Case Studies in Self-Care

Mary Barna Bridgeman, PharmD, BCPS, CGP, and Rupal Patel Mansukhani, PharmD
Published Online: Monday, March 18, 2013
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Case 1—Insomnia
KD is a 29-year-old woman who works as an overnight stock clerk at a local grocery store. She reports that she is unable to fall asleep after returning home from work in the morning. As a result, she feels drowsy and sluggish as she begins her shift each night, and midway through her shift, she sometimes wishes she could take a nap. KD would like the pharmacist’s recommendation for an herbal, all-natural treatment for her insomnia.

Answer:
KD is likely suffering from shift work sleep disorder (SWSD), a medical condition characterized by insomnia and excessive drowsiness that most often affects individuals working off-shift jobs.1 Insomnia associated with SWSD usually resolves once the individual has returned to a normal daytime work schedule and is not a permanent medical condition. Treatment of SWSD usually includes nonpharmacologic counseling on good sleep hygiene and pharmacologic agents to promote restfulness and regulation of the circadian rhythm or alertness.

Numerous herbal medications are touted to be useful in treating insomnia, including kava, melatonin, valerian, St. John’s wort, and 5-hydroxytryptophan. Other data support caffeine use in promoting wakefulness for shift workers. Some data also suggest that melatonin may help regulate circadian rhythms in those with SWSD.2 Supplemental melatonin produces a rapid, mild sleep-inducing effect, and the American Academy of Sleep Medicine has recommended melatonin for treatment of SWSD.2,3 KD should be advised to take melatonin before bed in the morning.3 Additionally, since melatonin content in supplements may vary, educate KD on the availability of a prescription product, ramelteon, which has a similar mechanism.

KD should also be instructed to reduce the number of consecutive night shifts she works; limit overtime and extended work hours; make time for family and social activities; minimize long commutes and avoid driving when tired; and get adequate sleep on days off.1 Herbal and prescription products have been promoted for treating SWSD, but the best approach to managing this disorder is to get adequate amounts of restful sleep.


Case 2—Fatigue
RB is a 58-year-old businessman who reports running out of energy mid-day, which he attributes to restless sleep and an inability to fall asleep at night. He is looking for a recommendation for a “natural” OTC product to use in lieu of the caffeinated beverages he uses to self-treat fatigue. BF reports allergies to sulfa drugs and he takes metformin 1000 mg twice daily, aspirin 81 mg daily, losartan 50 mg daily, pravastatin 20 mg daily, and amlodipine 5 mg daily. How can RB alleviate his daytime fatigue?

Answer:

RB’s daytime fatigue seems to stem from poor sleep hygiene and excessive mid-day caffeine consumption. He should reduce his use of alcohol, nicotine, and caffeine. He should also adhere to a regular sleep routine during the week and weekends; avoid going to bed until he feels sleepy; and get regular exercise, although not close to bedtime. RB may also want to avoid watching TV or reading in bed and minimize stress and anxiety around bedtime.4

Short-term use of a supplement can augment efforts to improve sleep habits. Of the natural agents used to promote sleep, valerian is among the most thoroughly studied as an aide in alleviating insomnia and is believed to have a mechanism similar to the benzodiazepines.4 RB should be counseled that several weeks of continuous valerian use may be required to achieve optimal effect. Valerian has been shown to be safe for short-term use, although reports of hepatotoxicity have been identified. In vitro, valerian is known to inhibit cytochrome P450 3A4; there are limited data in humans quantifying potential interactions, but caution is warranted with RB’s concomitant use of amlodipine, a known substrate of this isoenzyme. With longer-term use, valerian should be tapered to minimize the chance of rebound or worsening insomnia.


Dr. Bridgeman is an internal medicine clinical pharmacist in New Brunswick, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University. Dr. Mansukhani is a clinical pharmacist in South Plainfield, New Jersey, and clinical assistant professor, Ernest Mario School of Pharmacy, Rutgers University.

References:
  1. Shift work sleep disorder. http://my.clevelandclinic.org/disorders/Sleep_Disorders/hic_Shift_Work_Sleep_Disorder.aspx. Accessed February 21, 2013.
  2. Melatonin. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty; c1995-2013. Accessed February 21, 2013.
  3. Morgenthaler TI, Lee-Chiong T, Alessi C, et al; Standards of Practice Committee of the American Academy of Sleep Medicine. Practice parameters for the clinical evaluation and treatment of circadian rhythm sleep disorders: an American Academy of Sleep Medicine report [published correction appears in Sleep. 2008;31(7):table of contents]. Sleep. 2007;30(11):1445-1458.
  4. Natural medicines in the clinical management of insomnia. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty; c1995-2013. Accessed February 21, 2013.
  5. Wilkinson JJ. Headache. In: Krinsky DL, Berardi RR, Ferreri SP, et al, eds. Handbook of Nonprescription Drugs: An Interactive Approach to Self-Care. 17th ed.  Washington, DC: American Pharmacists Association; 2012:67-86.
  6. Holland S, Silberstein SD, Freitag F, et al. Evidence-based guideline update: NSAIDs and other complementary treatments for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1346.
  7. Natural medicines in the clinical management of headache. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty; c1995-2013. Accessed February 21, 2013.
  8. Natural medicines in the clinical management of Alzheimer’s Disease. In: Natural Medicines Comprehensive Database [Internet]. www.therapeuticresearch.net. Stockton, CA: Therapeutic Research Faculty; c1995-2013. Accessed February 21, 2013.


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