What is the best recommendation for a 46-year-old female with type-1 diabetes (T1D) and difficulty sleeping during daytime hours after starting overnight shifts?

From the Guidelines

For a 46-year-old female with type 1 diabetes experiencing difficulty sleeping during daytime hours after starting overnight shifts, I strongly recommend implementing a comprehensive sleep hygiene approach combined with careful diabetes management, as outlined in the most recent guidelines from 2025 1. This approach should include creating a completely dark sleeping environment using blackout curtains and an eye mask, and using earplugs or white noise machines to block daytime sounds.

• Maintaining a consistent sleep schedule even on days off, going to bed within 1-2 hours of arriving home from work, is crucial.
• For temporary assistance, short-term use of melatonin (1-3 mg) taken 30 minutes before bedtime may help regulate sleep cycles, as suggested by previous studies 1. Regarding diabetes management,
• adjusting insulin dosing schedules to align with the new sleep-wake cycle,
• with careful monitoring of blood glucose levels during this transition period, is essential to prevent complications. Additionally,
• avoiding caffeine at least 6 hours before planned sleep time,
• limiting screen exposure to blue light for 1-2 hours before sleep,
• and completing regular exercise at least 3-4 hours before attempting to sleep, can help improve sleep quality. These recommendations address both the circadian rhythm disruption from shift work and the additional complexity of managing type 1 diabetes, as blood glucose fluctuations can further disrupt sleep quality and the altered schedule can affect insulin requirements and timing, as highlighted in recent standards of care in diabetes-2025 1 and 2024 1.

From the FDA Drug Label

The effectiveness of modafinil tablets in improving wakefulness in patients with excessive sleepiness associated with SWD was demonstrated in a 12-week placebo-controlled clinical trial. The criteria include: 1) either, a) a primary complaint of excessive sleepiness or insomnia which is temporally associated with a work period (usually night work) that occurs during the habitual sleep phase, or b) polysomnography and the MSLT demonstrate loss of a normal sleep-wake pattern (i.e., disturbed chronobiological rhythmicity); and 2) no other medical or mental disorder accounts for the symptoms, and 3) the symptoms do not meet criteria for any other sleep disorder producing insomnia or excessive sleepiness (e.g., time zone change [jet lag] syndrome).

The best recommendation for a 46-year-old female with type-1 diabetes and difficulty sleeping during daytime hours after starting overnight shifts is to take modafinil prior to going to work to help her stay awake overnight. This is because modafinil has been shown to be effective in improving wakefulness in patients with shift work disorder (SWD) 2.

• Key points:
  • Modafinil is effective for SWD
  • The patient's symptoms are consistent with SWD
  • Modafinil can help improve wakefulness during night shifts
• Important consideration: The patient should be advised to continue taking her previously prescribed treatments for type-1 diabetes and to monitor her condition closely while taking modafinil 2.

From the Research

Recommendations for Improving Sleep

To address the difficulty sleeping during daytime hours experienced by a 46-year-old female with type-1 diabetes working overnight shifts, several options can be considered:

• Sleep Hygiene Practices: Engaging in sleep hygiene practices such as maintaining a consistent sleep schedule, creating a sleep-conducive environment, and avoiding stimulants before bedtime can help improve sleep quality 3.
• Melatonin Supplementation: Prolonged-release melatonin has been shown to improve sleep maintenance in diabetic patients with insomnia without affecting glucose and lipid metabolism 4.
• Caffeine Consumption: Caffeine can help alleviate impaired performance overnight, but its effects on sleep should be considered, and it should be consumed in moderation 5.
• Shift Work Schedule Optimization: Optimizing the shift work schedule to reduce circadian disruption, such as limiting consecutive night shifts and providing sufficient shift intervals, can help reduce health and safety risks 6.

Medication Considerations

When considering medication options, it's essential to evaluate the potential benefits and risks:

• Modafinil: While modafinil can help stay awake overnight, its use should be carefully considered, especially in individuals with type-1 diabetes, and is not directly recommended for improving sleep 3, 7.
• Ramelteon: Ramelteon is a melatonin receptor agonist that can help regulate sleep-wake cycles, but its effectiveness in shift workers with diabetes has not been specifically studied in the provided evidence.
• Propanolol: Propanolol is a beta-blocker that can help with relaxation, but its use as a sleep aid is not supported by the provided evidence.
• SNRI: SNRIs are typically used to treat depression and anxiety, and their use as a sleep aid is not recommended based on the provided evidence.

Additional Considerations

It's crucial to consult with a healthcare professional to determine the best course of action, considering individual circumstances and medical history. The provided evidence highlights the importance of addressing sleep disturbances in shift workers, particularly those with diabetes, to reduce health and safety risks 7, 6.