Pharmacotherapy for Insomnia in a 31-year-old Male Patient

Pharmacotherapy for Insomnia in a 31-year-old Male Patient

Pharmacotherapy for Insomnia in a 31-year-old Male Patient

Case Description

This case involves a 31-year-old patient presenting at the office complaining of sleep difficulties. The patient reports a worsening case of insomnia over the past six months. The patient has not had great sleep most of his life, but currently, the problem is severe because he struggles to fall asleep and stay asleep. It began 6 months ago after he lost his fiancé. The reports that the lack of sleep is impacting his capacity and ability to function properly, including working as a forklift operator at a local chemical company. The patient reports using diphenhydramine in the past to help him sleep but dislikes the side effects it causes in the morning after taking the drug. Due to lack of sleep from the night before, he has fallen asleep on the job. Per the previous physician assessment, the patient abused opiates before, which started when his ankle broke while skiing and followed a hydrocodone/apap (acetaminophen) prescription to manage the acute pain. The patient has not been prescribed opiate analgesic in 4 years, and he reports consuming alcohol recently to help him fall asleep, averaging four bears before going to bed.

Per the mental status assessment, the patient is alert and oriented to person, place, time, and event and maintains good eye contact and is dressed appropriately for the occasion and time of the year. The patient denies any auditory or visual hallucinations and has intact judgement, insight, and reality contact. The patient also denies any suicidal or homicidal thoughts or plans and is future-oriented.

Decision #1

Trazodone is the first option for treating insomnia in the patient. Trazodone is classified as a selective reuptake inhibitor with a low side effect profile. Trazodone is an effective medication to help the patient maintain sleep and low the frequency of early awakening. Research shows that trazodone can significantly improve perceived sleep quality and has good tolerance for insomnia short—term treatment (Yi et al., 2019). In a study involving 429 patients, patients prescribed trazodone perceived better sleep quality than individuals prescribed placebo (SMD = -0.41, 95% CI -0.82 to -0.00, P = 0.05) with an insignificantly moderate heterogeneity (Yi et al., 2019). Trazodone was also associated with a significant reduction in secondary efficacy outcomes compared to placebo.

It would not be appropriate to prescribe either sonata or hydroxyzine because trazodone presents better effectiveness and efficacy than the two. Also, sonata can cause the patient to experience complex sleep behaviors. Additionally, sonata is associated with adverse effects, including drowsiness, dizziness, diarrhea, grogginess, and impaired concentration (Bhandari & Sapra, 2019). Hydroxyzine has strong sedative properties, but most patients do not like the anticholinergic adverse effects the next morning, including xerostomia and xerophthalmia. Commonly, hydroxyzine leads to impaired motor function, blurred vision, dry mouth and throat, dizziness, confusion, abdominal stress, constipation and headache (Burgazli et al., 2023). It also leads to urinary retention complications and glaucoma.

Trazodone is an FDA-approved treatment for depression. Although it is not FDA-approved for aiding sleep, it is a common prescription with proven effectiveness and efficacy in improving sleep quality (Yi et al., 2019). This decision was selected as a short-term treatment for the patient’s insomnia. the effects would be assessed after some time before adopting a longer-term treatment or alternative therapy. Trazodone would be administered in low doses to promote safety and effectiveness in insomnia treatment. Generally, the decision to prescribe trazodone follows research evidence of its ability to improve sleep latency, duration, and quality, including helping the patient achieve deep sleep or slow-wave sleep.

Psychopharmacology often raises ethical issues attached to the respect of persons concerning a patient’s worth and dignity, information disclosure regarding the true risks and benefits of the drug, autonomy or self-governance, and beneficence. These ethical issues must be considered when developing the treatment plan and engaging the patient regarding their health problem.

Decision #2

Zolpidem has proved to enhance sleep latency and sleep duration measures and lower the frequency of awakenings in individuals with transient insomnia. It is effective in improving sleep quality in persons with chronic insomnia and can serve as a minor muscle relaxant (Edinoff et al., 2021). Despite the complex behavior associated with the medication, including hallucinations, increased risks of falls, accidents due to sleep driving, and increased suicidality and homicide ideation and plan, Zolpidem is a suitable treatment for insomnia.

Trazodone and eszopiclone are the other options that were not selected in the second decision because trazodone is suitable for short-term treatment, and eszopiclone presents a multitude of negative side effects, and it is recommended to avoid selecting it as either the initial or the second medication option due the complex side effects (Rösner et al., 2019). If mixed with alcohol or medications without the provider’s instruction, eszopiclone can cause euphoria until the patient is unconscious. It is also associated with an unpleasant taste, dry mouth, tiredness, and dizziness.

(Pharmacotherapy for Insomnia in a 31-year-old Male Patient)

Zolpidem is an FDA-approved short-term insomnia treatment. The primary aim of selecting the drug is to help the patient fall asleep because it has been proven to improve sleep latency, duration, and quality. The drug would also help the patient rapidly and effectively restore brain function (Edinoff et al., 2021). Ethically, the provider has to consider beneficence due to the complex adverse effects associated with Zolpidem, such as suicidality and homicidal ideation or sleep-driving, which threaten the patient’s safety. The provider should also disclose to the patient the risks and benefits of Zolpidem to guide decision-making.

Decision #3

Hydroxyzine can be used to treat insomnia with proven effectiveness and efficiency despite unpleasant side effects, including xerostomia and xerophthalmia. The drug has strong sedative properties, and research suggests it can be adopted as a short-term treatment for adults with sleeping difficulties (Burgazli et al., 2023). In a study, patients prescribed hydroxyzine reported improved sleep and fewer nightmares or hallucinations compared to controls (Burgazli et al., 2023). The drug is also well-tolerated despite the side effects like sleepiness and headache.

Trazodone and diphenhydramine were the other options in decision three but were not selected because of the associated side effects. Although trazodone is much safer and more effective, it can lead to headaches, sleepiness, and orthostatic hypotension. Diphenhydramine can be used together with hydroxyzine, but it can lead to impaired coordination, epigastric discomfort, dry mucous membranes, paradoxical, dizziness and drowsiness. Therefore, hydroxyzine was a better third-choice medication.

Hydroxyzine has a sedative effect that can help the patient start sleeping. It is not a typical prescription for people with insomnia but is more effective for primary insomnia not associated with any underlying cause (Burgazli et al., 2023). It was selected as a short-term treatment for insomnia in the patient as it has proven its ability to help the patient fall asleep. Ethically, the provider must assess whether the drug completely resolves the predisposition for insomnia. The provider must also maintain the confidentiality and privacy of the patient. The provider must communicate safety issues, including mixing hydroxyzine with alcohol or other CNS depressants.

Conclusion

Trazodone is the patient’s initial treatment option for insomnia. Trazodone is a powerful medicine that can help patients stay asleep and experience fewer frequent early awakenings. According to research, trazodone has an excellent tolerance for short-term treatment of insomnia and can greatly improve the quality of sleep as assessed by those taking it (Yi et al., 2019). To ensure safety and efficacy in treating insomnia, trazodone would be given in small dosages. The choice to prescribe trazodone typically results from research showing that it can increase sleep latency, duration, and quality, including assisting the patient in achieving deep or slow-wave sleep.

(Pharmacotherapy for Insomnia in a 31-year-old Male Patient)

Zolpidem is recommended as a substitute since it has been shown to improve sleep latency and sleep length measurements and reduce the frequency of awakenings in people with temporary insomnia (Edinoff et al., 2021). It can be used as a mild muscle relaxant and is beneficial in helping those with persistent insomnia get better quality sleep. Zolpidem is an effective treatment for insomnia despite the drug’s exacerbated side effects, including hallucinations, increased fall risks, accidents caused by sleep driving, and increased suicidal and homicidal thinking and planning (Edinoff et al., 2021). The third suggestion is Hydroxyzine, which has been shown to effectively treat insomnia despite having unfavorable side effects like xerostomia and xerophthalmia. The medication has potent sedative effects, and studies indicate that it may be used as an interim treatment for individuals who have trouble falling asleep (Burgazli et al., 2023). Patients who were given hydroxyzine in the research reported better sleep and fewer nightmares or hallucinations than the controls (Burgazli et al., 2023). Despite the side effects, including tiredness and headaches, the medication is also well tolerated.

References

Bhandari, P., & Sapra, A. (2019). Zaleplon. In: StatPearls [Internet]. Treasure Island (FL):

Burgazli, C. R., Rana, K. B., Brown, J. N., & Tillman, F., 3rd (2023). Efficacy and safety of hydroxyzine for sleep in adults: Systematic review. Human psychopharmacology, 38(2), e2864. https://doi.org/10.1002/hup.2864

Edinoff, A. N., Wu, N., Ghaffar, Y. T., Prejean, R., Gremillion, R., Cogburn, M., Chami, A. A., Kaye, A. M., & Kaye, A. D. (2021). Zolpidem: Efficacy and Side Effects for Insomnia. Health psychology research, 9(1), 24927. https://doi.org/10.52965/001c.24927

Rösner, S., Englbrecht, C., Wehrle, R., Hajak, G., & Soyka, M. (2019). Eszopiclone for insomnia. The Cochrane database of systematic reviews, 10(10), CD010703. https://doi.org/10.1002/14651858.CD010703.pub2

Yi, X. Y., Ni, S. F., Ghadami, M. R., Meng, H. Q., Chen, M. Y., Kuang, L., Zhang, Y. Q., Zhang, L., & Zhou, X. Y. (2019). Trazodone for the treatment of insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep medicine, 45, 25–32. https://doi.org/10.1016/j.sleep.2018.01.010

Pharmacotherapy for Insomnia in a 31-year-old Male Patient