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Review current medicines for ones that are associated with insomnia or a disturbed night's sleep. Examples include MAOIs, SSRIs, SNRIs, lamotrigine, aripiprazole, steroids, beta blockers, diuretics, statins and laxatives. Consider changing the time the person takes these to an earlier time in the day so as to hopefully prevent problems at night.
Try to ascertain if there is a physical reason for the insomnia such as pain or whether insomnia is secondary to an undiagnosed mental health disorder, and treat this appropriately (a WHO survey of people reporting sleep problems identified that 52% had a well-defined mental health disorder and 54% reported a physical disorder).
Remember: Hypnotics can provide relief from symptoms of insomnia but they do not treat any underlying cause.
Drug therapy should be avoided if at all possible. Good sleep hygiene is the cornerstone of any treatment plan for insomnia. This includes:
Psychological therapies (CBT) have also been shown to be effective in the management of persistent insomnia but are beyond the scope of this guideline.
Patients may need to take a hypnotic whilst they are in hospital. In order to avoid patients inadvertently continuing on hypnotics once discharged from hospital it has been agreed that patients discharged from local hospitals will not receive a supply of benzodiazepines unless it can be clearly established that they have been taking these long-term and a supply is needed.
Prescribers in secondary care are requested to review all prescriptions for hypnotics on discharge for appropriateness and ensure there is clear communication for GPs regarding whether hypnotics should not be continued once discharged.
Where a specialist recommends that treatment with a hypnotic is continued past the usual maximum of 4 weeks (i.e. off-licence prescribing) a clear rationale must be communicated to the GP, including a proposed treatment plan of when to review, reduce and/or discontinue treatment.
It is recognised that a number of patients are receiving long-term hypnotics. This is an unlicensed use and the prescriber needs to ensure that they fully consider the implications of prescribing an unlicensed medication.
The patient's record should show that patients receiving a long-term benzodiazepine have:
When individuals are prescribed hypnotics long term they should be offered the opportunity to withdraw from their treatments. This must be done collaboratively to produce the most success. The prescription should be converted to an equivalent dose of diazepam to facilitate a gradual reduction in dose, using liquid preparations where necessary. Commonly used benzodiazepine equivalent doses (not necessarily hypnotics) are listed below. Aim for a reduction of 10-20% of the dose every 1-2 weeks and adjust the rate according to the individual's response.
This patient letter that has been shown to result in reduced consumption of benzodiazepines. Practices may wish to adapt this letter to suit their needs.