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Hypnotics association with
Mortality
Charles Heaney
19/02/2013
BMJ
• Volume 2, Issue 1, 2012
Cohort Study
matching 10,500 patient’s (mean age of 54)
who were prescribed hypnotics with
23,500 matched controls and followed
them for 2.5 years.
Outcome
• Clear association between patient’s
prescribed any hypnotic, and higher risk of
death, even at low doses
• Risks were elevated for different hypnotics
including benzodiazepines, barbituates,
and anti-histamines, and each was
associated with an increased rate of death
Association with Cancer
• Also, there is an increased association
with cancer with hypnotic use in the upper
third
• Author claims results were robust within
groups suffering each co-morbidty
indicating that the hazard was not
attributable to pre-existing disease.
Conclusion
• Receiving hypnotic prescriptions is
associated with greater then threefold
increase in hazard of death, even when
prescribed less then 18 pills per year
BJGP 2011
• 61:558
Systemic review of RCT’s
of minimal intervention’s
• Sending a brief letter
• Self Help Information
• Consultation with a G.P.
• All of these explained concern over long
term use, their potential side affects, and
advise on gradual dose reduction
Results
• NNT, showed that for every 12 older
people who receive a letter, one will
cease Benzodiazepine use.
Epidemiology
• 50% of patient who attend primary care
have insomnia
• 30-40% of the population
Co-exisiting
• 50% had Depression
• 48% had Anxiety
• 43% had General Physical Health
Problems
• 22% Restless Leg Syndrome
• 9% had Obstructive Sleep Apnoea
• 12% had ethanol and substance missuse
• 12% have Primary Insomnia
• 2% have Delayed Sleep Phase Disorder
Outcome
• All three methods found a twice a
reduction in benzodiapines compared to
control groups
• NNT, 12 letters to older people need to
receive one letter for one to cease
benzodiazepines.
General Approach
• Treatment for any underlying medical
condition, psychiatric illness, and
substance abuse.
• Behavioural Therapies
• Medications
• Combination therapy
Sleep Hygiene
• Sleep as long as to get rested and then
get out of bed
• External Stimuli
• Regular Sleep Cycle
• Try not to force sleep
• Avoid caffeinated beverages after lunch
• Avoid smoking, particularly in the evening
Stimulus Control
• Bed is primarily for sleeping
Sleep Restriction Therapy
• Some patient’s stay in bed longer to make
up for lost sleep
Contraindications to meds
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Pregnancy
Alcohol consumption
Renal or hepatic disease
Pulmonary disease or sleep apnea
Night time decision makers
Older Patients
Hypnotic Drugs
• Shorter Acting Drugs, such as Zolpidem
are preferred for insomnia with delayed
sleep latency
• Medium Acting, such as Zopiclone and
Temazepam, if they wake at night
• Long Acting, such as Clonazepam, if they
have insomnia with day time anxiety
• Advise max 3 times a week
Antidepressants
• Sedating anti-depressants have not have
problems with dependence, there is less
evidence of eifficacy and side affects
• Antipsychotics
• Barbiturates
• Herbal Products
Adverse Affect
• sedation, drowsiness, dizziness,
lightheadedness, cognitive impairment,
motor incoordination, and dependence
• habit forming and rebound insomnia may
occur when some short-acting medications
are discontinued.
• Older Patient’s, threefold increase in
hazards of death, even when less then 18
pills per year
• In March of 2007, the FDA requested that
the manufacturers of sedative-hypnotic
medications strengthen their labeling to
include stronger language about the risks
of severe allergic reactions and complex
sleep-related behaviors (eg, driving,
making telephone calls, eating, having sex
while not fully awake).
Ciracdian Rythem Disorders
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Phototherapy
Chronotherapy
Cirrhosis
Jet Lag
• Speed of onset — The most important
distinction among the benzodiazepines, in
the context of abuse potential, is the
speed of onset .
• Drugs that more rapidly reach peak brain
levels after oral administration are
relatively more likely to produce brain
reward or euphoria, and are therefore
more likely to be abused.
Withdrawal
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Increased body temperature
Elevated blood pressure
Increased respiratory rate and heart rate
Aroused level of consciousness or frank
delirium
Tremulousness
Increased reflexes
Disorientation
Psychotic behavior including hallucinations