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Drug Treatments For Sleep

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By John. W. Addington • www.ProHealth.com • October 10, 2000

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Sleep can be one of the most illusive quests for those with Chronic Fatigue Syndrome (CFS) or Fibromyalgia (FM). In fact, unrefreshed sleep, sometimes accompanied by insomnia, is a hallmark of these disorders. Fortunately though, a host of drugs (see table below), are being used by many CFS and FM to improve these symptoms. This article outlines these medications and how they are being used.

Sonata (zaleplon)
One of the newest sleep aids on the market, Sonata, is unique among other sedatives in the speed and short duration of its affect. The majority of patients using Sonata fall asleep within 20 minutes and the affects of the drug usually last only an hour. This makes Sonata excellent for both those who have difficulty initially getting to sleep and for those who awake at night and need to take something to return to sleep.

Because the affects of other sleep aids can last 8 hours or more, those that have to rise from bed within several hours usually cannot use them. However since Sonata's sedation is brief it is excellent for persons in this situation. Additionally Sonata is not addictive, and its side effects are few and not serious.

Ambien (zolpidem)
Another quick acting sleeping pill with few side effects is Ambien. Ambien has the advantage of not worsening the sleep cycle like other sedatives can, and it normally does not cause any grogginess the next morning. Its affects, however, are longer than Sonata making it a better choice for those having difficulties with frequent awakenings. Studies have shown Ambien improves sleep quality by decreasing the time needed to fall asleep and increasing total sleep time resulting in greater evening energy levels. Further Ambien has shown to continue to be effective even with daily use. Nancy Klimas, M.D., cautions however, that this kind of medication may just trap you into a lighter sleep instead of the more restful deeper stages of sleep.

Klonopin (clonazepam)
In a class of medications like Ambien, is the drug Klonopin (clonazepam). "In sleep management, one of the best things we have found is Klonopin," states Charles W. Lapp, M.D. Klonopin can help you get to sleep fast and sleep longer and thus have less fatigue the next day. It also is a muscle relaxant that can help with restless leg syndrome and, as it is closely related to Valium, can relieve anxiety and panic attacks. Klonopin is not without drawbacks though, since it can be addictive, and thus if you need to discontinue its use, you must carefully taper it under a doctor's care. Also as with many sedatives one can build up tolerance to Klonopin's effects, thus reducing its benefit.

Providing suggestions on use, Jacob Teitelbaum, MD, says ".25 to 2 milligrams of Klonopin at night can have a dramatic effect. Start with low dose and work up gradually because Klonopin is initially quite sedating. I use Klonopin as a last resort because it is potentially addictive."

Elavil (amitriptyline)
Elavil is an antidepressant commonly used in low dosages for CFS and FM patients to improve sleep and reduce pain. Elavil can actually restore the deeper delta stages of sleep. Peter Manu, MD, observes that a trial in Elavil's use with FM revealed "highly significant levels of improvement for the severity of pain, fatigue, and sleep disturbance." Nevertheless, because Elavil can cause daytime grogginess it should be used at the lowest possible dosage yielding the best results. Many CFS and FM sufferers not excessively bothered by its side effects including dry mouth and possible weight gain feel this medication is a godsend.

Flexeril (cyclobenzaprine)
Flexeril is similar to Elavil in make-up and is used for its muscle relaxant, anti-inflammatory properties. Some studies in Flexeril use for FM have found it able to reduce pain and increase quality of sleep. Flexeril can be used to normalize altered sleep patterns found in CFS and FM patients. Like Elavil, however, it can have the side effects of dry mouth and mild weight gain.

Desyrel (trazodone)
Many others swear by the drug Desyrel (trazodone). According to Dr. Lapp, "if you are one of those persons who fall asleep pretty readily, but then wakes up every hour, or wakes up and can't go back to sleep, Trazodone may be the thing you want to take because it works best for that sort of problem." Dr. Lapp also notes that Desyrel can induce the more beneficial deeper sleep stages. Because Desyrel in addition to be an anti-depressant is a calming agent it can be helpful for those whose sleeping difficulties are coupled with anxiety.

What makes many people prefer this medication is what it does not do. Desyrel does not cause the same degree of dry mouth or weight gain as some sedating medications do. Also since Desyrel does not reduce respiration, it does not aggravate sleep apnea. This medication may not be for all males, though, since can cause prolonged erections of an hour or more in time.

Antihistamines (diphenhydramine, doxylamine)
The antihistamines diphenhydramine and doxylamine found in many over the counter sedatives such as Nytol, Sleep-Eze, Tylenol P.M. or Unisom have been used regularly by many. These ones have found that such medications help them to get to sleep and prevent awakenings during the night. This class of antihistamines has few side affects especially for younger persons and does not cause dependence or withdrawal symptoms. However, since they can negatively impact sleep cycles antihistamine sedatives are best for occasional use.

When To Use Drug Therapy
When should one turn to medications to assist with sleeping problems? When insomnia is chronic, that is, lasting more than several weeks and not the result of a condition such as medication side affect that should remedied differently. Additionally, it is wise to first attempt behavior changes that may resolve the sleep difficulty. These include avoidance of alcohol and caffeine, especially late in the day, exercising early in the day and keeping regular bed times and wake times. (For on behavioral modifications see Breaking Fibromyalgia's Sleepless Cycle)

Further, before turning to drug therapy, it is important to that sleep apnea or restless legs syndrome first be ruled out as a possible cause of the difficulty, since some sleep aids can actually worsen such conditions. Sleep apnea is a nighttime breathing difficulty usually caused by obstruction of the windpipe. A common sign of sleep apnea is heavy snoring and pauses in breathing during sleep. One study found that almost 50% of men with fibromyalgia had significant sleep apnea. Restless leg syndrome is more obvious to the patient as it is characterized by an uneasy sensation in the legs when trying to rest, relieved by moving the legs or walking. To best diagnose these kinds of sleeping difficulties a study of a patient's sleeping patterns may need to be done in a special sleep lab.

Finally before trying heavier medications used for sleep, one might want to first try the more natural sleep aids available without a prescriptions. These include melatonin and valerian with lemon balm. To learn more about these natural sleep aids see the article written by Jacob Teitelbaum, MD, "Importance of Solid Sleep in Chronic Fatigue Syn-drome and Fibromyalgia Sufferers," www.immunesupport.com/library/showarticle.cfm?ID=1420.

Sleeping Difficulties
A little background on the nature of the sleep difficulties in CFS and FM will round out this discussion. Normal sleep cycles through four stages becoming deeper and deeper followed by a dream stage called REM (rapid eye movement). Stages 1 and 2 of sleep are lighter and are called alpha whereas stages 3 and 4, referred to as delta, are much deeper. The progression through these stages repeats throughout the night with the deeper delta stages of sleep occurring more in the first part of the night and REM becoming more predominant in the latter stages of the night.

Studies done have shown that some CFS and FM patients have deviations in the normal sleep cycle. A Belgium study observed "sleep initiation and sleep maintenance disturbances" in a group of CFS patients. Similarly in England it was reported that "CFS subjects showed significantly higher levels of sleep disruption by both brief and longer awakenings."

Susan M. Harding, MD, states that the normal sleep pattern "is altered in FM patients showing an increase in stage 1, a reduction of delta sleep, and an increased number of arousals." Devin Starlanyl, MD, says that the irregularities in sleep causes persons with FM to be "jolted awake or into shallow sleep so that they either wake up many times during the night or sleep very shallowly." Many CFS and FM patients concur that insomnia, whether the inability to get to sleep, stay asleep, or sleep soundly is one of their more difficult symptoms.

Conclusion
Sound, restful, restorative sleep while more difficult for CFS and FM patients, may still be possible at least part of the time. Diet and other behavioral changes, sleep labs, natural sleep aids, over-the-counter sleep inducing medications and prescription drugs are all remedies we have at our disposal. And as research reveals why these sleep disturbances occur in the first place, other even more effective long-term resolutions may be available.

Sleep Medication Chart
(This list is not comprehensive but represents some of the most common medications used in several classes of drugs. Even with the over the counter medications, it is best to consult with one's physician before use.)



* This list is not comprehensive but represents some of the most common medications used in several classes of drugs. Even with over-the-counter medications, it is best to consult with one's physician before use.
** Onset of sedating properties in antidepressants varies but usually occurs within a couple of hours. Sedation increases within first several weeks of use but then tapers.
*** Commercially available in Canada but not in the U.S.







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