Throughout the book, we are guided by our main goal of providing practitioners with clinically relevant, evidence-based, and state-of-the-art information in the evaluation and management of insomnia. We have made a concerted attempt to ensure that our reviews are consistent with professional guidelines to the extent that current knowledge permits

Doghramji, Karl

Doghramji, Paul P

Name not available

Clinical Management of Insomnia

Jefferson Digital Commons

Thomas Jefferson UniversityJefferson Digital CommonsDepartment of Psychiatry and Human BehaviorFaculty Papers Department of Psychiatry and Human Behavior6-2015Clinical Management of InsomniaKarl DoghramjiThomas Jefferson University, karl.doghramji@jefferson.eduPaul P. DoghramjiLet us know how access to this document benefits youFollow this and additional works at: http://jdc.jefferson.edu/phbfpPart of the Psychiatry CommonsThis Article is brought to you for free and open access by the Jefferson Digital Commons. The Jefferson Digital Commons is a service of ThomasJefferson University's Center for Teaching and Learning (CTL). The Commons is a showcase for Jefferson books and journals, peer-reviewed scholarlypublications, unique historical collections from the University archives, and teaching tools. The Jefferson Digital Commons allows researchers andinterested readers anywhere in the world to learn about and keep up to date with Jefferson scholarship. This article has been accepted for inclusion inDepartment of Psychiatry and Human Behavior Faculty Papers by an authorized administrator of the Jefferson Digital Commons. For moreinformation, please contact: JeffersonDigitalCommons@jefferson.edu.Recommended CitationDoghramji, Karl and Doghramji, Paul P., "Clinical Management of Insomnia" (2015). Department ofPsychiatry and Human Behavior Faculty Papers. Paper 25.http://jdc.jefferson.edu/phbfp/25Clinical Management of InsomniaSecond EditionClinical Management of Insomnia K Doghramji  & PP DoghramjiKarl Doghramji, MDPaul P. Doghramji, MDClinicalManagement of InsomniaSecond EditionKarl Doghramji, MDProfessor of Psychiatry, Neurology, and MedicineMedical Director, Jefferson Sleep Disorders CenterProgram Director, Fellowship in Sleep MedicineThomas Jefferson UniversityPhiladelphia, PAPaul P. Doghramji, MDAttending PhysicianCollegeville Family PracticeCollegeville, PAxiv Figure 11.8 LOSMOTN During the Double-Blind Treatment Period .................................................197 Figure 11.9 Eszopiclone Enhances Sleep Continuity .............199 Figure 11.10 Zolpidem vs Zolpidem ER in a Noise-Induced Model of Insomnia ......................200 Figure 11.11 Ramelteon Reduced Patient-Reported Time to Fall Asleep in Older Adults With Chronic Insomnia .......................................203 Figure 11.12 Suvorexant Reduces Polysomnographically Assessed Time to Sleep Onset .............................207 Figure 11.13 Suvorexant Enhances Polysomnographically Assessed Sleep Maintenance (Reduces Wake After Sleep Onset) .....................................208 Figure 11.14 Suvorexant Reduces Patient-Estimated Time to Sleep Onset ............................................209 Figure 11.15 Suvorexant Enhances Patient-Estimated Total Sleep Time..................................................210 Figure 11.16 Long-Term Intermittent Treatment With Zolpidem ....................................................213 Figure 11.17 Improvements in PGI Scores for Items 1, 2, 3, and 4 Over 6 Months of Treatment With Zolpidem ER ..............................................214 Figure 11.18 PSG Assessment of Sleep Latency With Ramelton Over 6 Months in Adults With Chronic Primary Insomnia .........................216 Figure 11.19 Relative Abuse Liability of 19 Hypnotic Agents .............................................2221511 Introduction A staggering one third of all humans are affected by insomnia. Sleep-related complaints are also dispro-portionately high in prevalence in medical practice. This malady, which was once thought to be an innocuous annoyance, is now known to impair normal human func-tion, to cause a variety of medical and psychiatric disor-ders, and even to limit lifespan. For medical practitioners, therefore, the proper identi¿ cation, clinical evaluation, and effective management of insomnia are of signi¿ cant importance.  In this book, we take a systematic approach in inform ing the primary care practitioner in the evaluation and management of insomnia. In Chapter 2, we begin with a foundation in normal sleep neurophysiology. The past few decades have seen a tremendous advance in our understanding of the central underpinnings of sleep and wakefulness. We now know that this seemingly quiescent state is the product of a complex array of interactions that produce a balance between wake-promoting systems on the one hand, governed by norepinephrine, serotonin, dopamine, acetylcholine, and histamine, and sleep-pro-moting systems on the other hand, governed by GABA and galanin and under the circadian influence of the hormone melatonin. Newly discovered neurotransmitters, the orexins/hypocretins, play a critical role in maintaining an orderly transition between these two states.  In Chapters 3 through 6, we present the most recent diagnostic guidelines for insomnia. We explore key developments in clarifying the pathophysiology of insomnia, and explain how these have led to an evolution of our view of the relationship between co-occurring insomnia and medical/psychiatric disorders from a model of unidirectional causality to one of autonomous disor-ders interacting in a bidirectional fashion. We also delve into an in-depth review of the many consequences of this disorder. 16 In Chapters 7 and 8, we present some of the most important aspects of insomnia for clinical practitioners, ie, its evaluation and management. We stress the impor-tance of a thorough of¿ ce-based evaluation, and present guidelines for this endeavor based on the most recent practice parameter statements. We emphasize the impor-tance of treatment that is focused on underlying cause, as opposed to the uninformed entry into symptomatic management. In Chapters 9 through 11, we explore the many available pharmacologic agents for the treatment of insomnia and provide an evidence-based approach in their selection and use. Whereas GABA receptor agonists have traditionally dominated the therapeutic armamentarium, we review novel and investigational agents with mechanisms traversing the receptor systems that are involved in the control of sleep and arousal, such as selective histamine H1 receptor antagonists, selective melatonin receptor agonists, and dual orexin receptor antagonists. “Natural” compounds enjoy a signi¿ cant allure by virtue of their widespread availability and the perception that they are safer than prescription medica-tions for insomnia. We explore the vast array of such products utilized for sleep-related complaints and provide empirical data to guide practitioners through the morass of claims regarding the bene¿ ts of these agents. Although less widely utilized than pharmacologic agents, cognitive and behavioral therapies are of clear bene¿ t in insomnia. We explore the principles underlying these techniques and guidelines in their implementation. We also review exciting new evidence demonstrating the lasting bene¿ t of these therapies for extended periods of time following termination of treatment. Throughout the book, we are guided by our main goal of providing practitioners with clinically relevant, evidence-based, and state-of-the-art information in the evaluation and management of insomnia. We have made a concerted attempt to ensure that our reviews are consis-tent with professional guidelines to the extent that current knowledge permits. Nevertheless, we remind our readers that scienti¿ c discovery is ongoing. Since the publica-tion of this textbook, certain guidelines and standards for treatment may already have changed. In addition, in 171clinical practice, medications may be used for indications and at doses that are not covered by the package label. Therefore we advise readers to consult the peer-reviewed literature, as well as product labels, to obtain the most up-to-date information regarding recommended doses, safety pro¿ les, indications, and other guidelines. Useful resources include the FDA website (http://www.access-data.fda.gov/scripts/cder/drugsatfda/index.cfm) and FDA safety alerts at http://www.fda.gov/Safety/Recalls/default.htm. 

http://jdc.jefferson.edu/cgi/viewcontent.cgi?article=1024&context=phbfp

Clinical Management of Insomnia

Abstract

Similar works

Full text

Available Versions

Name not available

Jefferson Digital Commons