In asthma, daily variation in airway resistance results in marked increases in asthmatic symptoms at night, especially during sleep. Treatment of asthma with theophylline-based compounds, adrenergic agonists, or glucocorticoids can independently disrupt sleep. Inhaled glucocorticoids that do not disrupt sleep may provide a useful alternative to oral drugs. Chronic obstructive pulmonary disease, pain from rheumatologic disorders or neuropathy, cystic fibrosis, hyperthyroidism, menopause, and gastroesophageal reflux are other causes.
Treatment: Insomnia Primary insomnia is a diagnosis of exclusion. - Treatment of a medical or psychiatric disease that may be contributing should be addressed first.
- Attention should be paid to improving sleep hygiene and avoiding counterproductive behaviors before bedtime (Table 56-1).
- Cognitive behavioral therapy emphasizes understanding the nature of normal sleep, the circadian rhythm, the use of light therapy, and visual imagery to block unwanted thought intrusions.
- Pharmacotherapy reserved for instances when insomnia persists after treatment of contributing factors. Antihistamines are the primary active ingredient in most over-the-counter sleep aids. Benzodiazepine receptor agonists are effective and well tolerated; options include zaleplon (5-20 mg), zolpidem (5-10 mg), triazolam (0.125-0.25 mg), eszopiclone (1-3 mg), and temazepam (15-30 mg). Heterocyclic antidepressants such as trazodone (25-100 mg) are often used due to their lack of abuse potential and lower cost. Limit use to a short period of time for acute insomnia or intermittent use for chronic insomnia.
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