Side Effect: Insomnia

What is Insomnia?

Insomnia is commonly thought of as trouble sleeping, but there are different types of insomnia that are important to understand as the approach to preventing or treating these different types may differ.

Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and not being able to fall back asleep. One or more of these components of sleep disturbance can coexist. Each type of insomnia decreases either the quality of sleep, the quantity of sleep, or both and can result in feelings of exhaustion, irritability, and difficulty concentrating during the day.

What does Insomnia look like?

Insomnia can look different in different people. Some people may have trouble falling asleep, while others may wake up frequently during the night. Some may wake up too early in the morning and have difficulty falling back asleep. Insomnia can also vary in duration, with some individuals experiencing it only occasionally and others experiencing it on a long-term basis such as weeks, months, or even years.

Who gets Insomnia?

Anyone can develop insomnia, but certain factors may increase the likelihood of developing the disorder. These include stress, anxiety, depression, certain medications, caffeine and alcohol consumption, shift work, and medical conditions such as chronic pain, asthma, and restless leg syndrome. Women are also at higher risk of developing insomnia than men.

Studies have shown that 31-54% of newly diagnosed or recently treated cancer patients report difficulty sleeping. Additionally, up to 23-44% of breast cancer patients experience insomnia symptoms several years after diagnosis.

How to prevent Insomnia

To prevent insomnia, individuals can practice good sleep hygiene habits such as maintaining a regular sleep schedule, avoiding caffeine and alcohol before bedtime, creating a relaxing sleep environment, and engaging in relaxation techniques such as focused meditation.

Looking for factors that contribute continued sleep disturbance can be beneficial. For example, some people with insomnia may spend more time in bed in an attempt to “catch up” on sleep. However, Increased time in bed may fuel hyperarousal and contribute to continued problems with insomnia.

How do you treat insomnia in cancer patients?

In patients with cancer, insomnia can be a common side effect of both the disease and its treatments. Insomnia in cancer patients can be particularly challenging to treat, as traditional sleep medications may interact with cancer treatments or be less effective due to multiple factors driving different types of insomnia.

For example, a person might drink alcohol in an attempt to calm anxiety that is causing them to have difficulty falling asleep, but the alcohol itself may contribute to early waking and poor sleep quality thereby changing the type of insomnia, rather than fixing it.
In certain instances, referral to a sleep specialist can be useful when patients have symptoms of other sleep disorder, such as excessive daytime sleepiness (e.g. sleep apnea, or narcolepsy,) issues with loud snoring, or when a loved one notices that their family member stops breathing for short periods of time when sleeping (apneas), or an unusual sleep behavior or injury (parasomnia).

When sleep hygiene methods alone do not fix the insomnia, medications may be useful in certain circumstances. To avoid long-term dependency upon sleep medications, and to determine the optimal approach, discuss with your doctor non-nightly dosing when possible, combine this with sleep hygiene and behavioral treatments, and regularly re-evaluate whether the plan is working.

Here are some examples of medications used for insomnia in patients with cancer:

Prescription medications for insomnia:

• Benzodiazepines
  • Diazepam (Valium®)
  • Lorazepam (Ativan®)
  • Temazepam (Restoril®)
  • Triazolam (Halcion®)
  • Flurazepam (Dalmane®)
    • NOTE: may cause excessive daytime sleepiness because of its long half-life
•  Non-benzodiazepine
  • Zolpidem (Ambien®)
  • Zaleplon (Sonata®)
    • NOTE: useful for falling asleep, but not staying asleep because of its short half-life
  • Eszopiclone (Lunesta®)

Important note about benzodiazepines and non-benzodiazepines: Potential side effects of BzRA hypnotics include morning sleepiness, loss of memory of events occurring shortly after you take the medication, impaired balance and an increased risk of falling and subsequent hip fractures. Other side effects, although rare, may include complex sleep-related behaviors such as sleepwalking, or sleep-related eating.

• GABA analog
  • Gabapentin (Neurontin®)
  • Pregabalin (Lyrica®)
•  Antidepressant
  •  Trazodone
    • NOTE: useful for falling asleep, but may cause morning grogginess if taken late in evening
•  Antihistamines
  • Hydroxyzine (Atarax®)
• Tricyclic antidepressant
  • Doxepin
    
    • NOTE: when used for insomnia, the doses are much lower than doses used for depression. Doxepin dose range for insomnia is 3 mg to 6 mg
• Melatonin receptor agonist
  • Ramelteon (Rozerem®)
• Sedating antipsychotic drugs:
  • Olanzapine (Zyprexa®)
  • Quetiapine (Seroquel®)
  • Risperidone (Risperdal®)

Important note about antipsychotic drugs used for insomnia: If prescribed for another FDA-approved condition, these medications should be taken at night at bedtime when possible because they often cause sedation. However, due to the potential for serious adverse effects, including weight gain and heart problems when used long-term, doctors should carefully consider alternative medications to prescribing antipsychotic medications for insomnia.

Non-prescription, over-the-counter, medications for insomnia:

• Antihistamines
  • Diphenhydramine (Benadryl®)
  • Doxylamine (Unisom®)
• Melatonin

In certain instances, referral to a sleep specialist can be useful when patients have symptoms of other sleep disorder, such as excessive daytime sleepiness (e.g. sleep apnea, or narcolepsy,) issues with loud snoring, or when a loved one notices that their family member stops breathing for short periods of time when sleeping (apneas), or an unusual sleep behavior or injury (parasomnia).

Non-pharmacological approaches to treating insomnia in cancer patients include cognitive-behavioral therapy for insomnia (CBT-I), which has been shown to be effective in reducing insomnia severity and improving quality of life in cancer patients. Other approaches may include relaxation techniques, such as progressive muscle relaxation or guided imagery.

If insomnia is related to restless leg syndrome, it is important to check for iron deficiency even in those who do not have anemia (low hemoglobin or red blood cells) as low iron levels in the body can contribute to restless legs.