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Doctors' Answers to "Frequently Asked Questions" - Sleeping Problems


These comments are made for the purpose of discussion and should NOT be used as recommendations for or against therapies or other treatments. An individual patient is always advised to consult their own physician.

[posted 07/15/2000]
Question: My mother has narcolepsy and has taken Trazadone for years. Another person with Narcoplesy said that Trazadone is contraindicated for paitents with Narcolepsy. Is there data that says that Narcopelsy patients should not take Trazadone? If so, what kind of problems would it create?

Answer: Trazadone typically would increase Stage IV sleep and might help some with narcolepsy. Classical narcolepsy is best treated with amphetamines and avoidance of potentially sedative drugs(which some would have the next day with trazadone). Has she been in a sleep lab? That is really the only way to diagnose the problem and then determine the best drugs.

[posted 05/4/2000]
Question: I have been on Ambien 10mg for 2.5 yrs. Developed a tolerence to 40mg a night. Doc said "no way".

Tried Respidal..gave me a hang-over the next morning and very difficult to go to work...not functioning!

Now, Sonata 10mg. nothing. i tried 20mg. nothing.

I have 2 problems: 1 trouble falling asleep 2. trouble staying asleep "early morning awakening.


What to do?

Answer: Small doses of amitryptline(Elavil) are often helpful, but may also cause sedation the next day. Take them 2-3 hours before sleep to avoid this. Melatonin is occasionally useful as is kava.

[posted 02/16/2000]
Question: Over a 6-hour to 7-hour sleep period I wake up anywhere from 4 to 6 times. I am able to fall asleep again very quickly but wake up very shortly afterwards. So far my physician has prescribed various types of sleep aids: Lorazepam, imovane, another in the benzodiazepine family (can't remember the name) and currently Apo-Temazepam 30mg. The Apo-Temazepam helped considerably for the first few nights and slowly my wakefulness returned. Is there another sleep aid that would do better for me. The other medications didn't do much to help and left me with very unpleasant next-day effects. Apo-Temazepam doesn't bother me the next day other than waking up very groggy. I'm desperate for a solid night's sleep. This has been going on for about 17 years (coincides with the birth of my third child who was often sick during the night)

Answer: First ensure that you are not having any caffeine or chocolate after noon. Complete abstinence would also be helpful for a time. Second, abstain completely from alcohol. Alcohol has a major effect on the depth of sleep. It makes one sleepy, but prevents the deep Stage IV sleep necessary for restful sleep. Amitriptyline is the usual drug that we use for this problem, not the benzodiazepines. The benzodiazepines will help make you sleepy, but not usually sustain Stage IV sleep, this will usually be accomplished with amitriptyline. Start with 10 mg in the evening and work up. The drug is limited by sedation the following day, but is not habit forming. Melatonin might also be a help and is available otc at any pharmacy. If this is not helpful, I would see a sleep specialist for a sleep evaluation.

[posted 02/9/2000]
Question: I am a person who snores and has snored my whole life. I was diagnosed by one doctor w/sleep apnea but a second opinion came out negative. I was tested in a sleep center and woke up once every hour. I do have allergies to dust mites and mild hayfever. Can these be related? I am also 30-35 lbs. overweight at age 35.

Answer: Most people have some degree of apnea. This would be a mild case. Probably would improve with weight loss and decreased alcohol intake(alcohol also keeps one from Stage IV sleep). If you are falling asleep during the day, something needs to be done. If not, work on losing weight. Occasionally, removing some tissue in the back of the throat will help. An ENT who specializes in sleep disorders would be the person to see if weight loss does not aleviate the problem. Taking nasal steroids would remove the allergy component.

[posted 02/12/2000]
Question: My mother has been prescribed trazadone (100 mg)for help in sleeping. The doctor says it is also all right for her to take an over the counter sleeping pill (simply sleep)in addition to the trazadone. Since these don't seem to be helping, she has increased the trazadone to 150mg, with the additional sleeping pill. Is this a common procedure to have to take 2 different kinds of pills? Why would the prescription pill need to be supplemented?

Answer: Most of the OTC pills are in fact antihistamines. The side effect of the "traditional" antihistamines is sedation, hence why we use them for sleeping. Some patients just have difficulty with benzodiazepines, and some have a paradoxical effect becoming agitated. Trazadone is traditionally used as an antidepressant(belonging to the tricyclic class), but also has sedation as a side effect. I would avoid using high dosage antihistamines with the Trazadone since trazadone can have cardiac irregularity in some patients.

[posted 01/25/2000]
Question: I had a sleep test done and (originally for sleep apnea) but they found out I have limb movement disorder. In the sleep study (5 hrs 40 mins of which I thought was good sleep) I woke up 185 times (155 due to limb movement, 14 due to sleep apnea).

I have had headaches for years, depression, the works. Now that I am sleeping 7-8 hrs a day - I feel unbelievable better ... but I have some questions.

The doctor has me on 2 tab (he would prefer less but on 1 or 1.5 I only get about 5 hours sleep at most.

During the day I at times seem to loose balance. I don't feel dizzy but just loose balance. It usually happens when I get up too fast from sitting or laying down or walking up stairs too fast. It never happens when simply sitting (chair, car etc.). Could this be a result of the klonopin?

In your FAQ, you make it clear that klonopin is physically addicting. I can live with that as long as no other things happen as a result. It is better than being on ambien, prozac, zoloft and numerous other drugs.

But I wanted more input.

Who makes klonopin or its generic?

Thanks

Answer: Klonopin is made by Roche. Generics are made by Novopharm,Mylan, Par, and Watson. Probably the klonopin that it responsible for the balance problems. But, get your blood pressure checked to ensure it doesn't drop excessively when standing.

[posted 01/14/2000]
Question: I have a drug for sleeplessness called Zimovane manufactured by RPR. Before taking anything I like to know what it is, and what potential side effects are, but I can find out nothing about this drug (nothing in RPR's website). Can you please assist. Many thanks

Answer: Never heard of it and not in the 2000 PDR as you cited. Can't help you, sorry. Is it from another country?

[posted 11/30/1999]
Question: My doctor has recently prescribed Nasacort for my snoring (which is severe, sleep apnea has been ruled out in the past). I have 2 questions: 1)is taking nasacort a safe, long term solution (as my doctor states), I find it hard to believe since it is a steroid. 2)Should I request to see an ENT in addition to my doctor's simply handing me a prescription. (he said it was not necessary at this time, see if this works first, but I would like a second opinion)
Thanks very much!
-Tony















Answer: Nasal steroids are thought to be almost without side effects. Heavy, repetitive use could cause some systemic problems but it is estimated at less than 1% in all users. The options of treatment are nasal steroids to see if your snoring improves or surgical opening of the nasal passages. I'd use the nasal steroids for a few months before I saw an ENT. Nasslcrom available OTC is sometimes of help along with the steroids.

[posted 11/25/1999]
Question: My doctor prescribed PAXIL recently. The ogarmacist indicated that I should not drink alcohol while taking this meducation. Is this an absolute prohibition? I am not a heavy drinker but do have an occasional cocktail or a glass of wine with dinner. Is it all right to have a drink in the evening when I do not have to operate any dangerous machinery or drive a car. Would the intensifying effect of alcohol (dizzyness, for example) wer off during the night so that there would be little danger drinvin a car the next day?

The other question is this: I suffer from insomnia. The doctor thinks that this is a result of anxiety and tension. He prescribed PAXIL. However, the side effects for PAXIL include insomnia. How can I take a medication that is supposed to make me sleep better if it often causes insomnia?

Thank you very much.

Stan

Answer: Mild to moderate alcohol is not a problem with the drug in most cases. As to the insomnia, if the insomnia is due to depression Paxil will help. If due to other causes, it will have no effect or worsen the problem.

[posted 11/25/1999]
Question: my neurologist had me try Cylert for my very mild narcolepcy symptoms. I felt very emotional on the drug, and almost paranoid. i read the patient handout thig that came with the pills and it said not to stop taking the drug without checking with the docter. I asked the pharmasist why that was. he said that I would not want to just stop because it is changing chemicals in my brain. I called my docter, the advise nurse said I must ween off of the drug, then my docter said that I could just stop taking it. He also said that noone else had ever had these side effects. I know that I feel very different than normal whil on this drug. I don't particularly feel like my current docter really is interested in helping me and I am in the process of switching docters. In the meantime, I am trying to ween off of Cylert myself. I have been taking 1/2 a tablet each day for the last week and I do feel a little better, but have started waking up with headaches just the last three days. Do you have any helpful information on Cylert or on milder drugs to treat excessive daytime sleepiness and lack of focus.

Answer: The emotional reaction and the paranoia are seen about 5-10% of the time. The paranoia less than the emotionality. Your weaning protocol is fine, take Tylenol or equivalent for the headache. As to other drugs, they will probably have similar side effects. But, you will need to try and find out. Have you seen a sleep specialist or been in a sleep lab?

[posted 11/11/1999]
Question: I have had nightmares, disturbing, vivid dreams as long as I can remember. I feel as if I'm in REM sleep all night. I have always felt very groggy and when I get up in the mornings I feel as if I haven't slept at all. I wake up in the night burning up. I've always had uncontrollable mood swings as well. Finally, at the age of 25 I have just recently went to the doctor about this. She put me on Paxil and I felt great except for a very severe case of insomnia. Do SSRI's decrease your melatonin level? If not what would cause the insomnia? Also, is it possible for your body to overproduce melatonin? From what I've read about people who take it for jet lag and insomnia, they experienced vivid dreams and nightmares.

Answer: I don't know about the melatonin, but they commonly produce insomnia-this will persist as long as you are on the medication.

[posted 11/13/1999]
Question: I have had the problem of early morning awakenings for the last few years as well as occasional bouts of anxiety and daytime sleepiness. I am aware of the link between depression and this sleep problem, since my doctor has me trying Effexor to see if it relieves a possible underlying depressive disorder, which therefore might take care of the sleep problem. (BTW, I have a brother who was diagnosed as a manic-depressive) Since I do not feel depressed, what do you think is going on and what do you think of the use of an antidepressant here? Thanks.

Answer: This sounds like lack of Stage IV sleep. This is the deepest part of sleep when your muscles are nearly flaccid. Drugs that induce Stage IV sleep are antidepressants like Elavil. Usually 25 mg will accomplish this purpose. I am not aware that Effexor will do this, but I'm not a sleep specialist. If this doesn't work, then a night in a sleep lab may be the answer. Also, alcohol really decreases Stage IV sleep. Avoid any alcohol for a week and see if it makes any difference.

[posted 08/30/1999]
Question: My wife tells me that when I am sleeping, I shake a lot.
I shake my feet and shoulders all the time and also my head.
Is this something that I should be concerned about?

Answer: Not unless you are tired during the day. This is probably a variation of Restless Leg Syndrome or one of the other Sleep Disorders. This is potentially correctable. But, unless you are tired of little consequence. If you fall asleep during the day easily, I'd recommend a sleep lab.

Hallucinations and bad dreams [posted 1/11/99]
Question: I had a ear surgery that didn't go the way we planned, and since then I have had balance and dizziness problems that are kept under control to give me a life that will enable me to do some of the things that I want to do. Otherwise, I would have bad days everyday. I still have problems, but not to the extent that they were before I was put on the histamine blocker Claritin. This does help me, but it also causes me tachycardia. So the doctor has had to put me on various beta blockers. I have tried about 3 kinds now. The first one was Normodyne, which worked for about a year or so, but then the tachycardia became a problem once again so I was put on Inderal 60, which worked, but I started having terrible nightmares. It then led to nightly hallucinations, so I asked the doctor to give me something that wouldn't affect the brain so much. He put me on Lopressor 25 mg bid, which keeps the heart rate within reason, but am still having trouble at night with the dreams and the shadows in the rooms turning into people or animals that are walking or floating in the air. It's not a very good feeling, as I know that I probably am not really seeing this, so I try to focus on the object until the hallucination goes away, which it usually does within a few minutes. Why do drugs do this to our brain? Is there a drug that won't do this, but help with tachycardia that is caused by a different drug?

Answer: Well, I would try Atenolol, but you will probably experience the same problems.

PTSD [posted 1/8/99]
Question: Desyril was prescribed for sleeping problems due to multiple anal/oral rapes of child. Would this be drug of choice to manage symptoms? Also please provide information as to contraindications for this medication and any efficacy studies that may have been done to date. I was unable to locate any information of possible side effects. This child has extensive history of gastric dysfunction due to birth defects, i.e. Born with intestinal organs outside of body cavity.

Answer: This belongs to a class of anti-depressants called tricyclics. They tend to produce dry mouth, constipation, and drowsiness. Long term side effects do not appreciably differ from short. As to whether this is the best drug, impossible to say here.

Sleeplessness After Diagnosis with Heart Condition [posted 11/13/98]
Question:I am 73 years old, and I was diagnosed, few weeks back, with an atrial fibrillation. However, my great problem is sleeplessness, and unless I take a Temazepan pill, I seem to remain awake for the whole night -sometimes 2 nights in a row, leaving me feeling ghastly. I have to take Digoxin 125mcg, but am told this should have no effect on sleeping patterns. Being of a somewhat nervous disposition, my belief is that I remain anxious about my condition, yet I cannot crack my sleeplessness problem - it's as if I have lost the ability to know how to fall asleep! Wonder if you might have any ideas about what's going on.

Answer:Did they check your thyroids, a possible link if elevated. The digoxin won't cause this problem.

Sleep & Nortriptyline [posted 11/10/98]
Question:Is nortriptyline ever given to someone because they have problems sleeping at night?

Answer:Often, causes drowsiness as a side effect which is very helpful in helping patients sleep without any addiction.

Sleep Disorder [posted 7/21/98]
Question: I am 30 years old. I have always been one to take evening naps since middle school. For the past 5 years I have had an extremely difficult time staying awake during the day. It doesn't matter if I go to bed and get 8 hours of sleep or 4 hours of sleep, I am still tired. For the past two years I have been getting at least 30 minutes of exercise daily. Usually walking 2 miles. Nothing seems to work. I have even had a glucose tolerance test and it was normal. What could be the problem?

Answer: Most likely a sleep disorder. Have your physician check your thyroid function. If it’s normal, see a sleep specialist and spend a night in a sleep lab. There are several common problems, usually easily corrected which will lead you to be tired all day. Most of the problems center on the lack of ability to get into deep or Stage IV sleep which is necessary to avoid the fatigue you describe. It also tends to be inherited in certain types and may relate to your children (or eventual children) and your siblings.

Difficulty Sleeping
Question: I stopped taking Redux and phenteramine about 9 months ago. I took it for over a year and had to take Zoloft and Unisom to counteract the side effects. However, since I've been off of it (I never lost any weight) I have had trouble sleeping and sometimes one Unisom is not enough. I've asked my doctors about it but they seem flummoxed. Could it be nerve damage or something?

Answer: Hard to know. Have you tried melatonin? You are currently using an antihistamine to achieve sleepiness which is all right, but doesn't indicate any nerve damage.

Tired
Question: I'm a 15 year old girl with a very pressured schedule. Lately, I have been finding it very hard to stay awake after 10 p.m. I thought it might be mononucleosis, but I don't have any appetite problems. Should I have a blood test done?

Answer: You fail to mention how much sleep you are receiving on an average night. Most 15 year olds will have sleep deprivation with any amount less than 8-9 hours. Usually a pressured schedule means that sleep is minimal. I’d recommend that you schedule your day to ensure 8-9 hours a night for a week or so. If fatigue continues, see your physician.

Snoring
Question: My husband snores in any given position: on his stomach, side, or back. His mouth is never open and he doesn't quit when he is moved into another position. He used to only do this occasionally, but now it happens every time he goes to sleep. He is 41 years old and in good health. Could his adenoids be the cause of this?

Answer: Snoring usually indicates some partial blockage of the airway while sleeping. In severe cases this can cause sleep apnea, which is potentially very serious. I'd discuss this with his physician. He may need a visit to a sleep lab, especially if you see him stop breathing or if he is getting sleepy during the day. Large adenoids are a possible cause of this problem as is a short jaw.

Sleeping problems
Question: I am 48 years old and I don’t sleep very well. I go to bed about 11:00 p.m., sleep deeply for about half an hour and then get awaken for 2 to 3 hours. Even when I go to sleep early I wake up too early (about 3:00 or 4:00 a.m.). I feel I am not getting enough sleep because in the afternoon I get very tired at work around 2 p.m. I started taking 1 mg of Melatonin every night just before bed and that improved my sleeping somewhat, but still not very much.
Please advise me if I need any other medication.

Answer: Common culprits in disturbing sleep are alcohol and caffeine. In many people, as little as one drink will decrease the deep stage IV sleep substantially. Caffeine, tea, or chocolate are also possible causes. If eliminating alcohol does not help, a small dose of a drug like Elavil (usually used in depression) will usually fix this problem with no risk of rebound or addiction.

Sleeping on one side
Question: I am a 50-year old male. I can only get to sleep lying on my right side. I always wake lying on my right side and my bed partner says I spend the whole night on my right side. Is this normal or harmful.

Answer: This is very normal and not harmful.

Sleeping Problems
Question: Please recommend a prescription to make me sleep very hard for 8-10 hours. I have tried Temezepam, Ambien. I work odd shifts and MUST sleep unusual hours during some weeks.

Answer: Shift work is difficult to work because of the impact on sleep. Trying to shift the sleep cycle is difficult. Benzodiazepines like you have tried are the usual method. Taking higher doses may help, but continued use will blunt their effectiveness. Several people have tried melatonin with some success.

Sleeping Pattern
Question: I would like to know if there's any treatment for my condition. I am only 17 years old and for the last 3 years I have been sleeping for more than 9 hours each night. I exercise, eat a balanced diet and I am not depressed. I would like to know if there's a treatment or anything that would help since this is getting in the way of my studying.

Answer: If your thyroid and blood counts are OK, there probably is nothing medically wrong. Many 17 year olds will sleep this amount. Other medical causes would include different sleep disorder. These are usually marked by marked snoring, leg movement while asleep or jerking of muscles while asleep.

Thyroid & Insomnia
Question: My doctor tested my thyroid and increased my dose from .025 mg Synthroid to .075 Synthroid about three weeks ago. I am also taking Phen/fen (have been doing this since May, 1996 with NO insomnia). Over the past two and one half weeks I have been plagued by insomnia. I go days at a time without sleep. On one hand my psychiatrist (who prescribed sleeping meds) feels strongly that the Synthroid increased dose could well be causing the sudden onset of insomnia. On the other, the doctor who prescribes the phen/fen (30 mg Ionamin 1 x day and 20 mg fenfluramine bid, although I usually only take it once) says it surely can't be the Synthroid and must be the Phentermine. This makes no sense to me given that I've been taking it for well over a year with no side effects and all of the sudden (coincidental with the increased thyroid meds dose) I have begun to experience insomnia that is even resistant to sleeping pills. I have an appointment with the doctor who prescribes the phen/fen next Thursday however, he believes the p/f is causing the insomnia and is threatening to discontinue prescribing it. I have lost 75 lbs in the past 14 months and have NO INTENTION of going off the p/f, with or without this doctor's consent. There are pill mills on every street corner in my area, and I do not believe the p/f is responsible, and neither does my psychiatrist. I need an additional medical opinion before I go for my appointment with the p/f doctor on Thursday so that I can intelligently discuss this matter with him. Any advice you can offer (or any opinion) would be greatly appreciated.

Answer: Stop the phen/fen for a week or so to test which one is the culprit. Also, long term damage is being increasingly reported concerning patients who are on these drugs over a year. If you desire to continue phen/fen insure that you get a cardiac echo to check the valves and the pulmonary pressures.

Temazepamum
Question: I would like to know what brand name this sleeping pill is known as. " Temazepamum".

Answer: Brand name is Restoril.

Trouble Getting Up
Question: I am a 20-year old male with no prior major medical disorders. My question regards a problem I have with sleeping. For about a year or two, I have had trouble waking up in the morning. No matter how long I sleep, I still never feel like I am completely rested. Furthermore, the more that I sleep, the worse I feel. I sometimes wake up with headaches, and it is very difficult to wake up completely. Once I have gotten up, I am not usually tired for the rest of the day, it's just waking up that is so difficult. Is there something medically wrong with me? I have read about disorders such as sleep apnea, etc., and I was wondering if I could have such a thing. Or, if not, what can I do to end this problem?

Answer: First, how many hours a night are you sleeping. A 20 year old will need 8-9 hours a night. If you are getting less this is the most likely culprit. Secondly, avoid any alcohol and caffeine-both of whom change the level of sleep. One to two drinks will block some patients from reaching Stage IV sleep-necessary to avoid feeling tired. Thirdly, if this doesn't fix the problem you will need to see a physician to check your thyroid function. If normal, a sleep lab is the next step.

Insomnia [posted 10/1/98]
Question: In the past month or so I have had Chronic Insomnia ( I sleep no more thatn 3 or 4 hours a night ). I usually need at least 8 . I have both ADD and Bi-Polar II and am now on four different meds. I originally started taking the Klonopin to help me sleep but it really never did. In fact my Dr. told me to increase my evening dose to 2.5 or 3 mgs. I know that would knock most people our for days but it has had no effect. As a matter a fact, any drug I have taken that says it may cause drowsiness never does. I am seeing him again on Tuesday and my insomia is a big problem. My main problem is I just can't get to sleep: I am up until 4 or 5 most nights and get up around nine.

Answer: First, ensure you don't have a new problem like hyperthyroidism. Second, I'll need to know the other drugs to help.

Insomnia Treatment with Paxil and Trazadone [posted 8/10/98]
Question: What do you know about the use of Paxil and Trazadone for people who have trouble sleeping, but show no other signs of depression or anxiety? I'm wondering if these drugs are effective in just dealing with sleeplessness and if in lower doses the side-effects won't be as severe?

Answer: Paxil is generally not helpful for sleep, trazadone often is. I would not use Paxil in patients with difficulty sleeping, but often use trazadone. Side effects are drowsiness the next day, constipation and dry mouth. These are usually dose dependent and you should try for the smallest dosage that accomplishes the sleep goal.

Insomnia [posted 8/7/98]
Question: I have chronic insomnia. For over four years, I have been getting no sleep, or about three hours/night, three weeks of every month. That means I am severely sleep deprived. It is truly ruining my life. I am extremely bi-polar, have manic attacks at least five times/week, and have been on Prozac in the past. At this point, I am unsure of whether my insomnia is causing mania, or my mania is causing insomnia. What are your thoughts on this? I've contacted numerous sleep clinics and have either gotten no response at all, or a negative one since I have no health insurance.

Answer: 1) avoid any caffeine, chocolate, alcohol - all known to interfere with sleep cycles. 2) Try an antihistamine about 1 hour before bed - benadryl is good take 50 mg (available in 25 mg capsules in any pharmacy). 3) If you cannot tolerate the drowsiness you may see during the day with benadryl try melatonin - some patients get major improvements with this drug. 4) Ensure your thyroid functions have been checked - an over active thyroid will give sleep disturbances, about the only significant medical problem that will.

Chronic Insomnia
Question: My average 14 1/2 yr. old daughter has terrible insomnia. She is not depressed / drug user / stressed. She eats well and exercises. What can I do to help her. She goes to sleep fine, then wakes up approx. 2am and cannot get back to sleep until around 5a. She goes to bed around 10'ish most nights.

Answer: Is this new or has she had it her whole life? If new it definitely needs to be brought up with her pediatrician. If lifelong, I doubt that it will change. A sleep lab could be helpful to determine if she has any condition which is causing this.

Klonopin
Question: I have problems sleeping. I occasionally take klonopin to help me sleep. Lately I take it every night. I am finally able to wake up and feel good. I am able to sleep through the night. Is taking this bad for me? Can I just stop taking it?

Answer: Klonopin belongs to a class of drugs called benzodiazepines. In general, they are used for sedation and treatment of anxiety. They are usually effective as sleep inducing agents;but, tend to lose their effectiveness if used on a nightly basis. Antihistamines(Benadryl, etc.) are not addicting and do not tend to lose effectiveness. I would take these types and use Klonopin as a back-up if there is no effect. If you have taken them for a long period, I would not stop them cold. Rather taper them over a week. However, if you only take one a day you could probably taper fairly quickly.




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