New guidelines for diagnosis and treatment of insomnia

Abstract

The Brazilian Sleep Association brought together specialists in sleep medicine, in order to develop new guidelines on the diagnosis and treatment of insomnias. The following subjects were discussed: concepts, clinical and psychosocial evaluations, recommendations for polysomnography, pharmacological treatment, behavioral and cognitive therapy, comorbidities and insomnia in children. Four levels of evidence were envisaged: standard, recommended, optional and not recommended. For diagnosing of insomnia, psychosocial and polysomnographic investigation were recommended. For non-pharmacological treatment, cognitive behavioral treatment was considered to be standard, while for pharmacological treatment, zolpidem was indicated as the standard drug because of its hypnotic profile, while zopiclone, trazodone and doxepin were recommended. Key words: insomnia, diagnosis of insomnia, treatment of insomnia, cognitive behavioral therapy.Novas diretrizes no diagnóstico e tratamento das insônias resumo A Associação Brasileira de Sono reuniu especialistas em medicina do sono com o objetivo de desenvolver novas diretrizes no diagnóstico e tratamento das insônias. Nós consideramos quatro níveis de evidência: padrão, recomendado, opcional e não recomendado. Os tópicos abordados foram: conceito, avaliação clínica e psicossocial, indicação da polissonografia, tratamento farmacológico, terapia comportamental cognitiva, comorbidades e insônia na infância. Para o diagnóstico da insônia, foi recomendada uma avaliação psicossocial e a realização da polissonografia, enquanto que no que se refere ao tratamento, foi estabelecido como padrão a indicação da terapia comportamental cognitiva, e, quanto ao tratamento farmacológico, foi indicado o uso do zolpidem como hipnótico padrão, e sendo recomendado o zopiclone, a trazodona e a doxepina. Palavras-chave: insônia, diagnóstico da insônia, tratamento da insônia, terapia comportamental cognitiva.

Addressing sleep disturbances: An opportunity to prevent cardiometabolic disease?

“…PAP therapies for sleep apnoea (Avlonitou et al, 2012; Bertisch & Patel, 2012; Campbell et al, 2012; Ciccone et al, 2012; Filtness et al, 2012; Hegglin et al, 2012; Zhao et al, 2012), hypnotics or cognitive behavioural therapy for insomnia (CBTI) (Doghramji, 2010; Ebben & Narizhnaya, 2012; Gehrman & Gooneratne, 2010; Hall-Porter et al, 2010; Jarnefelt et al, 2012; Krystal, 2009; Morin & Willett, 2009; Pinto et al, 2010; Saddichha, 2010; Siebern & Manber, 2010; Siebern et al, 2012; Sullivan, 2010; Taylor et al, 2010), dopamine agonism for RLS and PLMD (Aurora et al, 2012; Benes et al, 2009; Earley et al, 2011; Earley & Silber, 2010; Garcia-Borreguero & Williams, 2010; Khalid et al, 2009; Natarajan, 2010; Quilici et al, 2008; Trenkwalder & Paulus, 2010; Wetter, 2010)), no intervention has been developed or evaluated for insufficient sleep or other aspects of general sleep disturbance. One potential reason is that the data needed to frame this form of sleep as important and relevant has only been recently aggregated in a way that makes the case compelling.…”

Therapeutic rationale for low dose doxepin in insomnia patients

“…These agents have also been associated with the potential for abuse and dependence in at risk populations, which led the US Drug Enforcement Agency to classify them as Schedule IV substances [16,17] .…”

“…Disadvantages of the current OTC antihistamines are their relatively long duration of action and next-morning drowsiness, potential side effects, and insufficient receptor selectivity has risk of undesired anticholinergic side effect (i.e. dry mouth, dry eye, retention of urine, constipation) [16] .…”

“…The TCAs can alter sleep architecture by reducing rapid eye movement (REM) sleep. In general, sedating properties of anti-depressant agents are related to antagonism of serotonin 5HT2, histamines, and α-1 adrenergic receptors [14][15][16] .…”

Evaluation of an individual sleep intervention programme in people undergoing peritoneal dialysis treatment

“…The interventions were limited to primarily sleep hygiene and sleep scheduling interventions, which are two components in the concept of cognitive behavioural therapy (CBT) for primary insomnia (Pinto et al 2010). A broader approach, that is, a full CBT intervention might have been more beneficial.…”