Download Insomnia and Drowsiness

Insomnia and
Drowsiness
Prepared by: Lindsey Brown
Winter Term 2006
A disorder not a disease…
 Diverse
etiologies & patient complaints
 Very subjective
½
of US population experienced insomnia
in the past year
 30% of patients have symptoms nightly
Questions?
Chief complaint?
 Specific
 How
complaint of insomnia?
is it affecting their daily activities?
Duration and Frequency?
 Transient
 Short
= < 1 week
term = 1-3 weeks
 Chronic
= > 3 weeks
Medical History?
 Current
Medical Problem or Conditions?
 Current
Medications (Rx or OTC)?
 Allergies
or Sensitivities?
Good Sleep Hygiene









Regular sleep pattern
Comfortable surroundings
Relax
Exercise
Break the cycle of daytime naps
Avoid overeating close to bedtime
Monitor caffeine and nicotine use
Alcohol – not a good sedative
Avoid sleep anxiety
Diphenhydramine
 The
only FDA approved OTC sleep aid
 Patient
specific dosing (25-50mg QHS)
 Duration
 Next
of sedation = 3 - 6 hours
morning hang-over & tolerance are
common
What to be aware of…
 Anticholinergic

SEs
Contraindications = BPH, difficulty urinating
narrow “closed” angle glaucoma, CVD,
dementia
 Do
not use more than 7-10 days
Melatonin
 Endogenous
hormone produced by pineal
gland
 Shifts circadian rhythm, body temp, and
alertness
 0.3-
1 mg taken 1-2 hours prior to bedtime
Drowsiness Case Study
23 yo male comes to your pharmacy and
states that he was up all weekend
studying for finals, and is worried he cant
stay alert to take the tests he studied so
hard for. He is looking for an OTC
stimulant to help stay awake for his 3 days
of exams.
What do you need to
know?
 Medical
or psychiatric problems
 Current medications
 Caffeine consumption
 Sleep patterns
 Lifestyle
Caffeine
 Not

a substitute for good sleep patterns
Most frequently used stimulant in the world
 Good
sleep hygiene, lifestyle
modifications, and referral should come 1st
If Caffeine is used…

Xanthine derivative that antagonizes the
receptors of Adenosine

Tolerance and withdrawal are common

Usual Dose: 100 -200mg Q3-4H PRN, NTE
600mg/day

Special considerations
Ginseng

Herbal product that inhibits thromboxane

Weak antiplatelet effects, increased risk of bleeding

May exacerbate psychiatric symptoms

Hypoglycemic effects

Usual Dose: 100-300mg BID
Musculoskeletal Injuries
“Sprains, Strains and Pains”
Musculoskeletal and
connective tissue injuries
rd
th
are the 3 and 5 leading
cause of lost work days in
men & women in the US,
respectively…..
Patient Assessment
There are no wrong answers…
P,Q,R,S,T
 Precipitating
factors
 Quality of pain
 Region or location
 Severity (changes in daily activities)
 Timing
Exclusions for self-treatment








Pain with N/V
Weakness in any limb
Visually deformed joint or abnormal joint
movement
Joint pain with systemic symptoms
Pelvic or abdominal pain
Pain that is increasing or changing
Flouroquinolone use
Duration >2 weeks
Tendonitis, Bursitis, Strains, and
Sprains
P
= protect
 R = rest
 I = ice (10-30 min TID-QID or at max Q2H)
 C = compress
 E = elevate
 NSAIDS

2 theories = early vs. withhold
Counterirritants
 Paradoxical
pain-relieving effect achieved
by producing a less severe pain to counter
a more intense one
 Psychological
component = placebo effect
Rubefacients
 MOA:
vasodilation producing reactive
hyperemia “redness”
 Methyl
salicylate “most widely used”
Cooling Sensation
 Dose

Dependent MOA:
Stimulates nerves that perceive cold while
depressing nerves that perceive pain, this is
followed by a sensation of warmth
 Menthol
 Camphor
Vasodilation
 MOA:



Marked power of diffusion which leads to
elevated skin temperature at very low
concentrations
Mediated by PG biosynthesis
SEs: drop in BP, pulse, and syncope
 Methyl
Nicotinate
Incite Irritation
 MOA:
depletes sensory neurons of
Substance P, which will cause burning
pain and redness
 Capsicum
= only counterirritant for chronic
pain

Apply TID-QID for long-term use
Unproven Effectiveness…
 MOA:
absorbed through the skin and
results in synovial fluid salicylate
concentrations slightly lower than oral
ASA.

Contraindications: renal insufficiency, liver
disease, hypothrombinemia, vitamin K
deficiency, scheduled for surgery, chronic
alcohol users
 Trolamine
Salicylate
Osteoarthritis
 Affects
½ of US population > 70 yo
 General


Treatment Approach:
APAP– NTE 4000mg/ day
Glucosamine – 1500mg QD
Don’t Forget…
 Warm-up
and Cool down
References
 Berardi
R, McDermott J, et al. HandBook
of NonPrescription Drugs. 14th Ed. 2004.
 Engle J, Stovitz S. Partners in Self-Care:
Self-Treatment Options for Common
Sports and Physical Activity Injuries. 2004;
12: 1-18.