1. Date of preparation March 2010
Insomnia
Key slides

2. Insomnia NICE TA 77, April 2004; CKS (Prodigy), July 2006; DTB 2004
Date of preparation March 2010
Insomnia: difficulty initiating sleep and/or difficulty maintaining sleep
Prevalence: estimates vary from 10% - 48%
Higher in women, with increasing age and in those with concurrent physical or mental health conditions
Primary insomnia:
Unknown origin or arising from sleep environment, irregular sleep routine, or negative conditioning to sleep
Secondary insomnia:
Underlying psychological or physical condition, prescribed/OTC medicines, caffeine or substance misuse
Important to avoid unrealistic sleep expectations
For all people with insomnia, offer advice on good sleep hygiene and stimulus control
Also consider exercise, relaxation therapies, etc.

3. Non-drug approaches CKS (Prodigy), July 2006
Date of preparation March 2010
Non-drug approaches CKS (Prodigy), July 2006
Sleep hygiene:
Avoid caffeine and nicotine 6 hours before bed time
Avoid alcohol around bedtime (alcohol may encourage sleep onset but tends to fragment sleep)
Avoid heavy meals before sleep (although a light meal may be helpful)
Avoid exercise within 4 hours of bedtime (although exercise earlier in the day is beneficial)
Minimise noise, light and excessive heat during the sleep period.
Stimulus control measures:
Only go to bed when sleepy
Only use the bed for sleeping and sex
Leave the bedroom if not asleep within 15–20 minutes and go back to bed only when feeling sleepy again
Get up at a fixed time in the morning, regardless of the amount of sleep achieved the previous night
Avoid sleep during the day.

4. Date of preparation March 2010
Hypnotics for insomnia CSM, Curr Problems Pharmacovigilance January 1988, No. 21 SPCs for zopiclone, zolpidem, zaleplon accessed from emc.medicines.org.uk, July 2008
Benzodiazepines should be used only if insomnia is severe, disabling or subjecting the patient to extreme distress
Use lowest dose, for maximum of 4 weeks
Use intermittently, if possible
Taper off gradually
Zopiclone, Zolpidem
Short–term treatment of insomnia…in situations where the insomnia is debilitating or is causing severe distress for the patient
Long–term continuous use is not recommended
Treatment duration: a single course of treatment should not continue for longer than 4 weeks including any tapering off
Zaleplon
Treatment duration: a single course of treatment should not continue for longer than 2 weeks.

5. NICE guidance: newer hypnotics (Z-drugs) NICE TA 77, April 2004
Date of preparation March 2010
NICE guidance: newer hypnotics (Z-drugs) NICE TA 77, April 2004
No compelling evidence of a clinically useful difference between the Z-drugs and shorter-acting benzodiazepines from the point of view of their effectiveness, adverse effects, or potential for dependence or abuse
The drug with the lowest purchase cost should be prescribed
Switching from one of these hypnotics to another should only occur if a patient experiences adverse effects considered to be directly related to a specific agent. These are the only circumstances in which the drugs with the higher acquisition costs are recommended
Patients who have not responded to one of these hypnotic drugs should not be prescribed any of the others.

6.  
Date of preparation March 2010
What would happen to 13 people who take sleeping tablets for more than a week? Glass J, et al. BMJ 2005;331:1169
The hypnotic makes no difference to what happens to these 12 people. Their sleep improves, or doesn’t improve, just as if they had taken placebo.
This person finds his/her sleep improves, who would not have done had he or she taken the placebo.

These 2 people have an adverse event, who would not have done had they taken the placebo.
The hypnotic makes no difference to what happens to these 11 people. They have adverse events, or don’t have adverse events, just as if they had taken placebo.


7. Road traffic accidents and benzodiazepines Bandolier 1998;57:5 (Hemmelgarn B, et al. JAMA 1997;278:27-31)
Date of preparation March 2010
Risks of RTA in Quebec
Short half-life benzos:
RR 0.96 (95%CI 0.88 to 1.05) NS
Long half-life benzos:
RR 1.28 (95%CI 1.12 to 1.45), higher risk in first week

8. Date of preparation March 2010
Hip fractures and benzodiazepines Wagner AK, et al. Arch Intern Med 2004;164:1567–72
Incident RR of hip fracture with BZD vs. no BZD use based on US claims data (194,071 person years of data, ):
Any BZD exposure: 1.24 (95%CI 1.06 to 1.44)
Long half-life BZD only: 1.13 (0.82 to 1.55) NS
Short half-life high potency: 1.27 (1.01 to 1.59)
Short half-life low potency: 1.22 (0.89 to 1.67) NS
>1 BZD type: 1.53 (0.92 to 2.53) NS
New BZD <16 days: 2.05 (1.28 to 3.28)
New BZD 16–30 days: 1.88 (1.15 to 3.07)
Continued BZD: 1.18 (1.03 to 1.35)
Authors conclude: incidence of hip fracture appears to be associated with benzodiazepine use.
Note: Different doses were not considered.

9. Other issues
Date of preparation March 2010
Some GPs have misperceptions about the safety and efficacy of Z-drugs compared to benzodiazepines
Siriwardena AN, et al. Br J Gen Pract 2006;56:964–7
Older people are not always being given appropriate safety warnings about taking these drugs
Iliffe S, et al. Aging Ment Health 2004;8:242–8
It is difficult to withdraw from hypnotic drugs
A letter from the GP can be effective in helping some to stop
Cormack MA, et al. Br J Gen Pract 1994;44:5-8
CBT can be helpful
Morgan K, et al. HTA 2004:8 (8)
See CKS guidance for further information
Published criteria for clinical audit are available
Shaw E, Baker R. Journal Clin Governance 2001;9:45-50, NICE TA 77, April 2004

10. Date of preparation March 2010
Trends in prescribing of hypnotics in general practice in England NHSBSA, September 2009

11. Summary of key messages
Date of preparation March 2010
Non-drug treatments should be considered and used routinely in all patients
1988 CSM advice re benzodiazepines still stands and is also applicable to Z-drugs
NICE guidance confirms that Z-drugs offer little or no advantage over benzodiazepines
However overall prescribing of benzodiazepines and Z-drugs is not decreasing
Long-term use of hypnotics is ‘off-label’ and is contrary to all available evidence and guidance
Think about auditing benzodiazepine and Z-drug use and changing practice
Resources exist for managing withdrawal
No evidence that new melatonin receptor agonists offer advantages over existing hypnotics.