Saturday, January 22, 2011

Medications for sleep in liver disease

Getting a Good Night Sleep

by Jennifer Pate on January 21, 2011

"Many medications and substances can cause sleep disturbance. For example, patients on interferon and ribavirin commonly have difficulty sleeping. Medications such as Propranolol or immunosuppressants such as Prednisone can also interfere with sleep"

Sleep Hygene
Dr. Pate in this post explains the importance of a good night sleep. During these 31 Days of Wellness, attaining a sound night of sleep is a prerequisite to maintaining good health and wellness.

Sleep is essential for physical and mental health. When we sleep well, we often take this vital activity for granted. However, approximately 30 % of adults struggle with insomnia (difficulty sleeping) on a regular basis and for 20 million Americans, this has become a chronic problem. The indirect costs of sleep disorders exceed 100 billion dollars per year. Sleep disorders are particularly common in patients with liver disease and are a problem I encounter in my practice on a daily basis.

Everyone has a different need for sleep. Some people may need as little as 6 hours per night, whereas, others may need up to ten hours per night. Our bodies will often indicate whether we are sleeping an adequate amount as indicated by feeling rested and alert in the morning and being able to sustain alertness in the afternoon. Research data have indicated that too much or too little sleep can be harmful to our health. For example, some studies have demonstrated that people who slept greater than eight hours per night died younger than those who slept six to eight hours per night. Too little sleep can have serious physical and mental health consequences and impair your ability to perform activities such as driving safely.

Causes of Insomnia

There are numerous causes of insomnia. For each patient with insomnia, the cause is likely to be multi-factorial. At one time or another, everyone experiences brief difficulty sleeping due to stress or changes in routine. In liver disease, there appears to be disruptions in one’s circadian rhythm, a natural cycle in humans that repeats every 24 hours. Melatonin is a hormone involved in regulating the sleep-wake cycle and abnormalities in melatonin play a role in insomnia. Patients with liver disease are often struggling with significant fatigue and may nap during the day. As a result, sleep is impaired at night. Patients with cirrhosis may experience episodes of confusion (hepatic encephalopathy) and sleep problems may be an early indication of this. If you or your family member suspects you are experiencing hepatic encephalopathy, you should discuss this with your physician. Left untreated, hepatic encephalopathy can worsen and result in coma or death.

Other causes for sleep problems include excessive stress, depression or anxiety. Other symptoms of depression may include feelings of sadness or lack of interest in usual activities. Decreased appetite, decreased energy and even suicidal thoughts are other symptoms of depression. Depression is a highly treatable condition and appropriate treatment often resolves the sleep disturbance. Anxiety disorders may be characterized by excessive worry, panic attacks or intrusive thoughts. These symptoms often become problematic when our minds are less active and may keep us up at night. Effective treatment is available.

Additionally, many medications and substances can cause sleep disturbance. For example, patients on interferon and ribavirin commonly have difficulty sleeping. Medications such as Propranolol or immunosuppressants such as Prednisone can also interfere with sleep. Diuretics (“fluid pills”) may indirectly keep patients up at night by causing them to urinate. If you feel your medications are keeping you up at night, please discuss this with your physician. Never make medication changes on your own.

Substance use also plays a critical role in causing or worsening sleep issues. Caffeine (present in chocolate, coffee, tea and some soft drinks) is a stimulant and should not be consumed after lunch. Nicotine may also keep patients awake at night. Alcohol is a particularly dangerous way to treat sleep problems in the context of liver disease.

If you have a liver disease or other medical problems, it is essential to work with your physician to address your insomnia. Do not try herbal supplements or over the counter medications without consulting your physician as these may be dangerous and even life threatening.

Sleep Hygiene

Sleep hygiene is the most important set of tools for treating insomnia. Here are some tips to help you get a good night’s rest.

Avoid napping during the day
Use your bed only for sleep or sex
Develop a relaxing bedtime ritual such as taking a warm shower or reading something relaxing before going to bed
Don’t go to bed until you feel sleepy
If you have gone to bed and are unable to sleep, get out of bed and do something relaxing before returning to bed. Otherwise, your bed may become psychologically associated with an inability to sleep and this may worsen the problem.
Go to bed at the same time each night and awaken at the same time each morning.
Avoid caffeine after lunch
Avoid nicotine especially before bedtime.
Avoid treating sleep problems with alcohol
10. Do not use over-the-counter or herbal medications without discussing these medications with your doctor. These may be dangerous to your liver and can worsen confusion (“encephalopathy”).

11. Exercise early in the day. Avoid exercising before bed as this may keep you up at night.

12. If you are prescribed sleep medications by your physician, take the medication only as prescribed. Do not increase the dose or combine medications without speaking with your doctor.

13. Keep bedroom dark and cool at night.

14. Don’t watch television in bed. Although this may seem to be relaxing, the lights in the television are activating to our brain.

Medications for sleep in liver disease

Safe and effective treatment for insomnia in patients with liver disease involves use of all the sleep hygiene strategies mentioned above. However, despite their best efforts, some patients are still unable to sleep. Sleep medications are problematic in the context of liver disease and require careful monitoring and weighing of the risks and benefits. I have mentioned a few of the more commonly used medications for sleep, but this list is not all-inclusive.

Ambien (Zolpidem) is a commonly used medication that may help people who have difficulty falling asleep. Ambien may worsen encephalopathy in cirrhosis. Ambien has also been noted to worsen memory problems in patients on Interferon.

Hydroxyzine is an antihistamine that was recently studied in a group of patients with cirrhosis. In very low doses, this may be a safe drug to use to treat insomnia on a short term basis. However, all antihistamines have the potential to worsen confusion. Benadryl (Diphenhydramine) is also an antihistamine which is sometimes used for insomnia. Patients quickly develop a tolerance to the sedative effect and may also experience side effects such as worsening confusion, dry mouth, urinary retention or constipation.

Lunesta (Eszopiclone) is a sleep medication with low abuse potential. An additional benefit is that tolerance does not appear to develop. Studies of this medication in patients with liver disease have not been conducted, but preliminary information suggests this may be a safer option for the treatment of insomnia.

Trazodone is an antidepressant medication that is used primarily for sleep. It may be effective for patients who experience trouble falling asleep as well as staying asleep. It has a rare risk of priapism (an abnormal erection that will not resolve). In some studies, Trazodone has caused reversible abnormalities in liver function tests. Trazodone may cause dizziness or residual sedation during the day.

Benzodiazepine medications such as Xanax (Alprazolam), Restoril (Temazepam), or Klonopin (Clonazepam) may interfere with the amount of time spent in each stage of sleep (sleep architecture). Xanax is highly addictive and is not safe in liver disease. Benzodiazepines such as Restoril or Klonopin are safer in liver disease, but may worsen encephalopathy. Benzodiazepines and alcohol are a deadly combination and can cause respiratory depression. If benzodiazepines are abruptly stopped after long term use, a potentially life threatening withdrawal syndrome may result.

Sleep problems that do not respond to treatment may represent sleep apnea. Sleep apnea is a disorder characterized by numerous episodes during the night when the patient briefly stops breathing. This may happen many times nightly and significantly impairs the quality of sleep. Evaluation by a physician specializing in sleep disorders and an overnight sleep study may be warranted. Weight loss is helpful to many patients with this disorder. Some patients may need additional treatment.

Sleep is an activity that is vital for your physical and emotional well-being. With changes in behavior, most people can improve the quality of their sleep and awaken feeling more rested for the next day.

Sweet dreams!

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