Treatment for Insomnia

Treatment for Insomnia

Decision #1

The first decision is to administer the patient with Zolpidem 10mg PO at bedtime. The decision to administer the patient with Zolpidem 10mg PO is because the main diagnosis for this patient is insomnia. Giving the patient Zolpidem 10mg PO at bedtime can help manage insomnia and help the patient relax and sleep. Firstly, Zolpidem is a sedative-hypnotic medication that is a non-benzodiazepine receptor modulator. The mechanism of action of Zolpidem includes having a gamma-aminobutyric acid (GABA) functionality, which improves the activity of the neurotransmitter GABA within the brain (Bouchette et al., 2022). Increased GABA activity has sedative effects on the brain, which leads to deeper and better sleep.

I selected Zolpidem 10mg and not the other options based on various patient factors such as their health and medical history and a consideration of the side effects of each available option. Compared to the other options used in the management of insomnia, Zolpidem has been found to have fewer side effects and serious negative outcomes (Bouchette et al., 2022).

I decided to use Zolpidem 10mg as the first line of therapy for insomnia because it improves how easily an individual can fall asleep and remain asleep. In a randomized controlled trial meta-analysis, Xiang et al. (2021) found that a treatment for insomnia using Zolpidem effectively reduced sleep latency and improved sleep onset and maintenance with improved overall sleep quality and sleep duration within a period of one month.

Ethics to consider in the development of the care plan include patients’ informed consent, allowing them autonomy, and considering potential drug-related risks. Ethical considerations can promote more open and honest communication with the patient. For instance, it can help the provider point out the risk of Zolpidem dependency. This can be a good way to include the patient in deciding the treatment to use.

Decision #2

The second decision is to use trazodone 50mg PO at bedtime. The decision to use trazodone 50mg is due to the progression of the patient’s insomnia disorder symptoms and other manifestations related to insomnia the patient experienced, especially depressive symptoms and anxiety related to the loss of their partner. The patient’s symptoms required a stronger dosage to have more effects in reversing the symptoms. Additionally, trazodone is a serotonin modulator and reuptake inhibitor (SARI). SARI medication works by suppressing the reuptake of serotonin as well as by blocking both histamine and alpha-1-adrenergic receptors. In high dosages, trazodone blocks the serotonin transporter (SERT), creating an anti-depressive effect (Gonçalo & Vieira-Coelho, 2021).

I selected trazodone 50mg and not the other options in the exercise by considering the drug’s mechanism of action and efficiency in managing depression and anxiety, and hence insomnia. I also considered the safety of the patient and selected the medication with the least risk of side effects. Trazodone 50mg has minimum side effects, has a pleasant taste, and users have reported minimal side effects; its sedative outcomes can be easily predicted based on how it affects human cognition (Gonçalo & Vieira-Coelho, 2021).

I selected trazodone 50mg as a supplement for the low melatonin levels of the patient and to help them manage other symptoms, such as anxiety and depression, which may further contribute to the development of chronic insomnia. Melatonin supplementation can contribute to better sleep quality and the duration of sleep in patients with insomnia disorder (Fatemeh et al., 2022). Additionally, trazodone has been found to change the polysomnographic sleep architecture without any impact on sleep quality and duration, making it an option for managing insomnia disorder (Zheng et al., 2022).

Ethical considerations at this point are important as they can impact the treatment plan and communication with the patient. For example, in order to change the medication, I will need to discuss this change with the patient. This means being honest with them about the progress of their condition and the risks associated with the new medication and, at the same time, avoiding being coercive.

Decision #3

My third decision is to use Hydroxyzine 50mg tab PO at bedtime. The use of Hydroxyzine 50mg was the last option to select. This decision was guided by the fact that Hydroxyzine 50mg is an antihistamine medication that can help manage insomnia by blocking the brain’s histamine receptors. The use of 50mg of Hydroxyzine, especially at bedtime, induces drowsiness, which can help the patient fall asleep faster and remain asleep.

The decision to select Hydroxyzine 50mg over the other two options was based on the patient’s condition and their existing medical history. It also considered the side effects of each available option and its efficiency and effectiveness in introducing and maintaining sleep. Although Hydroxyzine 50mg has major concerning side effects as compared to options selected in decisions 1 and 2, it is better than the options available for decision point three. The only major concern for the use of Hydroxyzine 50mg is prolonged periods of dry mouth (Burgazli et al., 2023).

By using 50mg of Hydroxyzine at bedtime, the patient was expected to get drowsy and help them fall asleep faster as well as remain asleep for the longest time possible. The medication was also expected to manage any allergies that could affect their ability to fall and remain asleep. From the available evidence, hydroxyzine has been shown to effectively improve sleep making it a short-term option for the management of insomnia in cases where other therapeutical methods have failed (Burgazli et al., 2023).

Ethical considerations such as informing the patient of some possible side effects of Hydroxyzine 50mg may influence their willingness to use the medication. This may affect the treatment plan as the medication option cannot be added to the plan without the patient’s consent.

Conclusion

Zolpidem 10mg is the first-line therapy for insomnia as it has a higher efficiency of action in effecting sleep and maintaining sleep. It also presents fewer risks for side effects compared to trazodone 50mg and Hydroxyzine 50mg. Additionally, the recommended medications in decision points 1 to 3 are justifiable as they not only help manage insomnia but also address other underlying factors that may be contributing to the patient’s insomnia. For instance, based on the information provided on the patient’s history, the patient has been having problems adjusting to his normal life since the sudden loss of his fiancé. Issues with work and other concerns in their daily life besides insomnia present a case for anxiety and depression. Insomnia, poor work performance, and increased consumption of alcohol can be behavioral responses to the stress from the loss of his loved one and substance use to cope with insomnia. Therefore, the recommended medications address not only the insomnia issue but also anxiety and depression. For instance, trazodone has anti-depressive effects, which can help manage agitation (Gonçalo & Vieira-Coelho, 2021). This option can manage both insomnia and other mental health issues affecting the patients for better sleep management outcomes. In conclusion, treatment decisions must consider the patient’s individual needs, medical history, and other risks associated with different medication options for their health problem. The patient should also be made a part of the decision-making process when selecting medication options and developing the treatment as part of the provider’s ethical obligations.

 References

Bouchette, D., Akhondi, H., & Quick, J. (2022). Zolpidem. XPharm: The Comprehensive Pharmacology Reference, 1–5. https://doi.org/10.1016/B978-008055232-3.62888-0

Burgazli, C. R., Rana, K. B., Brown, J. N., & Tillman, F. (2023). Efficacy and safety of hydroxyzine for sleep in adults: Systematic review. Human Psychopharmacology: Clinical and Experimental, 38(2), e2864. https://doi.org/10.1002/HUP.2864

Fatemeh, G., Sajjad, M., Niloufar, R., Neda, S., Leila, S., & Khadijeh, M. (2022). Effect of melatonin supplementation on sleep quality: a systematic review and meta-analysis of randomized controlled trials. Journal of Neurology, 269(1), 205–216. https://doi.org/10.1007/S00415-020-10381-W

Gonçalo, A. M. G., & Vieira-Coelho, M. A. (2021). The effects of trazodone on human cognition: a systematic review. European Journal of Clinical Pharmacology, 77(11), 1623–1637. https://doi.org/10.1007/S00228-021-03161-6/FIGURES/2

Xiang, T., Cai, Y., Hong, Z., & Pan, J. (2021). Efficacy and safety of Zolpidem in the treatment of insomnia disorder for one month: a meta-analysis of a randomized controlled trial. Sleep Medicine, 87, 250–256. https://doi.org/10.1016/J.SLEEP.2021.09.005

Zheng, Y., Lv, T., Wu, J., & Lyu, Y. (2022). Trazodone changed the polysomnographic sleep architecture in insomnia disorder: a systematic review and meta-analysis. Scientific Reports 2022 12:1, 12(1), 1–11. https://doi.org/10.1038/s41598-022-18776-7

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SUBJECTIVE

The patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job as a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/APAP (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states that he has been using alcohol to help him fall asleep, approximately four beers prior to bed.

MENTAL STATUS EXAM

The patient is alert and oriented to person, place, time, and event. He makes good eye contact and is dressed appropriately for the time of year. He denies auditory/visual hallucinations. Judgment, insight, and reality contact are all intact. The patient denies suicidal/homicidal ideation and is future-oriented.

Decision #1 (1 page)
Which decision did you select? Zolpidem 10mg PO at bedtime
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page) trazodone 50mg PO at bedtime
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page) Hydrozyxine 50mg tab PO at bedtime
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.