Nearly 1/3 of a person’s life is spent in sleep, and good or bad sleep directly affects the quality of life and learning in the other 2/3 of the time. In this course, the diagnosis and treatment of insomnia, as well as the detailed medication, are taught through a case sharing.
Case sharing
1.Case
Patient, male, 38 years old. He presented to the clinic with intermittent burning pain in the left side of the chest with insomnia for more than 4 months. Insomnia was characterized by difficulty in falling asleep (>1 hour), early awakening (2-3AM), shallow and dreamy sleep, and difficulty in falling asleep after waking up, 3-4 times/week. There is a feeling of fatigue after waking up in the morning. In the past month, she has been suffering from memory loss, concentration loss, low energy, reduced work ability, slower self-reaction, depressed mood, sometimes irritable and irritable. He had herpes zoster on the left side of the chest more than 4 months ago, and the herpes crusted over after 3 weeks of active treatment. On examination: post-herpetic hyperpigmentation was seen on the left side of the chest. Nociceptive hypersensitivity was present in the skin area affected by herpes. Consciousness was clear, facial expression was slightly painful, active description of the disease, eager to seek treatment, and complete self-knowledge.
Scale evaluation: HAMA score: 18
HAMD score: 22
Diagnosis: post-herpetic neuralgia, insomnia, depressive and anxiety state
2. Treatment
Drug treatment.
(1) Antidepressants: tricyclic antidepressants, SNRI can reduce neuropathic pain evidence is more. SSRI is less effective for neuropathic pain evidence.
(2) Anti-epileptic drugs: Carbamazepine is the first-line drug for trigeminal neuralgia. Oxcarbazepine, a newer antiepileptic drug derived from carbamazepine, also has partial evidence of effectiveness. Gabapentin and pregabalin have more evidence of effectiveness in the treatment of painful diabetic neuropathy and postherpetic neuralgia. Other antiepileptic drugs such as valproate, lamotrigine, and topiramate have also shown some efficacy for neuropathic pain.
(3) Opioid analgesics;
(4) N-methyl-D-aspartate (NMDA) antagonists;
(5) Topical medications.
Definition of insomnia
Insomnia: a subjective experience in which the patient is dissatisfied with the duration and/or quality of sleep and affects daytime social functioning. Insomnia is characterized by difficulty in falling asleep (sleep duration longer than 30 min), sleep maintenance disorders (≥2 awakenings throughout the night), early awakenings, decreased sleep quality and reduced total sleep duration (usually less than 6 h), accompanied by daytime dysfunction.
Classification of insomnia
1, according to the course of the disease: acute insomnia (duration < 1 month); subacute insomnia (duration ≥ 1 month, < 6 months); chronic insomnia (duration ≥ 6 months).
2, according to the etiology: primary insomnia; secondary insomnia; co-morbid insomnia.
Diagnosis of insomnia
1.The presence of one of the following symptoms: difficulty falling asleep, sleep maintenance disorder, early awakening, decreased sleep quality or no sense of recovery after waking up in the morning of daily sleep.
2. The above symptoms occur despite the availability of sleep and an environment suitable for sleep.
3. The patient complains of at least 1 of the following sleep-related impairments in daytime function.
(1) Fatigue or general malaise;
(2) Decreased attention, attention maintenance, or memory;
(3) Decreased ability to learn, work, and/or socialize;
(4) Mood swings or irritability;
(5) Daytime sleepiness;
(6) Decreased interest and energy;
(7) Increased tendency to make mistakes at work or while driving;
(8) Tension, headache, dizziness, or other physical symptoms associated with sleep deprivation;
(9) Excessive attention to sleep.
Medication for insomnia
1, benzodiazepine drugs (BZDs): can non-selectively agonize different α subunits on γ-aminobutyric acid receptor A (GABAA), with sedative, anti-anxiety, muscle relaxation and anticonvulsant effects. It can shorten the sleep latency and increase the total sleep time of insomniacs.
Commonly used drugs are alprazolam, chlordiazepoxide, diazepam, lorazepam, midazolam, etc.
Adverse reactions and precautions: Adverse reactions include daytime sleepiness, dizziness, hypotonia, falls, and cognitive impairment. Elderly patients should be especially aware of the muscle relaxing effects of the drug and the risk of falls. The use of medium- and short-acting BZDs for insomnia has the potential to cause rebound insomnia. Withdrawal symptoms may occur upon discontinuation of BZDs after continued use. The potential risk of substance abuse needs to be considered in insomnia patients with a history of substance abuse.
Contraindicated in: women who are pregnant or lactating; those with hepatic or renal impairment; patients with obstructive sleep apnea syndrome and those with severe ventilatory deficits.
2.non-benzodiazepine drugs (non-BZDs): have similar hypnotic efficacy to BZDs. It is more selective to the α1 subunit on GABAA and mainly exerts hypnotic effects. It has similar hypnotic effect to BZDs. It has a short half-life, generally does not produce daytime sleepiness, and has a lower risk of drug dependence than traditional BZDs.
Commonly used drugs include zolpidem, zolpidem controlled release, zopiclone, dezopiclone, zaleplon, etc.
Adverse effects and precautions: Treatment of insomnia is safe and effective, with no significant adverse drug reactions with long-term use, but there is a possibility of a transient rebound of insomnia after abrupt discontinuation of the drug.
Contraindicated: pregnant or lactating women; simultaneous application of other central depressants, morphine and ethanol can significantly enhance toxicity.
3, melatonin: involved in the regulation of sleep and wake cycle, can improve the symptoms caused by jet lag changes, sleep phase delay syndrome and circadian rhythm disorder sleep disorder, but because there is no consistent conclusion of clinical application, so melatonin is not recommended as a hypnotic drug to use.
4.Melatonin receptor agonists: alternative treatment for patients who cannot tolerate the aforementioned hypnotic drugs and for patients who have already developed drug dependence.
5, antidepressants: some antidepressants have hypnotic sedative effect, in insomnia accompanied by depression, anxiety state of mind when the application is more effective.
(1) tricyclic antidepressants;
(2) selective 5-HT reuptake inhibitors (SSRI);
(3) SNRI;
(4) Norepinephrinergic and specific 5-HT-ergic antidepressants (NaSSA);
(5) 5-HT receptor antagonists and reuptake inhibitors (SARI);
(6) antidepressants in combination with BZRAs.
Specific recommendations for drug treatment
1, grasp the balance of benefits and risks.
2.Follow the principle of treatment and individualization.
3, the mode of administration: for chronic insomnia patients with long-term application of sedative-hypnotic drugs, continuous drug treatment is not advocated. Intermittent treatment (the frequency of intermittent dosing is 3-5 times per week) or on-demand treatment dosing is recommended. An assessment every 4 weeks is recommended. “On-demand” dosing.
(1) When sleep is expected to be difficult: take 5-10 min before going to bed;
(2) As needed for nighttime sleep: Take 30 min after going to bed and still cannot fall asleep;
(3)If you wake up at night and cannot fall asleep again, and the expected time to wake up is more than 5h, you can take it (only for short half-life drugs);
(4) Taken at bedtime according to the needs of daytime activities (when there is an important job or business the next day).
(4) Not suitable for the treatment of chronic insomnia: antihistamines, anti-allergy drugs, other sleep-aiding over-the-counter drugs.
Other treatment methods
1.Psycho-behavioral treatment for insomnia.
2.Comprehensive intervention for insomnia.
3. Traditional Chinese medicine treatment.