What is the best approach to manage insomnia in a 67-year-old female patient with hypertension (HTN) and low high-density lipoprotein (HDL) who has already tried melatonin and magnesium glycinate?

From the Guidelines

For a 67-year-old female with hypertension, low HDL, and insomnia who has already tried melatonin and magnesium glycinate, the best approach would be to start with cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, which has proven efficacy without medication risks. This recommendation is based on the most recent and highest quality study, which suggests that CBT-I is the treatment of choice for chronic insomnia disorder in adults 1. CBT-I is a multicomponent intervention that includes sleep restriction therapy, stimulus control, and cognitive therapy, and has been shown to be effective in improving sleep outcomes and reducing symptoms of insomnia.

Some key points to consider when implementing CBT-I include:

• Sleep restriction therapy: limiting the time spent in bed to the actual time spent sleeping
• Stimulus control: associating the bed with sleep and removing distractions
• Cognitive therapy: addressing negative thoughts and beliefs about sleep
• Sleep hygiene: maintaining a consistent sleep schedule, avoiding caffeine and electronics before bedtime, and creating a relaxing sleep environment

If medication is necessary, low-dose trazodone (25-50mg at bedtime) or low-dose doxepin (3-6mg) may be considered, as they have a favorable cardiovascular profile and minimal impact on blood pressure or lipids 1. However, these medications should be used short-term (2-4 weeks) and in conjunction with CBT-I and sleep hygiene measures.

It's also important to note that benzodiazepines and Z-drugs (zolpidem, eszopiclone) should be avoided due to increased fall risk, cognitive impairment, and potential for dependence in older adults 1. This patient's cardiovascular conditions make it particularly important to choose treatments that won't exacerbate hypertension or further lower HDL levels, which is why non-pharmacological approaches and carefully selected medications with minimal cardiovascular effects are preferred.

From the FDA Drug Label

1. Dosage and Administration 2. 1 Dose Selection An initial dose of 150 mg/day in divided doses is suggested.

The patient has already tried melatonin and magnesium glycinate for insomnia. Trazodone can be considered as an alternative treatment option, given its sedating effects.

• The initial dose of Trazodone is 150 mg/day in divided doses, which may help with insomnia.
• However, it's essential to note that Trazodone is an antidepressant, and its use should be carefully evaluated, especially in patients with a history of bipolar disorder or other mental health conditions.
• The patient's hypertension and low HDL should also be considered when prescribing Trazodone, as it may interact with other medications or exacerbate these conditions.
• A conservative approach would be to start with a low dose and gradually increase as needed, monitoring the patient's response and potential side effects 2.

From the Research

Management of Insomnia

The patient, a 67-year-old female with hypertension (HTN) and low high-density lipoprotein (HDL), has already tried melatonin and magnesium glycinate for insomnia. Considering the available evidence:

• Cognitive-behavioral therapy for insomnia (CBT-I) is the treatment of choice for chronic insomnia, as stated in a 2019 study 3.
• A 2023 study comparing melatonin and trazodone for new-onset insomnia in hospitalized adult patients found no significant difference between the two agents in terms of treatment outcomes and adverse events 4.
• The SLEEPRIGHT clinical trial, scheduled for 2024, aims to evaluate whether CBT-I can improve markers of cardiovascular disease risk in patients with untreated hypertension and comorbid insomnia disorder 5.
• A 2021 pilot study found that trazodone, but not CBT-I, decreased fast-frequency EEG activity during non-rapid eye movement sleep in patients with chronic insomnia 6.
• A 2019 study on the effects of magnesium-melatonin-vitamin B complex supplementation in the treatment of insomnia found a beneficial effect in reducing insomnia symptoms 7.

Alternative Approaches

Given the patient's history of trying melatonin and magnesium glycinate, alternative approaches could be considered:

• CBT-I, as the gold standard treatment for insomnia, may be a viable option for this patient 3, 5.
• Trazodone, as an alternative pharmacological intervention, may be considered, especially if the patient has not responded to melatonin or has contraindications to its use 4, 6.
• Combination therapy, such as CBT-I with pharmacological interventions, may also be explored to enhance treatment outcomes 3.

Considerations for Hypertension and HDL

When managing insomnia in a patient with HTN and low HDL:

• It is essential to consider the potential impact of insomnia treatment on cardiovascular disease risk factors, as highlighted in the SLEEPRIGHT clinical trial 5.
• The choice of treatment should take into account the patient's overall health profile, including her hypertension and lipid profile.