Most of us have had a sleepless night or two. It’s part of life. But when a night of tossing and turning becomes a chronic problem, it may be time to dig a little deeper into what’s causing you to count sheep.
A first step to sweet dreams is to make sure you have good sleep hygiene habits and an environment conducive to a restful slumber, such as a dark, quiet room with no technology, i.e. a TV or laptop. If you continue to have sleep problems, consider seeing a physician to rule out any underlying health issue.
“Chronic insomnia is often secondary to another health condition like depression, a thyroid problem, chronic pain or cancer,” said
Kelly Lee, PharmD, associate professor of clinical pharmacy at University of California San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. “By identifying and treating the primary health issue, the insomnia may resolve itself.”
There are individuals, however, who can still benefit from a doctor-prescribed sleep aid.
Lee discussed the general categories of sleep medications and recommends taking these them on an empty stomach to improve absorption and avoid delayed effect.
Benzodiazepines – diazepam (Valium) and alprazolam (Xanax)
These medications non-selectively target the brain's GABA receptors, reducing neuronal excitability, causing sedation. But they are not the preferred sleep aid anymore, particularly for older adults.
“They have lots of side effects and may cause dependence,” Lee said. “I personally no longer recommend them for my patients.”
These side effects include morning drowsiness, a drugged feeling or dizziness that can predispose older adults to life-altering falls.
Non-benzodiazepine hypnotics – eszopiclone (Lunesta), zolpidem (Ambien) and zaleplon (Sonata)
Also known as Z Drugs, the Food and Drug Administration (FDA) considers this category of medication to have the most evidence of helping chronic insomnia.
Unlike their predecessors, Z Drugs target a specific part of the GABA receptor. They can still cause “a hangover effect” and their use may lead to dependence.
Sonata is particularly helpful in inducing sleep, said Lee, but is not as effective in maintaining it. Ambien and Lunesta are effective at both, but Ambien, in particular, has been associated with rare but serious side effects, including doing activities while not being fully awake and not remembering them the next day.
Antihistamines – diphenhydramine (Benadryl and Unisom)
Antihistamines are commonly found in over-the-counter sleep aids, but are not recommended for sustained or frequent use, Lee said. They have a high tolerance threshold and may begin to lose effectiveness after as few as three to five doses. They also cause “morning fog.”
“These drugs are good at treating allergies, but they are not as effective in treating chronic insomnia,” Lee said.
Melatonin – Over-the-counter supplement and Ramelteon
Melatonin is a naturally occurring compound in the brain that plays a role in maintaining the circadian rhythm that promotes the normal sleep-wake cycle. Melatonin, sold over-the-counter as a supplement, as well as the prescription melatonin receptor agonist Ramelteon, alter a person’s circadian clock, which is particularly helpful for jet lag or shift work.
Orexin receptor agonists – suvorexant (Belsomra)
Orexin is a hormone that regulates wakefulness. The discovery that narcolepsy is caused by the loss of orexin-containing neurons led to the development of a new class of sleep aid. Since the chemical plays a role in keeping people awake and alert, a medication that blocks its action has the potential to promote sleep. The first drug on the market to target orexin’s role in wakefulness is suvorexant, approved by the FDA in 2014.
“We know less about suvorexant because it is such a new drug,” Lee said. “We will have to see if it offers any benefit over currently available drugs, but the cost will be an issue since there are no generics available.”
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Sleep Medicine Center