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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?.

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Insomnia and Drowsiness

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  1. Insomnia and Drowsiness Prepared by: Lindsey Brown Winter Term 2006

  2. 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

  3. Questions?

  4. Chief complaint? • Specific complaint of insomnia? • How is it affecting their daily activities?

  5. Duration and Frequency? • Transient = < 1 week • Short term = 1-3 weeks • Chronic = > 3 weeks

  6. Medical History? • Current Medical Problem or Conditions? • Current Medications (Rx or OTC)? • Allergies or Sensitivities?

  7. Good Sleep Hygiene

  8. 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

  9. Diphenhydramine • The only FDA approved OTC sleep aid • Patient specific dosing (25-50mg QHS) • Duration of sedation = 3 - 6 hours • Next morning hang-over & tolerance are common

  10. 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

  11. 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

  12. 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.

  13. What do you need to know?

  14. Medical or psychiatric problems • Current medications • Caffeine consumption • Sleep patterns • Lifestyle

  15. 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

  16. 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

  17. Ginseng • Herbal product that inhibits thromboxane • Weak antiplatelet effects, increased risk of bleeding • May exacerbate psychiatric symptoms • Hypoglycemic effects • Usual Dose: 100-300mg BID

  18. Musculoskeletal Injuries “Sprains, Strains and Pains”

  19. Musculoskeletal and connective tissue injuries are the 3rd and 5th leading cause of lost work days in men & women in the US, respectively…..

  20. Patient Assessment There are no wrong answers…

  21. P,Q,R,S,T • Precipitating factors • Quality of pain • Region or location • Severity (changes in daily activities) • Timing

  22. 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

  23. 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

  24. Counterirritants • Paradoxical pain-relieving effect achieved by producing a less severe pain to counter a more intense one • Psychological component = placebo effect

  25. Rubefacients • MOA: vasodilation producing reactive hyperemia “redness” • Methyl salicylate “most widely used”

  26. 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

  27. 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

  28. 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

  29. 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

  30. Osteoarthritis • Affects ½ of US population > 70 yo • General Treatment Approach: • APAP– NTE 4000mg/ day • Glucosamine – 1500mg QD

  31. Don’t Forget… • Warm-up and Cool down

  32. 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.

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