Pharmacologic Approaches To The Treatment Of Insomnia In A Younger Adult

Insomnia

31-year-old Male

BACKGROUND

This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.

SUBJECTIVE

Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, and event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation, and is future oriented.

 

Point One

Select what you should do:

· Zolpidem: 10 mg daily at bedtime

· Trazodone 50 mg po at bedtime

· Hydroxyzine: 50 mg daily at bedtime

Decision Point One

Trazodone 50 mg po at bedtime

 

Results of decision point one

· Patient returns to clinic in 2 weeks

· Patient states medication works well but gives him an unpleasant side effect of an erection lasting approximately 15 minutes after waking

· Patient states this makes it difficult to get ready for work or go downstairs and have coffee with his girlfriend and daughter in the morning

· Patient denies auditory/visual hallucinations and is future oriented

 

 

 

Point Two

Select what you should do next:

· Explain that an erection lasting 15 minutes is not considered a priapism and should diminish over time, continue with current dose

· Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime

· Decrease trazodone to 25 mg daily at bedtime

Decision Point Two

Decrease trazodone to 25 mg daily at bedtime

 

Results of decision point two

· Patient returns to clinic in 2 weeks

· Patient states trazodone is very effective for sleep

· Patient states sometimes the 25 mg dosage isn’t quite enough to help him sleep through the night

· Patient denies auditory/visual hallucinations and is future oriented

 

Point Three

 

Select what you should do next:

· Discontinue trazodone. Initiate therapy with ramelteon 8 mg nightly at bedtime. Follow up in 4 weeks

· Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

· Discontinue trazodone. Initiate therapy with hydroxyzine 50 mg nightly at bedtime. Follow up in 4 weeks

 

Decision Point Three

Continue dose. Encourage sleep hygiene. Follow up in 4 weeks

Guidance to Student

Since the patient is already showing a partial response from trazodone, it may not be prudent to switch therapy. A thorough sleep hygiene analysis should always be performed prior to initiation of pharmacotherapy as well as at reassessments. If you find the patient isn’t practicing proper sleep hygiene, you may continue the dose and encourage sleep hygiene. If the patient is practicing good sleep hygiene, you may consider discontinuing trazodone and initiating hydroxyzine. Although there are some negative side effects associated with hydroxyzine such as Xerostomia and Xerophthalmia, it is still a safer medication to prescribe than ramelteon.