What is the most appropriate medication adjustment for a 60-year-old woman with insomnia, taking acetaminophen, furosemide, and ineffective melatonin, following a left knee replacement for severe primary osteoarthritis?

From the Guidelines

The most appropriate medication change for this patient is to discontinue furosemide (option D). The patient's insomnia appears to be directly related to nocturia (waking up to urinate at night), which is likely caused by the evening dose of furosemide, a loop diuretic. Furosemide has a relatively short half-life and causes increased urine production, so taking it in the evening predictably leads to nighttime urination. Since the medication was prescribed for end-of-day ankle and foot edema, it would be more appropriate to take it in the morning to avoid disrupting sleep. This change would allow the diuretic effect to occur during daytime hours rather than at night. Additionally, the edema appears to be localized to the surgical leg and is likely post-operative in nature rather than due to a condition requiring ongoing diuretic therapy.

According to the American Academy of Sleep Medicine clinical practice guideline for the pharmacologic treatment of chronic insomnia in adults 1, the use of melatonin is not recommended as a treatment for sleep onset or sleep maintenance insomnia. The guideline suggests that clinicians not use melatonin as a treatment for sleep onset or sleep maintenance insomnia (versus no treatment) in adults, based on trials of 2 mg doses of melatonin. Therefore, increasing the melatonin dosage (option E) or changing to zolpidem (option C) may not be the most effective approach.

The other options, such as adding oxybutynin (option A) or temazepam (option B), may help with sleep but do not address the underlying cause of the patient's insomnia, which is the nocturia caused by the furosemide. Discontinuing the furosemide would address the root cause of her sleep disturbance rather than adding medications to treat the symptoms.

Some key points to consider in this case include:

• The patient's insomnia is likely caused by the evening dose of furosemide
• Discontinuing furosemide would address the root cause of her sleep disturbance
• The American Academy of Sleep Medicine clinical practice guideline does not recommend the use of melatonin for sleep onset or sleep maintenance insomnia 1
• Adding other medications, such as oxybutynin or temazepam, may not address the underlying cause of the patient's insomnia.

From the FDA Drug Label

Dosage and Administration While the recommended usual adult dose is 15 mg before retiring, 7.5 mg may be sufficient for some patients, and others may need 30 mg. In transient insomnia, a 7.5 mg dose may be sufficient to improve sleep latency. In elderly or debilitated patients, it is recommended that therapy be initiated with 7. 5 mg until individual responses are determined. The most appropriate medication change is to add a medication that will help with sleep latency and duration, considering the patient's age and medical history.

• The patient is already taking melatonin, which is ineffective, so changing to another sleep aid may be necessary.
• Option B, add temazepam at night, as needed, is a viable choice, given the patient's transient insomnia and the recommended dosage for elderly patients, which is 7.5 mg before retiring 2.

From the Research

Medication Change Options

The patient is experiencing insomnia and nocturia, which may be related to her current medication regimen. Considering her symptoms and medical history, the following options are available:

• A. add oxybutynin at night: This option is not directly supported by the provided evidence.
• B. add temazepam at night, as needed: This option is not directly supported by the provided evidence.
• C. change melatonin to zolpidem: This option is not directly supported by the provided evidence.
• D. discontinue furosemide: According to 3, discontinuation of furosemide can lead to decreased PaCO(2) in patients with COPD, but its effect on nocturia is not directly addressed. However, 4 suggests that staggered furosemide and desmopressin can reduce nocturnal voids, implying that furosemide may contribute to nocturia.
• E. increase melatonin dosage: This option is not directly supported by the provided evidence.

Nocturia Treatment

The study 4 investigated the efficacy of staggered furosemide and desmopressin in treating nocturia in the elderly. The results showed a significant reduction in nocturnal voids and improved sleep quality. This suggests that adjusting the patient's furosemide regimen, rather than discontinuing it, might be beneficial in addressing her nocturia.

Furosemide Pharmacokinetics

The pharmacokinetics of furosemide are complex and can be affected by various factors, including disease states and organ function 5, 6. However, these studies do not provide direct guidance on managing the patient's nocturia and insomnia.

Medication Adherence

The patient's adherence to her medication regimen may also be a factor in her symptoms. As noted in 7, medication adherence can be challenging, especially in patients with multimorbidity. Ensuring the patient understands her medication regimen and addressing any potential issues with adherence may be important in managing her symptoms.