Return to: Current Perspectives in Insomnia, Volume 4

     Next Article

Expert Column - What Every PCP Should Know: Over-the-Counter Insomnia Treatments  CME

Disclosures

Irina V. Zhdanova, MD, PhD   

Introduction

According to various estimates, 15% to 40% of the general population suffer from transient, short-term, or chronic insomnia associated with subjective complaints of prolonged sleep latency, frequent nighttime awakenings, long periods of nighttime wakefulness, or early-morning awakening.[1,2] Because altered nighttime sleep leads to daytime fatigue and sleepiness, any type of insomnia negatively affects mood and performance, and thus increases the risk of accidents and health problems, including major depression.

Although some insomniacs consistently seek and follow medical advice in addressing their sleep problems and use prescribed therapy (pharmacologic, circadian, behavioral, or cognitive), many choose over-the-counter (OTC) sleep aids in an attempt to shorten latency to sleep or promote nighttime sleep maintenance. A rationale for using OTC sleep aids may differ; some are searching for a "quick fix" with a readily available medication, and others have found conventional hypnotics to be ineffective or their side effects intolerable. Many are also attracted by a label "dietary supplement," which is often perceived as a safer or more natural alternative to drugs.

It is critically important to know whether your patient suffers from insomnia and, if so, which medications he or she is using to combat it. The major categories of OTC sleep medications widely available in stores, pharmacies, and on the Web include antihistamines as well as hormonal and herbal preparations. In addition, some insomniacs use ethanol or marijuana as a sedative despite the disadvantages, such as dependence. OTC preparations also are frequently used in combination, which is likely to amplify both their sleep-promoting and adverse effects.

Antihistamines

First-generation antihistamines (eg, diphenhydramine, brompheniramine, or chlorpheniramine) have been used to treat allergies for a number of years and are available without prescription. However, they can also induce sedation via central antihistaminergic and anticholinergic mechanisms,[3,4] and this effect is widely exploited.

A number of clinical studies have addressed the dose- and time-dependent properties of antihistamines and found both subjective and objective changes in sleepiness, sleep, and psychomotor performance associated with the reduction in latency to sleep onset or increase in sleep duration.[5-8] Although previous studies tended to support the use of this class of drugs to treat occasional mild-to-moderate insomnia,[9,10] more recent opinions of sleep specialists have shifted strongly against this practice.[11]

The major reason for limiting the use of antihistamines for treating insomnia is their multiple side effects, including changes in sleep architecture, notably a reduction in rapid eye movement (REM) sleep caused by their anticholinergic effects; a reduction in cognitive functions;[12] day-after sedation; an increased risk of accidents;[13] the development of tolerance;[14] and interference with other medications. The side effects of antihistamines appear to be especially risky for elderly patients, almost 50% of whom use sleep medications occasionally or on a regular basis and who often choose OTC sleep aids.[15]Adverse Effects of Diphenhydramine

A recent study, involving 1627 individuals aged 65 and over, found that between 1989 and 1996 the use of prescription sedative-hypnotics (primarily benzodiazepines) rose from 1.8% to 3.1%, whereas OTC sedative-hypnotic use (primarily diphenhydramine) increased from .4% to 7.6%, and reached 8.17% by 1998.[16] This study also highlighted a significant association of diphenhydramine use and cognitive impairment in elderly individuals without dementia.

In a Yale University (New Haven, Connecticut) hospital study, 114 (27%) of 426 hospitalized medical patients aged 70 years or older received diphenhydramine during hospitalization.[17] Although at baseline these patients demonstrated similar characteristics (age, sex, delirium risk, and Mini-Mental State Examination scores) to those of patients who did not receive diphenhydramine, the ones who received diphenhydramine showed a significantly greater risk for delirium symptoms, disorganized speech, and altered consciousness during hospitalization. A diphenhydramine dose-response relationship was demonstrated for most adverse outcomes.

In view of the antihistamine-induced side effects, it is especially disturbing that a large number of OTC preparations contain diphenhydramine under a score of brand names,* which can confuse patients. Furthermore, many OTC medications include diphenhydramine as a second active ingredient (eg, Tylenol PM, Aspirin PM, Acetaminophen PM, Alka-Seltzer Plus, etc). Typical doses of diphenhydramine in these preparations are 25-50 mg per tablet or capsule, and, in most cases, 2 tablets are the recommended dose, 3-4 times per day. Syrup, elixir, spray, cream, and gel forms of diphenhydramine are also widely available.

The Swiss Toxicological Information Centre has recently studied the dose-dependent toxicity of diphenhydramine in 282 patients with acute diphenhydramine poisoning.[18] They found that mild toxicity symptoms (somnolence, anticholinergic signs, tachycardia, and nausea/vomiting) accounted for 55% to 64% of the cases and were associated with doses under 300 mg. Moderate symptoms (isolated and spontaneously resolving agitation, confusion, hallucinations, and electrocardiogram disturbances) were documented in 22% to 27% of those who ingested more than 300 mg of diphenhydramine. Severe symptoms (delirium/psychosis, seizures, and coma) manifested in 14% to 18% of the patients after ingestion of nearly 1 g of the drug. Thus, combining several tablets of an OTC "cold" medication with a topical cream for allergy could place a patient at health risk.

Recognizing the complexities of the OTC antihistamine market, in 2002 the US Food and Drug Administration (FDA) ruled that drug products containing diphenhydramine should carry warnings, advising consumers not to use oral OTC diphenhydramine products with any other product containing diphenhydramine, including products used topically.[19] Overall, occasional use of low-dose antihistamines for acute sedation may be relatively safe, but using them frequently to control sleep is not a good idea.

*40 Winks, Aid to Sleep, Aler-Dryl, Allergia-C, Allergy Medicine Antihistamine, AllerMax, Altaryl, Anti-Histamine, Antihist, Antihistamine, Antihistamine Allergy, Antituss, Banaril, Banophen, Beldin, Belix, Benadryl, Benadryl Allergy, Benadryl DF, Benadryl Dye-Free Allergy, Benadryl Ultratab, Benahist-10, Benahist-50, Benoject-50, Bydramine, Calm-Aid, Child Allergy, Complete Allergy, Complete Allergy Relief, Compoz Nighttime Sleep Aid, Diphedryl, Diphen, Diphen AF, Diphen Cough, Diphenadryl, Diphendryl, Diphenhist, Diphenhydramine Hydrochloride, Diphenyl, Diphenylin, DPH, Dytan, Dytuss, Genahist, Hydramine, Hydramine Compound, Hydramine Cough Syrup, Hyrexin, Nervine, Night Time Sleep-Aid, Nu-Med, Nytol Caplet, Pardryl, Phendry, Q-Dryl, Quenalin, Scot-Tussin Allergy Relief Formula, Siladryl, Siladryl DAS, Siladyl SA, Silphen Cough, Simply Sleep, Sleep, Sleep Aid, Sleep Tab II, Sleep Tabs, Sleep-ettes, Sleep-eze-3, Sleepinal, Sominex, Sominex Maximum Strength Caplet, Somnicaps, Total Allergy, Trux-adryl, Tusstat, Twilite, Uni-Hist, Unisom Sleepgels Maximum Strength, Valu-Dryl, Wehdryl(http://www.worldhealthsurvey.com).

Hormones

The onsets of sleepiness, sleep quantity, and sleep quality depend not only on the duration of prior wakefulness, the so-called homeostatic mechanism of sleep regulation, but also on the time of day when an attempt to initiate sleep is taking place. The latter reflects circadian mechanisms of sleep regulation and is linked to the biological clock structure, the suprachiasmatic nucleus of the hypothalamus.

The neuroendocrine system is likely to play a major role in both homeostatic and circadian sleep processes. However, so far we know very little about hormonal mechanisms of sleep regulation. An exception is melatonin, the principal hormone of the circadian system, released nightly into the cerebrospinal fluid and blood circulation by the pineal gland. The ability of high doses of melatonin to induce sleepiness was reported over 40 years ago, during an unrelated clinical trial.[20] More recently, low-dose melatonin (.1-.5 mg, orally) was found to promote objectively documented sleep.[21-25] Of importance, these low doses induced circulating melatonin levels within those normally observed in human blood (50-150 pg/mL). The latter suggests that melatonin may normally play a role in homeostatic sleep regulation, acutely promoting sleep onset and maintenance at night, in addition to its ability to shift a circadian phase of sleep, resulting from its effects on the "biological clock."

Melatonin does not appear to significantly affect nighttime sleep quantity and quality in healthy individuals but can help them to fall asleep during the day.[21-25] It was shown to be especially helpful for insomnias associated with neurologic disorders in children.[26-31] The results of melatonin administration to elderly insomniacs are more variable, ranging from mild but significant improvements in their sleep[32-34] to a lack of therapeutic effect.[35,36] Of note, sensitivity to the effects of melatonin on sleep is not uniform among individuals and may decline with age or as a result of neurodegenerative diseases.[37,38] Melatonin coadministration can also facilitate the effects of common hypnotics, helping to reduce their effective dose and side effects or attenuating drug withdrawal.[39] A combination of circadian and homeostatic effects of melatonin with its surprisingly low toxicity and lack of significant effects on sleep architecture and day-after performance at high pharmacologic doses makes it a popular compound among insomniacs.Sleep Effects

The nature of melatonin's effect on sleep, which is only starting to emerge, is such that it promotes a behavioral state resembling quiet wakefulness, which predisposes to normal sleep initiation, rather than sleepiness or profound drowsiness. A comparison of the effects of melatonin on human performance with those of conventional hypnotics (such as temazepam, zaleplon, and zopiclone) has shown that melatonin administration induces a smaller or no deficit in performance on a range of neurobehavioral tasks, despite a similar duration of subjective sleepiness.[40,41] However, stimuli that would interfere with normal sleep, eg, turning lights on, changing to an upright position, or the necessity of conducting a task requiring a high level of attention or motivation, will temporarily interfere with the effect of melatonin on the sleep process. Under such circumstances, a person would typically feel quite alert rather than sedated, despite the high circulating melatonin levels. Once the interference is removed, the ability to fall asleep faster under the influence of melatonin is restored.

It is important to distinguish between the circadian and acute effects of melatonin, because timing of administration may be crucial. Morning melatonin treatment can delay the onset of evening sleepiness by delaying the phase of the circadian rhythms, whereas administering melatonin in the evening can advance the circadian rhythms by 30-60 minutes per day, including time of sleep onset. By contrast, acute sleep-promoting effects of melatonin can manifest at different times of the day and, in insomniacs, at night, within 30 minutes after treatment.

Melatonin's short 20- to 40-minute half-life makes it possible to choose different approaches when using it to treat insomnia. Near-physiological doses of the hormone (.2-.5 mg) can be administered at bedtime to shorten sleep latency or to entrain the free-running circadian rhythms in individuals with circadian sleep disorders. Low melatonin doses (.1-.2 mg) can also be administered in the middle of the night, upon early awakening, in order to reinitiate sleep and prolong an overall sleep period.Preparations

It should be noted that despite melatonin being sold in the United States under the label of a dietary supplement, no meaningful amount of this pineal hormone is ever consumed through food intake. Normally, mammals rely on their own pineal glands to produce melatonin from tryptophan and to release it into the circulation. This process is precisely regulated, synchronizing melatonin secretion with both nighttime and darkness. Environmental light can suppress nocturnal melatonin production, whereas darkness during the day does not stimulate it.

In the United States, melatonin is available OTC in both immediate- and slow-release preparations and at a large variety of doses, typically from .1 to 5 mg. No major side effects have been documented after ingestion of high melatonin doses, and some researchers and practitioners choose to use them, hoping to augment melatonin efficacy. A few dose-dependency studies, however, failed to show significant improvement in the sleep-promoting effects of melatonin after the blood melatonin levels exceed those normally observed at night.[21-23, 25,34]

Slow-release melatonin preparations have a potential to mimic a physiological pattern of overnight melatonin production, prolonging their sleep-promoting effects. However, unless optimally designed, such preparations, as well as immediate-release doses higher than .5 mg, may result in increased daytime melatonin levels and thus alter a circadian signal provided by this hormone, which would provoke insomnia rather than treating it.[42]

Phytosedatives

Many herbs or herb-based preparations appear to have some sedative properties. These include valerian (Valeriana officinalis), hops (Humulus lupulus), skullcap (Scutellaria lateriflora), passionflower (Passiflora incarnata), lemon balm (Melissa officinalis), and kava (Piper methysticum).[43] Of these, valerian is the most popular and well-studied phytosedative. It has been and continues to be used in many cultures and is widely believed to have calming and relaxing effects that can also help to initiate sleep and ease anxiety in insomniacs.

Several recent reviews provide detailed information from clinical trials involving valerian.[44,45] Repeated administration of valerian was typically found to be beneficial to insomniacs, reducing time to sleep onset and promoting sleep maintenance.[46-49] By contrast, single-dose-treatment studies produced controversial results, some demonstrating sleep improvement in insomniacs,[49-51] others finding no difference between valerian and placebo.[52] These inconsistent outcomes may be related to both mild effects of valerian on sleep and individual sensitivity to its effects, or they may reflect differences in formulations, populations, and methodological approaches used to test these effects.

Gamma-aminobutyric acid (GABA)ergic and adenosine-ergic mechanisms of valerian's effects on sleep have been proposed, but remain to be further elucidated. Valerian root contains a number of biologically active substances, including valepotriates (iridoid esters), valeric acid, alkaloids, and free amino acids (including GABA). The role of each of these components in the sedative effects of valerian remains largely unknown, and a combined action of several of them and their correct proportions may be required. The nature of valerian preparations, however, suggests that their constituents may differ, depending on when and where the plants were harvested.Preparations and Treatment Duration

Because some components of valerian are not water-soluble, valerian extracts and tinctures are prepared with alcohol or alcohol-free (eg, glycerite) bases. Powdered valerian is available in capsule or tablet forms or as valerian tea. Typically, valerian preparations are taken about 30 minutes before bedtime, and the dose depends on the type of preparation. For example, 1-3 g of dried root can be used as valerian tea or 150-600 mg of valerian extract can be added to a small glass of water. Typically, individualized doses are established empirically, and a wide range of valerian doses appears to be well tolerated. That said, some individuals may experience a paradoxical reaction to this herb, associated with anxiety, tachycardia, and insomnia, and thus a gradual increase in dose should be recommended to first-time users.

The treatment duration depends on the specific symptoms of sleep disorder, and herbalists recommend a 2- to 3-week break after a 4- to 6-week period of valerian treatment. Perhaps shorter courses should be recommended to those who are initiating this treatment, before they acquire personal experience in using a specific valerian preparation. Until now, clinical trials have not documented valerian-withdrawal symptoms. However, a recent study suggests that valerian can have a positive effect on withdrawal from benzodiazepines.[53]

Valerian is often used in preparations containing multiple herbs that are traditionally believed to provide sedative or hypnotic effects. Interactions between different ingredients of these plants and their possible synergistic effects are very likely. However, representative placebo-controlled studies involving these other herbs (eg, passionflower, hops, lemon balm, or kava) and their combinations remain to be conducted. Possible toxic effects of individual herbs or their combinations also cannot be excluded. For example, repeated reports of liver damage linked to kava intake prompted European and North American regulatory agencies, including the FDA, to warn consumers of the risk involved in using this herb.Regulatory Issues

In addition to safety issues typical for any standardized medication, such as dose-response, toxicity, or interactions with other drugs, OTCs marked as "dietary supplements" pose an additional challenge. According to current US regulations, premarket evaluation and approval by the FDA are not required for the marketing of so-called "generally regarded as safe" (GRAS) ingredients, unless claims are made for specific disease prevention or treatment. GRAS status can result from a history of safe use before 1958, self-declaration by the manufacturer, or affirmation by the FDA. Furthermore, the FDA, rather than a manufacturer, has the burden to prove that a specific GRAS substance is unsafe.[54]

Dietary supplements are not required to be standardized in the United States but must comply with food Good Manufacturing Practice regulations, which are primarily concerned with safety and sanitation rather than dietary-supplement quality.[55,56] Such products are only infrequently tested for manufacturing consistency and batch-to-batch composition may vary considerably.

Conclusion

Although scores of sleep aid are on the OTC market, for the most part they represent 3 products: diphenhydramine, melatonin, and valerian. They are sold separately or in combination with other biologically active substances, including nonsteroidal anti-inflammatory drugs (with diphenhydramine), vitamins (with melatonin), or herbs (with valerian or melatonin).

All these substances can facilitate sleep onset or maintenance, with different potencies for different individuals. However, each of these sleep aids should be used by patients with appropriate caution, at the right time, with minimal effective doses, and (importantly) without combining several preparations containing the same active ingredient.

This program was supported by an independent educational grant from Takeda.

References

Ancoli-Israel S, Roth T. Characteristics of insomnia in the United States: results of the 1991 National Sleep Foundation Survey. Sleep. 2000; 22:S347-S353.National Sleep Foundation. Sleep in America. 1991. The Gallup Organization.Kaneko Y, Shimada K, Saitou K, Sugimoto Y, Kamei C. The mechanism responsible for the drowsiness caused by first generation H1 antagonists on the EEG pattern. Methods Find Exp Clin Pharmacol. 2000;22:163-168. AbstractTashiro M, Mochizuki H, Iwabuchi K, et al. Roles of histamine in regulation of arousal and cognition: functional neuroimaging of histamine H1 receptors in human brain. Life Sci. 2002;72409-414.Roehrs T, Zwyghuizen-Doorenbos A, Roth T. Sedative effects and plasma concentrations following single doses of triazolam, diphenhydramine, ethanol and placebo. Sleep. 1993;16:301-305. AbstractWitek TJ Jr, Canestrari DA, Miller RD, Yang JY, Riker DK. Characterization of daytime sleepiness and psychomotor performance following H1 receptor antagonists. Ann Allergy Asthma Immunol. 1995;74:419-426. AbstractGengo F, Gabos C, Miller JK. The pharmacodynamics of diphenhydramine-induced drowsiness and changes in mental performance. Clin Pharmacol Ther. 1989;45:15-21. AbstractRoehrs TA, Tietz EI, Zorick FJ, Roth T. Daytime sleepiness and antihistamines. Sleep. 1984;7:137-141. AbstractSunshine A, Zighelboim I, Laska E. Hypnotic activity of diphenhydramine, methapyrilene, and placebo. J Clin Pharmacol. 1978;18:425-431. AbstractRickels K, Morris RJ, Newman H, Rosenfeld H, Schiller H, Weinstock R. Diphenhydramine in insomniac family practice patients: a double-blind study. J Clin Pharmacol. 1983;23:234-242. AbstractMendelson WB, Roth T, Cassella J, et al. The treatment of chronic insomnia: drug indications, chronic use and abuse liability. Summary of a 2001 New Clinical Drug Evaluation Unit meeting symposium. Sleep Med Rev. 2004;8:7-17. AbstractManning C, Scandale L, Manning EJ, Gengo FM. Central nervous system effects of meclizine and dimenhydrinate: evidence of acute tolerance to antihistamines. J Clin Pharmacol. 1992;32:996-1002. AbstractHoward ME, Desai AV, Grunstein RR, et al. Sleepiness, sleep-disordered breathing, and accident risk factors in commercial vehicle drivers. Am J Respir Crit Care Med. 2004;170:1014-1021. AbstractSchweitzer PK, Muehlbach MJ, Walsh JK. Sleepiness and performance during three-day administration of cetirizine or diphenhydramine. J Allergy Clin Immunol. 1994;94:716-724. AbstractSproule BA, Busto UE, Buckle C, Herrmann N, Bowles S. The use of non-prescription sleep products in the elderly. Int J Geriatr Psychiatry. 1999;14:851-857. AbstractBasu R, Dodge H, Stoehr GP, Ganguli M. Sedative-hypnotic use of diphenhydramine in a rural, older adult, community-based cohort: effects on cognition. Am J Geriatr Psychiatry. 2003;11:205-213. AbstractAgostini JV, Leo-Summers LS, Inouye SK. Cognitive and other adverse effects of diphenhydramine use in hospitalized older patients. Arch Intern Med. 2001;161:2091-2097. AbstractRadovanovic D, Meier PJ, Guirguis M, Lorent JP, Kupferschmidt H. Dose-dependent toxicity of diphenhydramine overdose. Hum Exp Toxicol. 2000;19:489-495. AbstractUS Food and Drug Administration, HHS. Labeling of diphenhydramine-containing drug products for over-the-counter human use. Final rule. Fed Regist. 2002;67:72555-72559. AbstractLerner AB, Case JD. Melatonin. Fed Proc. 1960;19:590-592.Dollins AB, Zhdanova IV, Wurtman RJ, Lynch HJ, Deng MH. Effect of inducing nocturnal serum melatonin concentrations in daytime on sleep, mood, body temperature, and performance. Proc Natl Acad Sci U S A. 1994;91:1824-1828. AbstractZhdanova IV, Wurtman RJ, Lynch HJ, et al. Sleep-inducing effects of low doses of melatonin ingested in the evening. Clin Pharm Ther. 1995;57:552-558.Zhdanova IV, Wurtman RJ, Morabito C, Piotrovska VR, Lynch HJ. Effects of low oral doses of melatonin, given 2-4 hours before habitual bedtime, on sleep in normal young humans. Sleep. 1996;19:423-431. AbstractAttenburrow ME, Cowen PJ, Sharpley AL. Low dose melatonin improves sleep in healthy middle-aged subjects. Psychopharmacology (Berl). 1996;126:179-181. AbstractStone BM, Turner C, Mills SL, Nicholson AN. Hypnotic activity of melatonin. Sleep. 2000;23:663-669. AbstractJan JE, Espezel H, Appleton RE. The treatment of sleep disorders with melatonin. Dev Med Child Neurol. 1994;36:97-107. AbstractPillar G, Shahar E, Peled N, Ravid S, Lavie P, Etzioni A. Melatonin improves sleep-wake patterns in psychomotor retarded children. Pediatr Neurol. 2000;23:225-228. AbstractRoss C, Davies P, Whitehouse W. Melatonin treatment for sleep disorders in children with neurodevelopmental disorders: an observational study. Dev Med Child Neurol. 2002;44:339-344. AbstractMiyamoto A, Oki J, Takahashi S, Okuno A. Serum melatonin kinetics and long-term melatonin treatment for sleep disorders in Rett syndrome. Brain Dev. 1999;21:59-62. AbstractZhdanova IV, Wurtman RJ, Wagstaff J. Effects of low dose of melatonin on sleep in children with Angelman syndrome. Pediatr Endocrinol Metab. 1999;12:57-67.Smits MG, van Stel HF, van der Heijden K, Meijer AM, Coenen AM, Kerkhof GA. Melatonin improves health status and sleep in children with idiopathic chronic sleep-onset insomnia: a randomized placebo-controlled trial. J Am Acad Child Adolesc Psychiatry. 2003;42:1286-1293. AbstractHaimov I, Lavie P, Laudon M, Herer P, Vigder C, Zisapel N. Melatonin replacement therapy in elderly insomniacs. Sleep. 1995;18:598-603. AbstractGarfinkel D, Laudon M, Nof D, Zisapel N. Improvement of sleep quality in elderly people by controlled-release melatonin. Lancet. 1995;346:541-544. AbstractZhdanova IV, Wurtman RJ, Regan M, Leclair OU, Shi JP, Taylor JA. Melatonin treatment for age-related insomnia. Clin Endocrinol Metab. 2001;86:4727-4730.Hughes RJ, Sack RL, Lewy AJ. The role of melatonin and circadian phase in age-related sleep-maintenance insomnia: assessment in a clinical trial of melatonin replacement. Sleep. 1998;21:52-68. AbstractBaskett JJ, Broad JB, Wood PC, et al. Does melatonin improve sleep in older people? A randomized crossover trial. Age Ageing. 2003;32:164-170. AbstractAsayama K, Yamadera H, Ito T, Suzuki H, Kudo Y, Endo S. Double blind study of melatonin effects on the sleep-wake rhythm, cognitive and non-cognitive functions in Alzheimer type dementia. Nippon Med Sch. 2003;70:334-341.Serfaty M, Kennell-Webb S, Warner J, Blizard R, Raven P. Double blind randomized placebo controlled trial of low dose melatonin for sleep disorders in dementia. Geriatr Psychiatry. 2002;17:1120-1127.Singer C, Tractenberg R, Kaye J, et al. A multicenter, placebo-controlled trial of melatonin for sleep disturbance in Alzheimer's disease. Sleep. 2003;26:7893-7901.Garfinkel D, Laudon M, Zisapel N. Improvement of sleep quality by controlled-release melatonin in benzodiazepine-treated elderly insomniacs. Arch Gerontol Geriatr. 1997;24:223-231. AbstractRogers NL, Kennaway DJ, Dawson D. Neurobehavioural performance effects of daytime melatonin and temazepam administration. Sleep Res. 2003;12:207-212.Paul MA, Gray G, Kenny G, Pigeau RA. Impact of melatonin, zaleplon, zopiclone, and temazepam on psychomotor performance. Aviat Space Environ Med. 2003;74:1263-170. AbstractMiddleton BA, Stone BM, Arendt J. Melatonin and fragmented sleep patterns. Lancet. 1996;348:551-552. AbstractGyllenhaal C, Merritt SL, Peterson SD, Block KI, Gochenour T. Efficacy and safety of herbal stimulants and sedatives in sleep disorders. Sleep Med Rev. 2000;4:229-251. AbstractStevinson C, Ernst E. Valerian for insomnia: a systematic review of randomized clinical trials. Sleep Med. 2000;1:91-99. AbstractHadley S, Petry JJ. Valerian. Am Fam Physician. 2003;67:1755-1758. AbstractVorbach EU, Gortelmeyer R, Bruning J. Therapy of insomnia. The efficacy and tolerability of valerian. Psychopharmakotherapie. 1996;3:109-115.Ziegler G, Ploch M, Miettinen-Baumann A, Collet W. Efficacy and tolerability of valerian extract LI 156 compared with oxazepam in the treatment of non-organic insomnia: a randomized, double-blind, comparative clinical study. Eur J Med Res. 2002;25:480-486.Donath F, Quispe S, Diefenbach K, Maurer A, Fietze I, Roots I. Critical evaluation of the effect of valerian extract on sleep structure and sleep quality. Pharmacopsychiatry. 2000;33:47-53.Leathwood PD, Chauffard F, Heck E, Munoz-Box R. Aqueous extract of valerian root (Valeriana officinalis L.) improves sleep quality in man. Pharmacol Biochem Behav. 1982;17:65-71. AbstractLeathwood PD, Chauffard F. Aqueous extract of valerian reduces latency to fall asleep in man. Planta Med. 1985;(2):144-148. AbstractGlass JR, Sproule BA, Herrmann N, Streiner D, Busto UE. Acute pharmacological effects of temazepam, diphenhydramine, and valerian in healthy elderly subjects. J Clin Psychopharmacol. 2003;23:260-268. AbstractPoyares DR, Guilleminault C, Ohayon MM, Tufik S. Can valerian improve the sleep of insomniacs after benzodiazepine withdrawal? Prog Neuropsychopharmacol Biol Psychiatry. 2002;26:539-545.Hathcock J. Dietary supplements: how they are used and regulated. J Nutr. 2001;131:1114S-1117S. AbstractBotanical Dietary Supplements: Background Information. Office of Dietary Supplements. National Institutes of Health. Available at: http://ods.od.nih.gov/factsheets/botanicalbackground.asp Accessed December 1, 2004.U. S. Food and Drug Administration. Overview of dietary supplements. Center for Food Safety and Applied Nutrition. January 3, 2001. Available at: http://www.cfsan.fda.gov/~dms/ds-oview.html Accessed December 1, 2004.
 

     Next Article

Copyright © 2004 Medscape.
 
This is a part of article Expert Column - What Every PCP Should Know: Over-the-Counter Insomnia Treatments Taken from "Atarax Hydroxyzine 25Mg" Information Blog

Changes in Pharmacodynamics

Pharmacodynamic considerations include receptor number and affinity, signal transduction mechanisms, cellular responses, and homeostatic regulation.[59] Sensitivity to certain drugs may be either increased or decreased in the elderly, e.g., sensitivity to benzodiazepines is greater in older patients,[60] as is the response to some opioids and anticoagulants.

Conversely, the elderly seem to be less responsive to certain β-adrenoceptor agonists and antagonists.[27] Simons, et al. studied H1-receptor sensitivity to hydroxyzine by measuring changes in suppression of histamine-induced wheal and flare and suggested an enhanced suppression of H1-receptor activity in the elderly.[24]  Printer- Friendly Email This

Skin Therapy Lett.  2006;11(8):1-7.  ©2006 SkinCareGuide.com
This is a part of article Dermatological Drug Dosage in the Elderly Taken from "Atarax Hydroxyzine 25Mg" Information Blog

A Lincolnshire woman who lost her newborn twins to a bacterial infection is hoping to raise awareness of the condition which killed them.

Jane Gothorpe's children, Euan and Kirsten, died from Group B Streptococcus, an infection related to meningitis, within days of being born.

The infection, carried in the mother's gut, is passed on during labour.

But a swab test not routinely given on the NHS can detect it. Campaigners want this to be made available to everyone.

Mrs Goathorpe from Dunholm near Lincoln had been trying for a family with her husband John for more than four years.

The twins were born in February.

She said that although the babies appeared perfectly healthy after their normal birth in February, their conditions soon worsened.

"About six o'clock the following evening John and the midwife were changing Kirsten's nappy and the midwife just thought she didn't look very well, so they called a paediatrician.

"It became apparent very quickly that she wasn't going to survive and Euan also started to deteriorate."

But the condition can be detected by a simple swab test costing around £32.

Mrs Gothorpe added: "You wonder why it's not available for everybody - and can you put a price on a treatment that might prevent what me and my husband have been through?"

Campaigners say women should be offered swab tests during pregnancy to see if they have the bacteria, and be given intravenous antibiotics in labour as an option.

But critics of the proposal fear antibiotics may do more harm than good and that there is a risk of allergic reaction.

This is a part of article Swab test ‘may have saved twins’ Taken from "Metronidazole Flagyl 500Mg" Information Blog

International Approvals

International Approvals: NovoRapid, Fentanyl, Atriance

Yael Waknine

September 24, 2007 — The European Commission (EC) has approved insulin aspart subcutaneous injection for use in the elderly and patients with renal or hepatic impairment; the Japanese Ministry of Health, Labor, and Welfare has approved fentanyl citrate 0.1- and 0.25-mg injections for use in pediatric patients aged 2 years and younger; and the EC has approved nelarabine intravenous infusion for the treatment of refractory and relapsed T-cell acute lymphoblastic leukemia and lymphoblastic lymphoma.

Insulin Aspart (NovoRapid) for Use in Elderly Patients in EU

On September 20, the European Commission approved an expanded indication for insulin aspart subcutaneous injection (NovoRapid, Novo Nordisk), allowing its use for the treatment of types 1 and 2 diabetes in the elderly and in patients with renal or hepatic impairment.

According to the International Diabetes Federation, approximately 20% of the world's elderly population has diabetes, and that figure is steadily rising, the company said in a news release. Insulin aspart is the only rapid-acting, modern insulin approved for use in this population.

Insulin aspart previously was approved by the EC for use in children aged 2 years and older and pregnant women. Marketed as NovoLog in the United States, it has been approved by the US Food and Drug Administration for the control of hyperglycemia in diabetic patients, with the caveats that its benefits should justify the risk to the fetus during pregnancy and that lower doses may be required in the setting of renal or hepatic impairment.

Fentanyl Injection for Use in Children Aged Less Than 2 Years in Japan

On August 28, the Japanese Ministry of Health, Labor, and Welfare (MHLW) approved an expanded indication for fentanyl citrate 0.1- and 0.25-mg injections (Daiichi Sankyo Company, Ltd), allowing use of the drug in pediatric patients aged 2 years and younger.

According to a company news release, the approval was based on data from a physician-led phase 3 trial that demonstrated the drug's safety in children and infants.

Fentanyl injection is approved by the MHLW and the US Food and Drug Administration (FDA) for use as a short-term analgesic during anesthetic periods, induction/maintenance, and immediate postoperative period; as a narcotic analgesic supplement in general/regional anesthesia; and as an anesthetic agent with oxygen in high-risk patients. It also may be used with a neuroleptic as an anesthetic premedication, for the induction of anesthesia, and as an adjunct in the maintenance of general/regional anesthesia.

Although the FDA does not contraindicate use of fentanyl injection in children aged less than 2 years, the safety labeling states that rare cases of unexplained clinically significant methemoglobinemia have occurred in premature neonates undergoing emergency anesthesia and surgery that included combined use of fentanyl, pancuronium, and atropine. A direct cause between use of these drugs and methemoglobinemia has not been established.

Nelarabine Injection (Atriance) for Refractory T-ALL and T-LBL in EU

On August 28, the European Commission approved nelarabine intravenous injection (Atriance, GlaxoSmithKline) for the treatment of T-cell acute lymphoblastic leukemia (T-ALL) and T-cell lymphoblastic lymphoma (T-LBL) in patients who have not responded to or have relapsed after treatment with at least 2 chemotherapy regimens. The approval is valid in all 27 member states of the European Union, with identical national licenses usually issued in Norway, Iceland, and Liechtenstein.

Nelarabine is a prodrug of arabinosylguanine with T-cell selectivity. The nucleoside analog is converted into arabinosylguanine nucleotide triphosphate, which inhibits DNA synthesis and induces apoptosis.

The approval was based on complete response rates induced by nelarabine therapy; randomized trials demonstrating increased survival or other clinical benefits have not been conducted.

Data from 2 multicenter, phase 2 clinical studies of single-agent therapy of nelarabine in relapsed/refractory patients (28 adults, 39 children) showed that 21% of adults and 23% of children achieved a complete response (defined as the disappearance of all detectable signs of disease) both with and without full hematologic recovery. One adult and 4 children went on to receive a stem cell transplant; median overall survival after nelarabine therapy was 21 and 13 weeks in adults and children, respectively.

These findings were supported by those of a German ALL Study Group trial (n = 57), in which 47% of patients treated with nelarabine achieved remission and 74% of those demonstrating complete response were transferred to a stem cell transplant.

Hematologic toxicity was the most common moderate-to-severe (grade 3 – 4) nelarabine-associated adverse event. As with other cytotoxic agents, nelarabine is associated with treatment-limiting neurologic adverse events; close monitoring of patients is recommended, and dosing should be discontinued if neurologic events of grade 2 or greater severity occur.

The recommended regimen for nelarabine in adults is 1500 mg/m², administered intravenously over 2 hours on days 1, 3, and 5 and repeated every 21 days. Pediatric patients should be given 650 mg/m² intravenously over 1 hour daily for 5 consecutive days, repeated every 21 days.

Nelarabine (marketed as Arranon) previously was approved for this indication by the US Food and Drug Administration in October 2005.
This is a part of article International Approvals: NovoRapid, Fentanyl, Atriance Taken from "Atarax Hydroxyzine 25Mg" Information Blog

Rifaximin

Rifaximin is a semisynthetic analog of the rifamycin antimicrobial rifampin. The addition of a benzimidazole ring makes rifaximin essentially nonabsorbed (bioavailability <0.4%); hence, its usefulness for treatment of intraabdominal infections. The Food and Drug Administration (FDA) approved this agent for the treatment of travelers' diarrhea caused by noninvasive strains of Escherichia coli in patients who are 12 years of age or older. Rifaximin has been used in Italy since 1987 for the treatment of various infections. It has also been useful in hepatic encephalopathy, as well as in pre- and postsurgical prophylaxis.[14,15] This drug exerts its activity by inhibiting the initiation of RNA synthesis by binding to the ß subunit of the RNA polymerase.[14]

In vitro, the minimum inhibitory concentration (MIC) values of C. difficile are among the lowest of any enteric pathogen for rifaximin. Gerard et al.[14] identified one study in which 34 of 56 clinical isolates of C. difficile were inhibited by rifaximin at a concentration of 0.78 µg/mL, with the remainder inhibited at concentrations greater than 25 µg/mL. Although the interpretation of these MIC results is difficult in the absence of known gastrointestinal concentrations, it is likely that the drug concentration achieved at the site of action would largely exceed the reported MIC values. Fecal levels after oral administration of the agent have been shown to range from 4000 to 8000 µg/g of stool.[15] In addition, the microorganism shows a particularly low incidence of spontaneously resistant mutants (<1 × 10-9), which could prove useful in treating the emergent strain.

In an open-label study, Boero et al.[16] compared rifaximin 200 mg 3 times daily for 10 days with oral vancomycin 500 mg twice daily for 10 days (N = 20). Time to toxin disappearance ± SD was significantly shorter with vancomycin, at 4.8 ± 1.48 days, versus rifaximin, at 8.1 ± 1.79 days (p < 0.005). Time to stool normalization was similar with vancomycin, at 3.8 ± 1.48 days, versus rifaximin, at 4.9 ± 2.38 days (p = NS). Overall, rifaximin was found to be effective in 9 of 10 patients, while vancomycin was successful in all 10 patients who received it.

We have identified several cases in our practice in which rifaximin wassuccessfully used for CDAD when other agents failed or were contraindicated,but more supportive evidence is needed. Overall, rifaximin appears to be avalid alternative for the treatment and management of CDAD, although further,larger studies are needed to clearly define its role.  Printer- Friendly Email This

Ann Pharmacother.  2006;40(12):2164-2169.  ©2006 Harvey Whitney Books Company
This is a part of article Emerging Therapies in the Treatment of C difficile-Associated Disease Taken from "Metronidazole Flagyl 500Mg" Information Blog