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Rupal Patel, PharmD Mary Barna Bridgeman, PharmD
AQ is a 34-year-old woman who frequents your pharmacy for her health care needs. While picking up a prescription for naproxen, she inquires about your suggestion for a sleep remedy. She reports having trouble falling asleep several nights over the past 2 weeks, which she attributes to the stress of starting a new job. AQ describes tossing and turning in bed for over an hour each night and says that her poor sleep habits have resulted in her feeling tired at work the next day. She denies using medication for allergies, and her medication profile reveals she takes naproxen as needed for pain as well as a hormonal contraceptive. Describe lifestyle modifications AQ can implement to improve her condition. Would you recommend pharmacologic therapy for AQ?
Insomnia is a common complaint that drives individuals to seek self-treatment with OTC medications. Patients experiencing insomnia may describe symptoms that include difficulty falling or staying asleep, awakening too soon, or nonrestorative sleep that leaves one feeling tired. These symptoms all may be classified by their duration as transient (lasting less than 1 week), short term (lasting 1-3 weeks), or chronic (lasting more than 3 weeks).1,2
AQ’s insomnia can be classified as short term and would make her a candidate for self-treatment. Individuals reporting chronic insomnia, daily symptoms, or nocturnal awakenings several times per night, or those with insomnia secondary to other medical conditions, should be referred to a primary care provider for treatment.3
Nonpharmacologic interventions may be tried before initiating medication therapy for the treatment of insomnia or may be used in conjunction with medication. AQ has self-identified the stress of starting a new job with triggering her insomnia. Counsel her on the importance of pursuing relaxing activities in the time prior to bedtime and avoiding things like rigorous exercise, alcohol or caffeine intake, or consuming a large amount of food in the hours prior to bedtime, all of which may contribute to her difficulty falling asleep. AQ should ensure that her bedroom environment is comfortable for sleep, and be reminded that temperature, noise, light, and sounds should be minimized. Finally, counsel AQ to limit the use of her bed to sleep or intimacy; if she cannot fall asleep within a few minutes, she should be instructed to perform a relaxing activity until tired.3,4
In addition to reiterating good sleep hygiene practices, drug therapy could also be considered in the case of AQ. Recommend AQ select a product containing diphenhydramine and take 25 to 50 mg prior to bedtime only on an asneeded basis. Remind AQ of the expected anticholinergic side effects, including dry mouth and constipation, and that it can cause a “hangover” effect the next morning. If she is experiencing pain that is contributing to her symptoms, recommend a combination analgesic/diphenhydramine product (eg, Tylenol PM, Advil PM), or recommend she use her naproxen for pain relief.
Case Two—Migraine Headache FH is a 22-year-old woman seeking a pain-relieving medication to help with her migraine headaches. She describes these headaches as occurring each month just prior to the onset of her menstrual period. At her last physical examination, her physician indicated she should pick up an OTC analgesic; however, she cannot remember which product her doctor recommended. She has no medication allergies and uses the vaginal hormonal contraceptive ring for prevention of pregnancy. How will you counsel FH regarding the treatment of her migraine headaches?
Recommending an OTC analgesic for patients experiencing migraine headaches is appropriate only after a primary care provider has diagnosed the condition and other serious medical conditions have been ruled out. Because FH’s symptoms occur in a cyclic pattern, recommend she use a nonsteroidal antiinflammatory drug, such as naproxen or ibuprofen, on a scheduled basis (rather than as needed) at the onset of symptoms and for the first few days of menstruation. Either ibuprofen or naproxen are appropriate agents to alleviate pain caused by migraines; naproxen may be administered at a dose of 220 mg every 8 to 12 hours, whereas ibuprofen is dosed 200 to 400 mg every 4 to 6 hours, not to exceed 1200 mg per 24-hour period. Remind her to take the selected agent with food to minimize gastric upset.
PharmD Dr. Bridgeman is an internal medicine clinical pharmacist in Trenton, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Patel is a clinical pharmacist in North Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.
1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed, text revision. Washington, DC: American Psychiatric Association; 2000.
2. National Institutes of Health. National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep. 2005;28:1049-1057.
3. KirkwoodCK, Melton ST. Insomnia. In: Berardi RR, Ferreri SP, Hume AL, et al (eds). Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 16th ed. Washington, DC: American Pharmacists Association, 2009:869-881.
4. Morin AK, Jarvis CI, Lynch AM. Therapeutic options for sleep maintenance and sleep-onset insomnia. Pharmacotherapy 2007;27:89-110.