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Sleep Disorders

Chronic Insomnia

06/21/2010

Question:

I have been taking 5 mg. Ambien for my chronic insomnia. It works well, but I would like to try something natural. Is the dosage of melatonin based on weight? Would taking melatonin on occasion help, or does it work best if taken on a nightly basis? Does melatonin interfere with any blood pressure medications (such as a beta blocker or calcium channel blocker) or with Synthroid?

Answer:

Insomnia is very common in modern society with an estimated 1/3 of Americans suffering from insomnia at any one point in time. Fortunately, the majority of cases are short-term and resolve within weeks, rarely requiring prolonged therapy. However, up to 20 million Americans complain of problems with chronic insomnia that may significantly effects their life, so you are not alone.

Insomnia has multiple underlying causes. Identifying the issues that may lead to and contribute to insomnia are extremely important to ensure appropriate treatment. Insomnia can usually be divided into two broad categories: trouble falling asleep at the start of the night (also known as sleep onset insomnia) and difficulty staying asleep during the night (also known as sleep maintenance insomnia). Some individuals may experience problems with both. As you can see, insomnia is a complex problem that requires a detailed evaluation to help sort out important underlying factors that may need to be addressed. This type of evaluation often starts with your primary care physician, but may require the help of specialist in insomnia. Referral to a Sleep Specialist is necessary in some cases.

Most cases of chronic insomnia can be managed without the use of sleep-inducing medications. If a specific cause of the insomnia can be identified, then treatment should be directed at that issue. Often times, behavioral therapy can be very effective for patients whose insomnia is the result of a poor sleep environment, poor sleep habits or psychological conditions. Improving “Sleep Hygiene” can make a dramatic impact in some cases (see the “Steps You Can Take to Improve Your Sleep” on the website).

Drug therapy is required to manage the insomnia of some individuals, though caution should be exercised with long-term use of some medications. Certain sleep agents, such as benzodiazepines, are often accompanied by daytime sleepiness, fatigue and problems with tolerance (or losing effectiveness over time). These effects may be seen less with some of the newer sleep-inducing medications such as zolpidem (Ambien) or zaleplon (Sonata), though chronic long-term use of these agents has not been well-studied. You seem to be tolerating ambien well and it appears to remain effective for you. However, due to the limited data on long-term use of this medication, you should be under the care of a physician with experience managing patients who take ambien.

You had asked about potentially switching to melatonin. Melatonin, a naturally occurring sleep-inducing substance, has been found to be variably effective for treating insomnia. It may play a role in treating some individuals who have insomnia and are lacking in normal melatonin secretion, but this does not appear to be common. It is probably most effective in treating those who have problems related to their underlying biologic or circadian rhythms, as melatonin will help to regulate these. Usually a dose of 1 mg at bedtime is adequate, though up to 5 mg can be used. The dosing is essentially by trial and error and is not weight based. Melatonin can be taken on an as-needed basis for insomnia, though should taken daily if it is being used to regulate your circadian rhythms. I am not aware of reports of melatonin interacting with synthroid. However, melatonin can interact with calcium channel blockers to raise the blood pressure, so I would avoid melatonin if you are taking a calcium channel blocker. Beta-blockers apparently can decrease melatonin levels, so higher doses of melatonin may be needed in those taking beta-blockers. Users of melatonin should be aware that this drug is not regulated by the FDA and thus there is no guarantee as to the quality of the drug.

To learn more about insomnia or other sleep disorders, please visit the American Academy of Sleep Medicine's website at www.aasmnet.org. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The American Insomnia Association website (at www.americaninsomniaassociation.org) also provides information and links to support groups for those with this condition. Good luck and here's to good sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University