Southeast Houston Sleep Medicine

SLEEP MEDICATIONS

AMBIEN (Zolpidem)

Zolpidem is a sleep aid that falls into the technical category of
“nonbenzodiazepine benzodiazepine agonists.” 
It binds to receptors in the brain that regulate a neurotransmitter called GABA. 

The duration of action is 7-10 hours.  Some patients describe drowsiness when they wake up. Other reported side effects include headache, nausea, dizziness and an unsteady gait.  Although Zolpidem was originally touted as non-addictive when it was released, experts are now agreed that Zolpidem is addictive.  Physical dependence can develop in two to three weeks and sudden withdrawal of Zolpidem can cause anxiety, difficulty sleeping or even seizures.

Recent evidence has also linked Zolpidem to sleep walking and other involuntary behaviors at night.  After taking Zolpidem, patients have spoken on the phone without remembering it, gone to the refrigerator in the middle of the night and even driven cars during their sleep.

LUNESTRA (Eszopiclone)

Eszopiclone is a sleeping aid in the same category as Ambien (Zolpidem).  It indirectly affects the level of the neurotransmitter GABA in the brain and causes sleep. The most common side effects are daytime sleepiness, dizziness, fatigue, and loss of coordination.  Like Ambien (Zolpidem) and Sonata (Zaleplon), Eszopiclone can be addictive, and has been associated with walking, eating, talking on the phone and even driving during sleep.  These activities are sometimes not remembered upon awakening.

Eszopiclone stands out from the other two medications in its class (Zalepon and Zolpidem), because of its extra long half life.  The effects of Eszopiclone can persist long after the person awakes, making daytime sleepiness a problem with this medication.

 

MELATONIN

Melatonin is a hormone produced by the pineal gland.  It helps regulate the sleep-wake cycle.  The pineal gland naturally secretes melatonin in response to darkness, while light suppresses its secretion.

Melatonin is not classified by the Federal Drug Administration as a drug, but instead is sold as a natural supplement.  Sleep specialists use melatonin to regulate the sleep-wake cycle in blind patients whose brains cannot respond to the natural fluctuations of light and dark.  By taking melatonin shortly before going to sleep, blind patients can regulate their sleep-wake cycle so that it conforms to conventional patterns.  Otherwise, blind patients develop a “free running sleep disorder” in which they sleep intermittently through the 24 hour period, making it more difficult for them to fit in with the rest of society.

Sleep specialists also use melatonin to treat jet lag.  By taking a dose shortly before the acceptable bedtime in a new time zone, patients will adjust more quickly to the new schedule. The side effects of melatonin are minimal, but include sleepiness, vivid dreams and morning headaches.

MIRAPEX (Pramipexole)

Sleep specialists use Pramipexole to treat restless leg syndrome.  Pramipexole mimics a chemical in the brain (neurotransmitter) called dopamine.  It acts by binding to receptors on brain cells in place of dopamine, inducing the same response as natural dopamine. This alleviates the symptoms of restless leg syndrome (excessive leg movement at night, cramping of the legs and an urge to move the legs during the day).

Patients with restless leg syndrome take Pramipexole two to three hours before going to sleep.  Initially, the dose is usually small and gradually increased until symptoms improve. Common side effects include dizziness, confusion, nausea, drowsiness, heartburn, diarrhea or constipation.  Rare but more severe side effects include muscle rigidity, abnormal movements, or compulsive behaviors such as excessive gambling or hypersexuality.

NUVIGIL (Armodafinil)

Armodafinil prevents sleepiness and fatigue.  It is a longer acting, more potent variation of Modafinil (Provigil).  Although the mechanism of action is stated to be unknown, many experts believe it increases the available amount of the neurotransmitter dopamine in the brain.  So far, the Federal Drug Administration has improved Armodafinil for the treatment of narcolepsy, shift-work disorder, and excessive fatigue from sleep apnea.  Psychiatrists are currently investigating its use in depression and attention deficit disorder

Numerous side effects have been associated with Armodafinil.  The most worrisome side effect is a severe skin reaction called Stevens-Johnson Syndrome.  Although much less than one percent of patients taking Armodafinil will ever develop Stevens-Johnson Syndrome, the problem can be devastating.  It causes blisters to develop on the surface of the skin and mucous membranes, and in severe cases, the blistering can involve the mouth and eyes.  The blisters sometimes slough off leaving denuded skin similar to a burn.

More common, but less severe side effects include nausea, headache, and insomnia.  Abnormal movements of the arms and legs or stress on the heart can also occur.  Patients over sixty-five and patients with heart disease should be careful before taking Armodafinil. Psychiatric side effects such as anxiety, mania, depression, thoughts of suicide, and the potential for addiction have been reported as well.

Armodafinil can interact with other medications metabolized by the liver.  Patients on Coumadin or seizure medications need to be especially careful with Armodafinil.  Interactions with ulcer medications, oral contraceptives and other medications can occur as well.

PROVIGIL (Modafinil)

Modafinil is used to treat daytime sleepiness and drowsiness.  The FDA has approved Modafinil for the treatment of narcolepsy, idiopathic hypersomnolence and daytime sleepiness associated with sleep apnea.  Although the exact mechanism of action is not known, most experts believe Modafinil mimics a chemical in the brain called dopamine.

Possible side effects include nausea, headache, insomnia, abnormal movements of the arms and legs, hyperactivity, rashes, and irregular heart rhythms.  Modafinil can be addictive, therefore the FDA has classified it as a Schedule IV medication.

Modafinil is eliminated from the body by the liver.  Therefore, it can affect the blood concentrations of other medications metabolized by the liver, such as the blood thinner Coumadin.  Drug interactions with seizure medications, antidepressants and birth control pills can occur as well.

RESTORIL (Temazepam)

Temazepam falls into a category of medications called benzodiazepines.  Benzodiazepines cause sleepiness and relieve anxiety by binding to specific receptors in the brain that increase the concentration of the neurotransmitter GABA.  Like other benzodiazepines, Temazepam has been associated with tolerance and addiction.  Patients should avoid using this drug for extended lengths of time and should not stop it suddenly. Stopping Temazepam suddenly can result in anxiety, sleeplessness, irritability, difficult concentrating or seizures.

Temazepam lasts for approximately 7 to 8 hours, so patients should avoid using it unless they will be able to remain asleep for a full 8 hours.  It interacts with alcohol and sedatives, so patients should avoid drinking or taking medications such as Soma, hydrocodone, methadone, or Demerol with Temazepam.  Temazepam can interact with some antidepressants, older antihistamines and tranquilizers as well.

The most common side effects include difficulty concentrating, dizziness, drowsiness, nausea or vomiting.  In rare cases, unusual behavioral reactions occur.  Reports in the medical literature describe patients who have become aggressive, irritable, delusional or even suicidal.  It is important for a patient to notify his or her doctor of any prior suicidal thoughts, depression or psychiatric illnesses before using Temazepam.

REQUIP (Ropinirole)

Sleep specialist use Ropinirole to treat restless leg syndrome, a condition manifested by frequent leg movements that disrupt sleep at night and cause leg cramping while awake.  Patients with restless leg syndrome often notice an uncontrollable urge to move the legs while sitting still.   Prior to starting Ropinirole or any other prescription for restless leg syndrome, your doctor should check for reversible causes of the condition. These can include iron deficiency, and side effects from other drugs such as some antidepressants and older ulcer medications.

Ropinirole works by fooling receptors in the brain that it is a neurotransmitter called dopamine, and it binds to the receptors in place of dopamine.  When treating restless leg syndrome, sleep specialists use a single dose of Ropinirole at night (for Parkinson’s disease the dose may be up to three times a day).   In order to minimize unpleasant side effects, patients start taking Ropinirole at small doses and increase the dosage gradually.  The most common side effects are dizziness, weakness, dry mouth, difficulty urinating and nausea. In rare cases, more serious side effects can occur, such as hallucinations, irregular heartbeat, confusion, compulsive behaviors such as hypersexuality or excessive gambling, inflammation and scarring of the lungs, or abnormal body movements.

Ropinirole can interact with other medications that affect the levels of dopamine in the brain, such as Reglan (Metoclopramide), Provigil (Modafinil), Nuvigil (Armodafinil), and some antidepressants.  The liver removes Ropinirole from the body, and other medications that are processed by the same enzymes can overwhelm the liver, causing overly high blood levels of either drug.  Drugs that can interact with Ropinirole in this manner include a class of antibiotics called fluoroquinolones (Levaquin, Ciprofloxacin, Avelox), some oral contraceptives, and alcohol.  Pregnant patients, people with a history of schizophrenia, and patients with a history of chorea (abnormal involuntary movements) should refrain from using Ropinirole.

TRAZODONE

Doctors usually prescribe Trazodone as an antidepressant, but sleep specialists also use it as a sleeping aid.  Trazodone treats insomnia and prevents frequent awakenings during sleep by increasing the concentration of a chemical (serotonin) in the brain.  Possible side effects from Trazodone include dizziness, nausea, vomiting, constipation, nightmares and dry mouth.  Potential drug interactions can occur with other medications eliminated by the liver including seizure medications, Coumadin, and some antibiotics. 

Trazodone should never be taken in combination with a class of antidepressants called MAO inhibitors (Marplan, Nardil, Eldepryl, Zelapar, and Tranylcypromine).  The combination of these medications can cause severe elevations in blood pressure, chest pain, heart attacks or strokes.

SONATA (Zaleplon)

Zaleplon is a sleeping aid in the same category as Ambien (Zolpidem).  It indirectly affects the levels of the neurotransmitter GABA in the brain and induces sleep.  Its duration of action is 7 to 8 hours.  The most common side effects are dizziness, drowsiness, loss of appetite and headaches.  Rarely, people experience emotional side effects such as depression, aggressiveness or unusual behaviors.  Just as with Zolpidem, there are reports of individuals talking on the phone, eating or even driving while asleep.  These episodes are sometimes not remembered in the morning.  Just like Zolpidem, Zaleplon can be habit forming.

XYREM (Sodium Oxybate)

Sodium Oxybate is a rarely prescribed medication used to treat narcolepsy with cataplexy (sudden loss of muscle control associated with strong emotion).  Sodium Oxybate cannot be purchased in a regular pharmacy.  Your physician must order it directly from the manufacturer.  It is a controlled substance with the potential for addiction and abuse.

Although Sodium Oxybate has been helpful in treating cataplexy, it interacts with sedatives and some antidepressants.  This combination of medications can stop a person’s breathing.  Other more common side effects include dizziness, nausea, vomiting and sleepiness.