promote treatment outcomes for patients with insomnia (Levenson et al., 2015; Zhand & Milin, 2018). It is however necessary to evaluate the treatment outcome after 4 weeks for possible long-term side effects of the drug like confusion (Sateia et al., 2017).
Discontinuing using trazodone and using ramelteon was irrelevant as the former is safer than the latter and the patient already displayed great tolerance and adherence to the medication (Krystal et al., 2019; Palagini et al., 2020). Hydroxyzine on the other hand was also not necessary as it is an antihistamine, hence would lead to similar side effects that made the patient stop using diphenhydramine (Levenson et al., 2015).
Expected Outcome
With the adoption of sleep hygiene and the use of trazodone 25mg, the patient is expected to exhibit improved sleeping patterns (Bollu & Kaur, 2019). He should be able to have enough sleep at night, to promote his productivity at work the following day (Levenson et al., 2015). No side effects are expected (Zhand & Milin, 2018).
Ethical Considerations
With the main obligation of protecting patients from harm while treating them, the PMHNP needed to consider using another intervention to reduce the use of another medication due to associated side effects (Krystal et al., 2019; De Crescenzo et al., 2022). Ethical principles such as nonmaleficence and respect for patient autonomy were thus considered in making the last decision (Sateia et al., 2017).
Conclusion
When prescribing medication to patients, several factors affecting their pharmacokinetic and pharmacodynamic processes are normally considered. For instance, the adult patient in the case study assigned presented with worsening insomnia, with previous use of diphenhydramine without success (Bollu & Kaur, 2019). Based on such factors it was necessary to initiate the use of trazodone 50mg at bedtime given the severity of the patient’s insomnia and the proven effectiveness of the drug in managing insomnia (Krystal et al., 2019). Zolpidem and hydroxyzine were not appropriate as they are associated with side effects that would otherwise compromise the patient’s health (Levenson et al., 2015). After two weeks, the patient reported positive outcomes with the medication, but with side effects of prolonged erection in the morning which promoted the second decision in reducing the dose to 25mg at bedtime (Sateia et al., 2017). It was not necessary to discontinue using the drug and replace it with suvorexant or only explain the side effects to the patient with no action taken, as this would compromise patient compliance (Bollu & Kaur, 2019).
The final decision was to continue taking trazodone 25mg at bedtime and consider appropriate sleep hygiene given that the drug displayed potential effectiveness with great tolerance in the management of insomnia (Zhand & Milin, 2018). Replacing trazodone with another medication at this point was not necessary given that the patient was already satisfied with how the drug was working (Medalie & Cifu, 2017). The PMHNP thus had to consider several ethical principles such as nonmaleficence and respect for the patient’s autonomy at each decision point (De Crescenzo et al., 2022). Additionally, healthcare professionals have the obligation of putting the patient’s interest at hand when promoting their health (Palagini et al., 2020). As such it was necessary for the clinician to explain to the patient every decision made and why it was made.
References
Bollu, P. C., & Kaur, H. (2019). Sleep Medicine: Insomnia and Sleep. Missouri Medicine, 116(1), 68–75. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6390785/
De Crescenzo, F., D’Alò, G. L., Ostinelli, E. G., Ciabattini, M., Di Franco, V., Watanabe, N., … & Cipriani, A. (2022). Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. The Lancet, 400(10347), 170-184.
Krystal, A. D., Prather, A. A., & Ashbrook, L. H. (2019). The assessment and management of insomnia: an update. World Psychiatry, 18(3), 337-352.
Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The Pathophysiology of Insomnia. Chest, 147(4), 1179–1192. https://doi.org/10.1378/chest.14-1617
Medalie, L., & Cifu, A. S. (2017). Management of Chronic Insomnia Disorder in Adults. JAMA, 317(7), 762. https://doi.org/10.1001/jama.2016.19004
Palagini, L., Manni, R., Aguglia, E., Amore, M., Brugnoli, R., Girardi, P., … & Biggio, G. (2020). Expert opinions and consensus recommendations for the evaluation and management of insomnia in clinical practice: joint statements of five Italian scientific societies. Frontiers in Psychiatry, 11, 558.
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(02), 307–349.
Zhand, N., & Milin, R. (2018). What do we know about the pharmacotherapeutic management of insomnia in cannabis withdrawal: A systematic review. The American journal on addictions, 27(6), 453-464.
