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National Prescribing Service Presented by Joyce McSwan Accredited Consultant Pharmacist.

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Presentation on theme: "National Prescribing Service Presented by Joyce McSwan Accredited Consultant Pharmacist."— Presentation transcript:

1 National Prescribing Service Presented by Joyce McSwan Accredited Consultant Pharmacist

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3 80% 95%

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5  D ifficulty falling asleep  D ifficulty staying asleep OR  D ay time distress (associated with non refreshing sleep)

6 Medications Medical condition Primary sleep disorder Environmental Psychiatric Disorder Behavioural Substance Use Circadian rhythm disorder Situational Insomnia Complaint

7  Benefits: ◦ Persistent sleep improvements after therapy ◦ Reduced potential for harms ◦ No risk of drug dependence

8  Most evidence - Behavioural and cognitive therapies  In 4-8 weeks, ◦ Fall asleep faster (23 mins vs 14 mins earlier) ◦ Reduce their time awake (30 mins after sleep onset) ◦ Improvement up to 2 years ◦ > 55 yo  Hypnotic medicines do not provide this long- term benefit

9 Advice on good sleep practices Cognitive Therapy Stimulus Control Sleep restriction Relaxation therapy

10 Length of action DrugsRecommended Dosage PBS eligibility Very short T ½ < 6hrs Zolpidem Zolpidem CR Zopiclone 5-10mg hs 6.25mg- 12.5mg hs 3.75mg- 7.5mg before bedtime Non-PBS RPBS-R Short T ½ 6-12 hrs Temazepam Oxazepam 10mg before hs mg before hs PBS/PBS-A

11 Diazepam Flunitrazepam Nitrazepam AVOID

12 Engage Patient Confirm duration – short term use only Inform tolerance, dependence, rebound insomnia, adverse effects Continuing non-drug therapies Hypnotic indicated 2-5 times per week PRN < 2 weeks Short acting hypnotic Avoid > 60 years – BUT weight it up! Regular Review Review indication for long term use Discontinue when conditions allow Watch for increased doses or resistance to discontinue hypnotics.

13  Meta analysis – ◦ NNT 13 >60 yo for 1 month to improve sleep ◦ NNT 6 causing adverse effect - fatigue, cognitive impairment, serious events following falls, fractures and MVA

14 Adverse EventsOdds Ratio (95% Cl) Cognitive Events – memory loss, confusion, disorientation 4.8 Psychomotor events (dizziness, loss of balance) 2.6 Falls1.6 Motor Vehicle collisions1.3 Urinary incontinence1.4 Benzodiazepine use is associated with an increased risk of hip fracture

15  Simple strategies may start the ball rolling.  Lack of evidence for adjunctive therapy in place of hypnotics.  1/3 have trouble stopping  Gradual dose reduction may still be required after short-term use  Minimise Rebound insomnia

16 Tapering dose gradually on an individual basis (8-12 weeks) Time in between dose reductions (several days) Reduce by 10-20% / week Change to equivalent diazepam then reduce dose Reduce one benzodiazpine at a time. Tapering dose gradually on an individual basis (8-12 weeks) Time in between dose reductions (several days) Reduce by 10-20% / week Change to equivalent diazepam then reduce dose Reduce one benzodiazpine at a time.

17 Share views and agree on a stopping plan S Taper dosage gradually on an individual basis T Ongoing review and use of non-drug therapies O Provide support and reassurance P

18 Hypnotic medicines may be acceptable for: Chronic use: No adverse effects Sleeping well Aware about unintentional dependence Attempts have been made to stop but refused or unsuccessful Combination with non-drug therapy might reduce hypnotic dose Review regularly

19  NPS News 67, 2010 – Addressing hypnotic medicines use in primary care  NPS Prescribing Practice Review 49: Management options for improving sleep  Clinical audit: Use of benzodiazepines, zolpidem and zopiclone in insomnia  For Patients : Reduction plan for your sleeping tablets  Case study 62: Maximising sleep and minimising potential harms

20 Good Night and Sweet dreams


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