Palliative Care and Pain Management at the End of Life ___________________________________________
Cognitive behavioral therapy has also been reported to be effec- tive when used in combination with behavioral interventions [365; 372]. No nonpharmacologic strategy has been found to be superior to another [372]. These interventions are effective and recommended for older individuals and can also be effec- tive for people with life-limiting disease when strategies are individualized according to the patient [366; 372]. Several drugs have been approved by the FDA for the treatment of insomnia; the classes of these drugs are sedative-hypnotics and benzodiazepines ( Table 19 ). In addition, antidepressants and antihistamines are often used for insomnia, but this use is off-label. Among sedative-hypnotics, zolpidem (Ambien) is a short- to intermediate-acting drug used primarily for sleep-onset insom- nia [365; 373]. Zolpidem is recommended by the NCCN for insomnia as part of palliative care for people with cancer
[310]. Another sedative-hypnotic, eszopiclone (Lunesta), is intermediate-acting and is one of only three insomnia medica- tions approved by the FDA for long-term use [373]. There is a limited number of studies regarding the use of ben- zodiazepines in palliative care [374]. However drugs in this class are the most commonly used drugs for the treatment of short- term insomnia in people with life-limiting disease [366]. Ben- zodiazepines are effective in decreasing the time needed to fall asleep as well as the likelihood of waking up during the night [366; 373]. Their use should be short term, as their long-term efficacy has not been clearly defined, although this issue is not as important for patients with a limited life expectancy [366]. Lorazepam (Ativan) is a recommended drug for insomnia in people with cancer [310]. The long-acting effect of flurazepam (Dalmane) may be of benefit for some patients [366].
PHARMACOLOGIC MANAGEMENT OF INSOMNIA
Typical Dose a
Drug
Comments
Sedative-Hypnotics (FDA approved for insomnia) Zolpidem 5–20 mg
Useful for sleep-onset insomnia; lower dose should be used for older or debilitated individuals or those with impaired hepatic function Useful for sleep-onset insomnia; lower dose should be used for older or debilitated individuals, patients with impaired hepatic function, and patients taking cimetidine Has favorable side-effect profile in older individuals, though a lower dose should be used for debilitated individuals; FDA approved for long-term use Lower dose should be used for female, older, or debilitated individuals; long-acting effect increases risk of daytime drowsiness Lower dose should be used for older or debilitated individuals Lower dose should be used for older or debilitated individuals Lower dose should be used for older or debilitated individuals
Zaleplon
5–20 mg
Eszopiclone
1–3 mg
Benzodiazepines (FDA approved for insomnia) Flurazepam 15–30 mg
Estazolam Temazepam Triazolam Quazepam
0.5–2 mg 7.5–30 mg
0.125–0.25 mg
7.5–15 mg — Melatonin Receptor Agonists (FDA approved for insomnia) Ramelteon 8 mg Orexin Receptor Agonists (FDA approved for insomnia) Suvorexant 10–20 mg Antidepressants (Not FDA approved for insomnia) Trazodone 50–150 mg — Amitriptyline 10–100 mg — Antidepressants (FDA approved for insomnia) Doxepin 3–6 mg
Useful for sleep-onset insomnia; FDA approved for long-term use
Adjust dose with concomitant use of CYP3A inhibitors
Useful for difficulty with sleep maintenance
Nonprescription (FDA approved for occasional insomnia) Diphenhydramine 25–50 mg For occasional use only a Doses are given as guidelines; actual doses should be determined on an individual basis. Source: [252; 365; 373]
Table 19
48
MDCA1525
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