Consensus on Drug Treatment, Definition and Diagnosis for Insomnia
Abstract
Thirty-four experts and a literature supervisor got together in order to reach a consensus regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient s quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.
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Introduction
Insomnia is a highly prevalent condition. Chronic insomnia affects 10% of the general population,[1,2] and the figure increases to 34% when chronic and transient insomnia are combined.[3,4] The social and healthcare impact of these conditions is highly significant,[5-10] and has been well studied.[11-15] The importance of adequate treatment is therefore obvious. In this context, management of insomnia should only be addressed after an adequate diagnosis has been established, and should be aimed at aetiological treatment with pharmacological and, finally, non-pharmacological measures. This article presents a consensus on pharmacological measures.
, 百拇医药
Current adequate sleep medicine practice poses the need for making decisions when faced with problems that cannot be resolved quantitatively. This leads us to seek qualitative solutions, such as consensus recommendations or methods relating to specific problems. Consensus methods aim to establish agreements among experts over problems that can imply uncertainties in case of persisting discrepancies. The users of consensus recommendations subsequently decide if such recommendations are useful or sufficient for taking decisions.[16]
, http://www.100md.com
Because of their extensive use, consensus recommendations may also be subject to controversy about their validity, objectivity and value. This article therefore attempts to address the different limitations of a consensus so that they can be avoided, reduced or at least taken into account. We think that a precise and concise methodology will contribute to a higher credibility of the result and thus enhance its impact., 百拇医药(E. Estivill等人)
Thirty-four experts and a literature supervisor got together in order to reach a consensus regarding the definition, diagnosis and pharmacological treatment of insomnia. Insomnia is a subjective perception of dissatisfaction with the amount and/or quality of sleep. It includes difficulty in initiating or maintaining sleep or early awakening with inability to fall asleep again. It is associated with complaints of non-restorative sleep and dysfunction of diurnal alertness, energy, cognitive function, behaviour or emotional state, with a decrease in quality of life. The diagnosis is based on clinical and sleep history, physical examination and additional tests, although polysomnography is not routinely indicated. Therapy should include treatment of the underlying causes, cognitive and behavioural measures and drug treatment. Hypnotic therapy can be prescribed from the onset of insomnia and non-benzodiazepine selective agonists of the GABA-A receptor complex are the drugs of first choice. It is recommended that hypnotic treatment be maintained in cases where withdrawal impairs the patient s quality of life and when all other therapeutic measures have failed. Experience suggests that intermittent treatment is better than continuous therapy. The available data do not confirm safety of hypnotics in pregnancy, lactation and childhood insomnia. Benzodiazepines are not indicated in decompensated chronic pulmonary disease but no significant adverse effects on respiratory function have been reported with zolpidem and zopiclone in stable mild to moderate chronic obstructive pulmonary disease and in treated obstructive sleep apnoea syndrome. Data for zaleplon are inconclusive. If the patient recovers subjective control over the sleep process, gradual discontinuation of hypnotic treatment can be considered.
, http://www.100md.com
Introduction
Insomnia is a highly prevalent condition. Chronic insomnia affects 10% of the general population,[1,2] and the figure increases to 34% when chronic and transient insomnia are combined.[3,4] The social and healthcare impact of these conditions is highly significant,[5-10] and has been well studied.[11-15] The importance of adequate treatment is therefore obvious. In this context, management of insomnia should only be addressed after an adequate diagnosis has been established, and should be aimed at aetiological treatment with pharmacological and, finally, non-pharmacological measures. This article presents a consensus on pharmacological measures.
, 百拇医药
Current adequate sleep medicine practice poses the need for making decisions when faced with problems that cannot be resolved quantitatively. This leads us to seek qualitative solutions, such as consensus recommendations or methods relating to specific problems. Consensus methods aim to establish agreements among experts over problems that can imply uncertainties in case of persisting discrepancies. The users of consensus recommendations subsequently decide if such recommendations are useful or sufficient for taking decisions.[16]
, http://www.100md.com
Because of their extensive use, consensus recommendations may also be subject to controversy about their validity, objectivity and value. This article therefore attempts to address the different limitations of a consensus so that they can be avoided, reduced or at least taken into account. We think that a precise and concise methodology will contribute to a higher credibility of the result and thus enhance its impact., 百拇医药(E. Estivill等人)