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Sleeplessness and Circadian Rhythm Disorder (cont.)

Medications

Therapy for a circadian rhythm disorder is largely behavioral. Light therapy has been shown to be an effective modifier of circadian rhythms. The short-term use of hypnotics (medications that promote sleep) is a useful option in treating a circadian rhythm disorder and has improved the therapeutic response, especially in persons with Alzheimer disease.

Melatonin

Melatonin has been reported to be useful in the treatment of jet lag and sleep-onset insomnia in elderly persons with melatonin deficiency. Melatonin is used for enhancing the natural sleep process and for resetting the body's internal time clock when traveling through different time zones. Melatonin is believed to be effective when crossing 5 or more time zones but is less effective when traveling in a westward direction. Melatonin has also been used in the treatment of circadian rhythm sleep disorder in persons who are blind with no light perception.

Melatonin is available as an over-the-counter (OTC) preparation. Melatonin is still considered a diet supplement, and dosing guidelines have not been established. Because of the effect of melatonin on immune function, persons with immune disorders and those taking systemic corticosteroids or immunosuppressive drugs should be cautioned against taking melatonin. Melatonin may interact with other medications. Persons should consult their doctor before using melatonin.

Melatonin stimulants

Ramelteon (Rozerem) is a prescription drug that stimulates melatonin receptors. Melatonin is a hormone produced by the pineal gland during the dark hours of the day-night cycle (circadian rhythm). Melatonin levels in the body are low during daylight hours. The pineal gland (located in the brain) responds to darkness by increasing melatonin levels in the body. This process is thought to be integral to maintaining circadian rhythm. Ramelteon promotes the onset of sleep and helps normalize circadian rhythm disorders. Ramelteon is approved by the Food and Drug Administration (FDA) for insomnia characterized by difficulty falling asleep.

Hypnotics

Short-term use of hypnotics may be beneficial in selected patients. Patients interested in the use of hypnotics for a circadian rhythm disorder should discuss them with their doctor.

Benzodiazepines

Short-acting benzodiazepines are often chosen in the early treatment of a circadian rhythm disorder and are used in conjunction with behavioral therapy. Triazolam (Halcion) is a benzodiazepine frequently chosen for short-term use in addition to behavioral therapy. This short-acting agent is effective in helping persons fall asleep.

Triazolam is not effective in persons with sleep maintenance issues. For persons with sleep maintenance insomnia, a benzodiazepine with an intermediate half-life (for example, estazolam [ProSom]) or a long half-life (for example, quazepam [Doral]) may be considered.

Nonbenzodiazepine hypnotics

Nonbenzodiazepine hypnotics are gaining popularity because they do not have a significant effect on sleep architecture and are not associated with the rebound phenomenon seen with benzodiazepines. Zolpidem (Ambien) is a good short-term option for persons with DSPS who require pharmacologic support.

Treatment of sleep disorders associated with shift work

Modafinil (Provigil) is a stimulant indicated to treat workers with sleep disorders caused by their shift work. Modafinil has wake-promoting actions and is taken 1 hour before the start of the work shift.

For more information, see Understanding Insomnia Medications.