Insomnia and Insomnia and DrowsinessDrowsiness

Prepared by: Lindsey BrownPrepared by: Lindsey BrownWinter Term 2006Winter Term 2006

A disorder not a disease…A disorder not a disease…

Diverse etiologies & patient complaintsDiverse etiologies & patient complaints Very subjectiveVery subjective

½ of US population experienced insomnia ½ of US population experienced insomnia in the past yearin the past year

30% of patients have symptoms nightly30% of patients have symptoms nightly

Questions?Questions?

Chief complaint?Chief complaint?

Specific complaint of insomnia?Specific complaint of insomnia?

How is it affecting their daily activities?How is it affecting their daily activities?

Duration and Frequency?Duration and Frequency?

Transient = < 1 weekTransient = < 1 week

Short term = 1-3 weeksShort term = 1-3 weeks

Chronic = > 3 weeksChronic = > 3 weeks

Medical History?Medical History?

Current Medical Problem or Conditions?Current Medical Problem or Conditions?

Current Medications (Rx or OTC)?Current Medications (Rx or OTC)?

Allergies or Sensitivities?Allergies or Sensitivities?

Good Sleep HygieneGood Sleep Hygiene

Regular sleep patternRegular sleep pattern Comfortable surroundingsComfortable surroundings RelaxRelax ExerciseExercise Break the cycle of daytime napsBreak the cycle of daytime naps Avoid overeating close to bedtimeAvoid overeating close to bedtime Monitor caffeine and nicotine useMonitor caffeine and nicotine use Alcohol – not a good sedativeAlcohol – not a good sedative Avoid sleep anxietyAvoid sleep anxiety

DiphenhydramineDiphenhydramine The only FDA approved OTC sleep aidThe only FDA approved OTC sleep aid

Patient specific dosing (25-50mg QHS)Patient specific dosing (25-50mg QHS)

Duration of sedation = 3 - 6 hoursDuration of sedation = 3 - 6 hours

Next morning hang-over & tolerance are Next morning hang-over & tolerance are commoncommon

What to be aware of…What to be aware of…

Anticholinergic SEsAnticholinergic SEs Contraindications = BPH, difficulty urinatingContraindications = BPH, difficulty urinating

narrow “closed” angle glaucoma, CVD, narrow “closed” angle glaucoma, CVD, dementiadementia

Do not use more than 7-10 daysDo not use more than 7-10 days

MelatoninMelatonin

Endogenous hormone produced by pineal Endogenous hormone produced by pineal glandgland

Shifts circadian rhythm, body temp, and Shifts circadian rhythm, body temp, and alertnessalertness

0.3- 1 mg taken 1-2 hours prior to bedtime0.3- 1 mg taken 1-2 hours prior to bedtime

Drowsiness Case StudyDrowsiness Case Study

23 yo male comes to your pharmacy and 23 yo male comes to your pharmacy and states that he was up all weekend states that he was up all weekend studying for finals, and is worried he cant studying for finals, and is worried he cant stay alert to take the tests he studied so stay alert to take the tests he studied so hard for. He is looking for an OTC hard for. He is looking for an OTC stimulant to help stay awake for his 3 days stimulant to help stay awake for his 3 days of exams.of exams.

What do you need to What do you need to know?know?

Medical or psychiatric problemsMedical or psychiatric problems Current medicationsCurrent medications Caffeine consumptionCaffeine consumption Sleep patternsSleep patterns LifestyleLifestyle

CaffeineCaffeine

Not a substitute for good sleep patternsNot a substitute for good sleep patterns Most frequently used stimulant in the worldMost frequently used stimulant in the world

Good sleep hygiene, lifestyle Good sleep hygiene, lifestyle modifications, and referral should come 1modifications, and referral should come 1stst

If Caffeine is used…If Caffeine is used… Xanthine derivative that antagonizes the Xanthine derivative that antagonizes the

receptors of Adenosinereceptors of Adenosine

Tolerance and withdrawal are commonTolerance and withdrawal are common

Usual Dose: 100 -200mg Q3-4H PRN, NTE Usual Dose: 100 -200mg Q3-4H PRN, NTE 600mg/day600mg/day

Special considerationsSpecial considerations

Ginseng Ginseng Herbal product that inhibits thromboxaneHerbal product that inhibits thromboxane

Weak antiplatelet effects, increased risk of bleedingWeak antiplatelet effects, increased risk of bleeding

May exacerbate psychiatric symptomsMay exacerbate psychiatric symptoms

Hypoglycemic effectsHypoglycemic effects

Usual Dose: 100-300mg BIDUsual Dose: 100-300mg BID

Musculoskeletal InjuriesMusculoskeletal Injuries

““Sprains, Strains and Pains”Sprains, Strains and Pains”

Musculoskeletal and Musculoskeletal and connective tissue injuries connective tissue injuries are the 3are the 3rdrd and 5 and 5thth leading leading cause of lost work days in cause of lost work days in men & women in the US, men & women in the US,

respectively…..respectively…..

Patient AssessmentPatient Assessment

There are no wrong answers…There are no wrong answers…

P,Q,R,S,TP,Q,R,S,T

Precipitating factorsPrecipitating factors Quality of painQuality of pain Region or locationRegion or location Severity (changes in daily activities)Severity (changes in daily activities) Timing Timing

Exclusions for self-treatmentExclusions for self-treatment Pain with N/VPain with N/V Weakness in any limbWeakness in any limb Visually deformed joint or abnormal joint Visually deformed joint or abnormal joint

movementmovement Joint pain with systemic symptomsJoint pain with systemic symptoms Pelvic or abdominal painPelvic or abdominal pain Pain that is increasing or changingPain that is increasing or changing Flouroquinolone useFlouroquinolone use Duration >2 weeksDuration >2 weeks

Tendonitis, Bursitis, Strains, and Tendonitis, Bursitis, Strains, and SprainsSprains

P = protectP = protect R = restR = rest I = ice (10-30 min TID-QID or at max Q2H)I = ice (10-30 min TID-QID or at max Q2H) C = compressC = compress E = elevateE = elevate

NSAIDSNSAIDS 2 theories = early vs. withhold 2 theories = early vs. withhold

CounterirritantsCounterirritants

Paradoxical pain-relieving effect achieved Paradoxical pain-relieving effect achieved by producing a less severe pain to counter by producing a less severe pain to counter a more intense onea more intense one

Psychological component = placebo effectPsychological component = placebo effect

RubefacientsRubefacients

MOA: vasodilation producing reactive MOA: vasodilation producing reactive hyperemia “redness”hyperemia “redness”

Methyl salicylate “most widely used”Methyl salicylate “most widely used”

Cooling SensationCooling Sensation

Dose Dependent MOA:Dose Dependent MOA: Stimulates nerves that perceive cold while Stimulates nerves that perceive cold while

depressing nerves that perceive pain, this is depressing nerves that perceive pain, this is followed by a sensation of warmthfollowed by a sensation of warmth

MentholMenthol CamphorCamphor

VasodilationVasodilation

MOA: MOA: Marked power of diffusion which leads to Marked power of diffusion which leads to

elevated skin temperature at very low elevated skin temperature at very low concentrationsconcentrations

Mediated by PG biosynthesisMediated by PG biosynthesis SEs: drop in BP, pulse, and syncopeSEs: drop in BP, pulse, and syncope

Methyl NicotinateMethyl Nicotinate

Incite IrritationIncite Irritation

MOA: depletes sensory neurons of MOA: depletes sensory neurons of Substance P, which will cause burning Substance P, which will cause burning pain and rednesspain and redness

Capsicum = only counterirritant for Capsicum = only counterirritant for chronic chronic painpain Apply TID-QID for long-term useApply TID-QID for long-term use

Unproven Effectiveness…Unproven Effectiveness… MOA: absorbed through the skin and MOA: absorbed through the skin and

results in synovial fluid salicylate results in synovial fluid salicylate concentrations slightly lower than oral concentrations slightly lower than oral ASA.ASA. Contraindications: renal insufficiency, liver Contraindications: renal insufficiency, liver

disease, hypothrombinemia, vitamin K disease, hypothrombinemia, vitamin K deficiency, scheduled for surgery, chronic deficiency, scheduled for surgery, chronic alcohol usersalcohol users

Trolamine SalicylateTrolamine Salicylate

OsteoarthritisOsteoarthritis

Affects ½ of US population > 70 yoAffects ½ of US population > 70 yo

General Treatment Approach:General Treatment Approach:

APAP– NTE 4000mg/ dayAPAP– NTE 4000mg/ day Glucosamine – 1500mg QDGlucosamine – 1500mg QD

Don’t Forget…Don’t Forget…

Warm-up and Cool downWarm-up and Cool down

ReferencesReferences

Berardi R, McDermott J, et al. HandBook Berardi R, McDermott J, et al. HandBook of NonPrescription Drugs. 14of NonPrescription Drugs. 14thth Ed. 2004. Ed. 2004.

Engle J, Stovitz S. Partners in Self-Care: Engle J, Stovitz S. Partners in Self-Care: Self-Treatment Options for Common Self-Treatment Options for Common Sports and Physical Activity Injuries. 2004; Sports and Physical Activity Injuries. 2004; 12: 1-18.12: 1-18.