Management of insomnia

The choice of management strategy for insomnia is dependent on the duration and nature of presenting symptoms.

Psychological therapies

  • Cognitive behavioural therapy (CBT) has been shown to be effective in the management of persistent insomnia but is beyond the scope of this guideline.

Sleep hygiene measures

Good sleep hygiene is the cornerstone of any treatment plan for insomnia. This includes:

  • Increase daily exercise but not in the evening
  • Reduce daytime napping
  • Avoid caffeine and alcohol before bedtime
  • Do not watch TV in bed
  • Use anxiety management or relaxation techniques
  • Develop a regular routine of rising and retiring at the same time each day

Patient information leaflet - NEW Devon CCG Good Sleep Guide

Drug therapy

Hypnotics can provide relief from symptoms of insomnia but they do not treat any underlying cause. Pharmacological treatment should only be used as a last resort.

Before commencing a hypnotic

Review current medicines for drugs that are associated with insomnia or a disturbed sleep. Examples include MAOIs, SSRIs, venlafaxine, lamotrigine, aripiprazole, steroids, beta blockers, diuretics and laxatives. Consider taking these agents earlier in the day to minimise problems at night.

Try to ascertain if there is a physical reason for the insomnia such as pain or whether insomnia is secondary to an undiagnosed mental health disorder, and treat this appropriately. A World Health Organisation (WHO) survey of people reporting sleep problems identified that 52% had a well-defined mental health disorder and 54% reported a physical disorder.

Hypnotic treatment

Treatment should be for a maximum of four weeks including any tapering-off period.

Zopiclone
  • Adult over 18 years, 7.5mg at bedtime; Elderly, initially 3.75mg at bedtime increased if necessary
  • Zopiclone has an elimination half-life of 3.5 to 6.5 hours. It is indicated for insomnia including difficulty in falling asleep, nocturnal awakening and early awakening.
  • See section 4.1 Hypnotics and anxiolytics
Promethazine hydrochloride
Zaleplon
  • 10mg (5mg in elderly) at bedtime or after, for difficulty in falling asleep
  • Zaleplon has an elimination half-life of one hour and is not equivalent in activity to zolpidem or zopiclone. It is indicated only for patients who have difficulty falling asleep. It is unlikely to be of benefit in patients who experience nocturnal or early awakening. It is licensed only where insomnia is severely debilitating; treatment duration should not exceed two weeks.
  • See section 4.1 Hypnotics and anxiolytics
Zolpidem
  • 10mg (5mg in elderly) at bedtime
  • Zolpidem has an elimination half-life of two and a half hours. It is licensed for short-term debilitating insomnia. Treatment should usually vary from a few days to 2 weeks with a maximum of 4 weeks, including tapering off where appropriate.
  • See section 4.1 Hypnotics and anxiolytics

Notes

  1. Pharmacological treatment should only be used as a last resort
  2. Choice of hypnotic should be made based on individual preference where appropriate, using the least expensive agent where possible
  3. There is no evidence that patients who have not responded to one hypnotic will respond to another
  4. Switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent.
  5. Sedating antihistamines such as promethazine hydrochloride may be useful in aiding sleep where possible benzodiazepine dependence is a major concern, but their sedative effect diminishes quickly. There is also an increased risk of drowsiness the next day so advise the individual not to take too late in the evening
  6. Prescribers must warn individuals about the risk of drowsiness the next day and to avoid driving when affected
  7. Prescribers in secondary care are requested to review all prescriptions for hypnotics on discharge for appropriateness and ensure there is clear communication for GPs regarding whether hypnotics should be continued once discharged. Where a specialist recommends that treatment with a hypnotic is continued past the usual maximum of 4 weeks (i.e. off-licence prescribing) a clear rationale must be communicated to the GP, including a proposed treatment plan of when to review, reduce and/or discontinue treatment
  8. The prescribing of hypnotics to children is not justified (with the exception of occasional use for conditions such as night terrors and somnambulism). Treatment with melatonin should only be initiated by or on the recommendation of a Child and Adolescent Mental Health Services (CAMHS) or Learning Disability specialist
  9. Antidepressants should not be used to treat insomnia, but insomnia may improve in response to adequate treatment of a depressive episode. Low dose amitriptyline should not be used as tolerance develops quickly and the relative side effects are unfavourable compared to the formulary choice hypnotics above
  10. Antipsychotics should not be used to treat insomnia, but insomnia may improve in response to adequate treatment of a psychotic episode with antipsychotics
  11. Some individuals may wish to try alternative remedies and care should be taken to ensure these are safe for the individual with no interactions with their medicines or illnesses. Such remedies are not available through the NHS

Managing withdrawal of long term hypnotics

If individuals have been prescribed hypnotics long term they should be offered the opportunity to withdraw from their treatments. This must be done collaboratively to produce the most success. The prescription should be converted to an equivalent dose of diazepam to facilitate a gradual reduction in dose, using liquid preparations where necessary. Commonly used benzodiazepine equivalent doses (not necessarily hypnotics) are listed below. Aim for a reduction of 10-20% of the dose every 1-2 weeks and adjust the rate according to the individual's response.

Drug

Diazepam equivalent*

Zopiclone 7.5mg 5mg
Zolpidem 10mg 5mg
Zaleplon 10mg 5mg
Non-formulary
Temazepam 20mg
10mg
Nitrazepam 5mg 5mg (may be less, caution)
Lormetazepam 1mg 5mg
Clonazepam 2mg

2.5-40mg (Caution: huge potential inter-person variability)

Lorazepam 1mg 5-10mg
Oxazepam 15mg 5mg

*adapted from Bazire's Psychotropic Drug Directory 2009

Sample letters inviting individuals for a review of their benzodiazepine therapy are available at the NPC website.

Patient focussed resources

  • The Good Sleep Guide and sample letters for inviting individuals for a review of their benzodiazepines are available at the NPC website
  • The Royal College of Psychiatrists have produced an information leaflet on sleep that contains useful information about sleep including good sleep hygiene
  • A patient decision aid (which includes information on relative side effects but also some non-formulary treatments) is available at Choice and Medication

 

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