Insomnia

Prescribing Notes:

• NICE MTG70 recommends Sleepio as a cost-saving option for insomnia in patients who cannot access cognitive behavioural therapy for insomnia (CBT‑I). It offers an evidence based, NHS recommended treatment that is free for all adults in Scotland.
• Before a hypnotic is prescribed, the cause of the insomnia should be established and underlying factors be addressed.
• Routine prescribing for insomnia is undesirable. Zopiclone should be used in short courses only (preferably one week) when insomnia is severe, disabling, or subjecting the individual to extreme distress.
• New patients should not be put on a repeat prescription system and existing patients receiving a hypnotic should be reviewed and offered the chance to stop or reduce (see BNF withdrawal protocol).
• Hypnotics should be avoided in older patients if possible. Older patients can become ataxic, confused and are at increased risk of falling and injuring themselves.
• Barbiturates [unlicensed preparation] should only be prescribed to patients already taking them, who have severe intractable insomnia, when attempts to discontinue treatment have been unsuccessful.
• A patient self help guide on sleep problems is available at the Mood Café website.
• Prescribers should exercise caution when starting a patient on a benzodiazepine or ‘z’ drug as these medicines have a ‘street value’.
• Relative durations of action are:
  • short-acting: lorazepam, temazepam, zopiclone.
  • intermediate-acting: nitrazepam.
  • long-acting: chlordiazepoxide, diazepam.
• Short-acting hypnotics are preferable in patients with sleep onset insomnia when sedation the following day is undesirable or when prescribing for elderly patients.
• Short-acting hypnotics have a higher potential for abuse and withdrawal phenomena are more common.
• Long-acting hypnotics are indicated in patients with poor sleep maintenance (e.g. early morning waking), when an anxiolytic effect is needed during the day or when sedation the following day is acceptable.
• Longer acting hypnotics can increase the risk of falls in the elderly and may cause ataxia and confusion.
• The sedating antihistamine promethazine is regarded as less suitable for prescribing in the BNF. However, it is sometimes used in patients for occasional insomnia when ‘z’ drugs and benzodiazepines are considered inappropriate.
• There is no evidence to support benefit beyond five weeks, and tolerance may develop within 2-3 weeks.
• Rebound insomnia is to be expected after stopping hypnotic use.
• Patients should be reviewed routinely and offered the opportunity to stop hypnotic therapy – withdrawal should be gradual.

Prescribing Notes:

• Non pharmacological treatment including sleep hygiene.
• The NHS website has information on sleeping tips for children. It also gives an indication of how much sleep children at different ages need. The Sleep Scotland website has information for families and health care professionals.

Melatonin

• Melatonin is a pineal hormone that may affect sleep pattern. Adverse events reported with melatonin in children include: somnolence, fatigue, mood swings, headache, irritability, aggression and “hangover”. There is a lack of long-term safety data for melatonin use in children.
• Melatonin should only be initiated on specialist advice. It is used in children over 3 years of age with neurodevelopment disability, autism, visual impairment or neuropsychiatric disorders and chronic sleep disturbance:
  • where symptoms of sleep disturbance have been present for at least 6 months or sleep disturbance is so severe that the family are heading for crisis
  • after failure of sleep hygiene improving measures e.g. a fixed bedtime routine, minimising screen time before bedtime, etc.
  • if melatonin is not effective, it should be discontinued after 1-2 months.
  • once a good sleep pattern has been established for 3-6 months, consider a trial break of 2-3 days (reinforcing good sleep hygiene), to see whether normal circadian rhythm has been re-established. If melatonin is still required consider review every 12 months thereafter.
• There are several melatonin products available on the market with variations in product licensing.
• Melatonin 3mg film-coated tablets may be crushed and mixed with water prior to administration or mixed with a small amount of cold or room temperature soft food such as yogurt, jam or mashed potato, the mixture should be swallowed straight away, without chewing.
• Melatonin MR tablets may be given whole or halved which retains the slow release profile or may be crushed and mixed with water prior to administration. Crushing the Melatonin MR tablet, changes the release profile from modified release to immediate release.
• Note that for patients with sensory issues crushing tablets may not be acceptable. This is only exception where the melatonin liquid can be used.

Chloral hydrate

• Although hypnotics (such as chloral hydrate) are generally effective initially, tolerance develops quickly and many cause unacceptable adverse effects e.g. respiratory depression and dependence.
• Use of chloral hydrate in children and adolescents is not generally recommended and should be under the supervision of a medical specialist for complex needs children and in intensive care.
• The paediatric indication for chloral hydrate (for children aged 2 years and older) has been restricted to short term treatment (maximum 2 weeks) of severe insomnia only when the child or adolescent has a suspected or definite neurodevelopmental disorder and when the insomnia is interfering with normal daily life. Chloral hydrate should only be used when other therapies (behavioural and pharmacological) have failed.
• For all patients, treatment should be for the shortest duration possible and should not exceed 2 weeks. Repeated courses are not recommended and can only be administered following medical specialist re-assessment.
• Chloral hydrate and melatonin should only be prescribed as part of a comprehensive package of treatment including sleep hygiene methods.
• Chloral hydrate oral solution contains sugar and teeth should be cleaned following administration before bedtime.