Innovations in the treatment of insomnia
Recently, insomnia has become a common health disorder. Literature indicates that 10 to 35 percent of people complain of insomnia. It is a frequent symptom of various somatic and mental disorders, but it can also be the sole ailment of a patient. According to numerous epidemiological and clinical studies, untreated or improperly treated insomnia often recurs and becomes chronic. Problems caused by insomnia manifest during the day and can lead to severe or even life-threatening consequences (e.g., traffic accidents), worsen health conditions, exacerbate comorbidities, increase morbidity, and mortality.
Definition and Symptoms of Insomnia
Insomnia is a condition where the quality and/or duration of sleep are unsatisfactory for a relatively long period. Patients suffering from insomnia often complain of difficulty falling asleep, less frequently - poor sleep quality and early awakening or both of these symptoms. If insomnia recurs, there may be a fear of insomnia and excessive worry about its consequences.
Insomnia is classified into 3 types based on duration: short-term, transient, and chronic. Short-term insomnia lasts for a few weeks. Transient insomnia manifests as brief recurring episodes. If insomnia persists for more than 3 weeks on many nights, it is considered chronic or long-term.
Based on severity, insomnia is categorized as mild (occurs almost every night but has little impact on quality of life), moderate (poor sleep every night, accompanied by fatigue, anxiety, irritability), and severe (poor sleep constantly, prominent fatigue symptoms, anxiety disorder, irritability, and poor quality of life).
Treatment of Insomnia
Insomnia can be treated with non-pharmacological methods (sleep hygiene, cognitive behavioral therapy (CBT), relaxation, sleep deprivation) and medications.
Non-pharmacological treatments aim to reduce the intensity of stimuli reaching the brain cortex. For example, by following sleep hygiene rules, the patient is encouraged to go to bed and get up at the same time every day, create a suitable sleep environment, etc.
Pharmacological treatment of insomnia
The problem of treating insomnia is far from solved. Insomnia has most commonly been treated with benzodiazepines (BZDs). These drugs are still widely used to treat insomnia, although there is insufficient evidence of the long-term effectiveness of BZDs. Prolonged use of BZDs leads to dependence, tolerance, cognitive function impairment, increased risk of falls, especially in older adults. It is widely acknowledged that BZDs should be used for treating insomnia for as short a time as possible: it is recommended not to use them for more than
4-6 weeks, as the sedative effect weakens over time, increasing the risk of dependence and abuse. The American Psychiatric Association (APA) emphasizes that long-term treatment of insomnia with BZDs is particularly harmful to older adults because the muscle-relaxing effect of BZDs can increase the risk of falls.
Currently, Z-drugs are universally recommended for treating insomnia, as they are safer, rarely cause dependence or tolerance, and are more effective than BZDs. Therefore, Z-drugs are chosen as first-line agents for treating insomnia in the treatment algorithm. These drugs help avoid the undesirable effects of BZDs: increasing tolerance and dependence, withdrawal symptoms, psychomotor impairment, and cognitive function deterioration.
When selecting drugs to treat insomnia, it is essential to assess their safety, tolerability, risk of dependence, and half-life (HL). The patient's well-being during the day depends on the drug's HL - the shorter the HL, the fewer daytime side effects.
Zopiclone - a new Z-drug sedative
The new Z group drugs, like BZD, bind to gamma-aminobutyric acid (GABA) receptors, but are more specific to certain receptor subtypes. It has been determined that BZD binds to two GABA receptor sites: omega 1 and omega 2. When BZD binds to the omega 1 site, a sedative effect occurs, and with omega 2 - cognitive functions, especially memory, are impaired. The new hypnotic drugs selectively bind to the omega 1 receptor site and, unlike BZD, do not disrupt memory functions and do not cause retrograde amnesia. These drugs act briefly, helping to fall asleep quickly, and the next day there is no noticeable sedation, sleep stages are not disturbed. When using the new hypnotic drugs, dependence and tolerance develop less frequently.
One of the new non-benzodiazepine hypnotic drugs is zopiclone. It is classified as a cyclopyrrolone based on its chemical structure, characterized by a strong hypnotic effect. Since zopiclone acts briefly (half-life 3.5-6.5 hours), there are no residual sedation effects the next day, the patient does not feel drowsy. The usual dose of zopiclone is 7.5 mg per night. Placebo-controlled studies have shown that it effectively accelerates falling asleep, prolongs sleep duration, and reduces the number of awakenings.
A clinical trial evaluated whether withdrawal symptoms occur after discontinuing zopiclone treatment. It was found that after 9 months, the frequency of withdrawal symptoms in the group of patients who discontinued zopiclone treatment and in the group of patients who continued treatment was the same. This indicates that individuals who stopped taking zopiclone did not experience withdrawal symptoms. According to other study data, after discontinuing zopiclone, short-term insomnia may occur, but much less frequently than when taking BZD.
It should be noted that zopiclone prolongs the slow-wave sleep phase, which shortens with age, thus improving sleep quality.
Zopiclone, among the new non-benzodiazepine Z group hypnotic drugs, stands out in that it causes not only a hypnotic but also a strong anxiolytic effect, which has been clinically proven. Zopiclone has a relatively higher affinity for many GABA receptor subtypes, thus it suppresses anxiety much more strongly than other Z group drugs. Since anxiety is one of the most important factors in insomnia, zopiclone's anxiolytic effect can be very effective in treating insomnia. And due to zopiclone's longer half-life compared to other new hypnotic drugs, it is beneficial for prolonging sleep duration in individuals who often wake up.
Summary
Insomnia - the most common sleep disorder. About a third of the population suffers from it. It worsens quality of life, causes severe social and economic consequences, worsens health, exacerbates comorbidities, increasing morbidity and mortality. Insomnia has many causes. As a comorbid disorder, it often occurs in somatic, neurological, and psychiatric diseases.
Insomnia is treated with non-drug methods and medications. Benzodiazepines are used to treat insomnia only in exceptional cases. The first-line drugs for insomnia now are Z group hypnotic drugs. One of the Z group hypnotic drugs, zopiclone, is particularly useful for those who have difficulty falling asleep, wake up frequently, and are troubled by anxiety. It improves sleep quality.
Prepared by Dr. A. Pilkauskas
