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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.