What is Acute Insomnia? • Characterized by: 1,2 – Sudden onset – Short course (duration ≤3 months) • Patient may experience: – Difficulty initiating sleep – Sleep fragmentation – Increased duration of nocturnal awakenings – Short duration of sleep – Poor sleep quality 1. American Academy of Sleep Medicine. ICSD-2 – International Classification of Sleep Disorders, 2nd ed: Diagnostic and coding manual. 2005. 2. Alberta Medical Association. Toward Optimized Practice (TOP) Adult Insomnia: Diagnosis to Management Clinical Practice Guidelines . 2010.
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What is Acute Insomnia? Characterized by: 1,2 –Sudden onset –Short course (duration ≤3 months) Patient may experience: –Difficulty initiating sleep –Sleep.
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What is Acute Insomnia?
• Characterized by:1,2
– Sudden onset
– Short course (duration ≤3 months)
• Patient may experience:
– Difficulty initiating sleep
– Sleep fragmentation
– Increased duration of nocturnal awakenings
– Short duration of sleep
– Poor sleep quality
1. American Academy of Sleep Medicine. ICSD-2 – International Classification of Sleep Disorders, 2nd ed: Diagnostic and coding manual. 2005.
2. Alberta Medical Association. Toward Optimized Practice (TOP) Adult Insomnia: Diagnosis to Management Clinical Practice Guidelines. 2010.
Why Treat Insomnia?
• Early therapy can prevent the evolution of more complex sleep-related syndromes
• Recurrent, untreated insomnia may lead to more chronic, intractable insomnia
• Patient may develop psychophysiological (conditioned) insomnia over time; more difficult to resolve1
• Bidirectional link between insomnia and depression2
1. Drake CL, Roth T. Sleep Med Clin. 2006;1:333-349.2. Staner L. Sleep Med Rev. 2010;14:35-46.
Relative lack of evidence in insomniaWeight gain can be problematic with mirtazapine
Amitriptyline Relative lack of evidence in insomniaAdverse effects; eg, dose-related weight gainAnticholinergic effects can be bothersome
Antihistamines:chlorpheniramine
Relative lack of evidence in insomniaExcessive risk of daytime sedation, psychomotor impairment, and anticholinergic effects
Antipsychotics• Conventional or first-generation
(chlorpromazine, methotrimeprazine, loxapine)
• Atypical or second-generation (risperidone, olanzapine, quetiapine)
Relative lack of evidence in insomniaUnacceptable risk of anticholinergic effects and neurological toxicityRelative lack of evidence in insomniaUnacceptable cost and risk of metabolic toxicity (eg, hypercholesterolemia, hyperglycemia, weight gain), psychotic behaviours
Excessive risk of daytime sedation and psychomotor impairment (lorazepam has a long half-life, but a short duration of action due to rapid tissue redistribution)Very slow absorption: Tmax ~180 minUnacceptable risk of memory disturbances, rebound insomnia, and rebound anxiety
Short-term Therapies: Effective and Safe First- and Second-line Options
First LineZolpidem 10 mg Tmax ~30+ minutes (1.4 hours)