Click here to see how Dr. Jones determines “Best Meds”
Sleep medications should only be used when good sleep habits don’t work. (See Sleep Do’s and Dont’s Handout) Because almost everybody has at least occasional sleep problems due to acute stress, early flights, late meetings, jet lag, shift work, etc., and because not sleeping well even one night has potentially adverse effects on functioning and or health, having a sleeping pill available when needed can be very helpful.
The problem with OTC sleep medications like Tylenol PM is they don’t provide a normal night’s sleep and really haven’t been shown to have no carry over affects the next day. All OTC sleep medications are antihistamines.
Many people use alcohol to sleep. This is actually a horrible idea because although alcohol may help you fall asleep, it wears off in 2-3 hours and disrupts the quality of sleep in the middle of the night. Alcohol should not be consumed in the 2-3 hours before bedtime.
Benzodiazepines are frequently used for sleep, including Xanax, Klonopin, Ativan, Valium, Dalmane, Restoril and others. They help you fall asleep but they decrease deep Stage 4 sleep-the most important type of sleep we get. (See Sleep Newsletter)
Trazodone, Seroquel and Zyprexa are sometimes used for sleep, but they haven’t been adequately studied for sleep and probably don’t provide completely normal sleep. Clonodine increases Stage 4 sleep, but affects on dream sleep (REM) aren’t clear. Tricyclics like Amitriptyline, Nortriptyline, Doxepin, and Imipramine are sometimes used-they increase Stage 4 sleep but decrease dream sleep (REM).
So, we are left with a few good choices. Neurontin appears to provide normal sleep. It also helps anxiety and certain kinds of pain but it may cause weight gain or sexual dysfunction so it’s not usually a first choice. Gabatril increases stage 4 sleep without interfering with REM sleep. In one study in elderly people, Gabatril doubled stage 4 sleep. It also helps anxiety but it’s not very sedating. It is not used first line, especially on an as needed basis.
So, now we are down to the best medications. They provide normal sleep. At the proper dose they don’t cause any next day drowsiness or impairment. You get a reliable good night’s sleep and you feel rested the next day. As of January 2005, we have 3 choices.
Sonata-This is the mildest option. It is usually taken as a 10mg capsule. Some people require 2 capsules. It is completely out of the system in 5 hours. This is sometimes an advantage because it can be taken during the night as long as you have 4 hours before you need to be up and alert. But for many people it is not strong enough, or they wake up too early, sometimes after 3-4 hours and don’t like having to repeat it during the night. Many people like it. At one capsule there is usually no impairment in thinking or functioning if there’s an emergency during the night. It is extremely unlikely that you will not remember the next morning if anything did happen during the night.
Ambien-This has been around for about 10 years and is the number 1 selling sleeping pill. It comes in a 10 mg tablet that is about 21/2 times stronger than Sonata. Because the tablets can be easily broken in half (which is still slightly stronger than Sonata 10mg) the 10mg tablet is more cost effective. It is more likely to keep you asleep for 61/2 hours or more-but some people wake up after 5-51/2 hours. Some people complain of having grogginess the next morning. It is an excellent medication and in my practice it’s about equally popular to Sonata.
Ambien CR-New on the market, this form of Ambien comes in 12.5mg and lasts longer than regular Ambien. It has a duel release (7.5mg immediately, and 5mg delayed) It also does not have short term restrictions so insurance should be easier.
Lunesta-This is the newest sleep medication to be approved in the U.S. It will be available in January 2005. It is actually an improved form of the most popular sleep medicine available in Europe for the past 15 years. The dose forms have been carefully chosen to optimize effectiveness while minimizing risk for next day drowsiness. Lunesta is the first sleeping pill to be approved in the U.S. not just for helping you get to sleep, but maintaining sleep. Sonata is just approved for helping you get to sleep. Ambien is approved for help in getting to sleep and increasing sleep duration (on average 61/2 hours). Lunesta helps you get to sleep and reduces time awake during the night by an average of 50%. At 3mg it increases total sleep time to 7-8 hours per night for 70% of people with chronic insomnia. This was documented with all night monitoring in a sleep lab, not just patient reporting.
Lunesta is also the first sleep medication approved in the U.S. that is not specifically restricted to 10-14 nights maximum usage. Although many physicians and patients know that Sonata and Ambien can be effective and tolerated for longer periods of time, insurance companies frequently use the time restriction in the PDR to limit coverage of the prescription supply to 2 weeks.
Lunesta has also demonstrated efficacy and tolerability in placebo controlled studies for up to 6 months and extended open studies to 1 year without loss of effectiveness or tolerability. The company studied 2,000 patients, which is encouraging. As always with a new medication, we will have to see how well it does in clinical practice. There are a few people who complain of a metallic taste in the AM but only 1-2% were bothered enough to discontinue it for that reason.
The bottom line is although Sonata and Ambien have worked well for many patients, there are still many patients they are not adequate for. We all welcome this new option, Lunesta.
