What medication can be given to a patient in the cardiac care unit (CCU) for insomnia?

From the Guidelines

For patients in the cardiac care unit (CCU) experiencing insomnia, I recommend starting with non-pharmacological approaches and considering eszopiclone (2-3mg) or zolpidem (10mg) as a treatment option, as suggested by the American Academy of Sleep Medicine clinical practice guideline 1. When managing insomnia in the CCU, it's essential to prioritize the patient's cardiac condition and potential interactions with other medications.

• Non-pharmacological approaches, such as maintaining a quiet environment, dimming lights, and minimizing disruptions, should be the initial step in managing insomnia.
• If medication is necessary, eszopiclone (2-3mg) or zolpidem (10mg) may be considered, as they have been suggested for the treatment of sleep onset and sleep maintenance insomnia in adults 1.
• Other options, such as zaleplon (10mg) or temazepam (15mg), may also be considered, but with careful cardiac monitoring due to potential cardiovascular effects.
• It's crucial to start with the lowest effective dose and monitor vital signs, especially in patients with heart failure, arrhythmias, or those on multiple cardiac medications.
• The goal is to improve sleep while maintaining cardiovascular stability, and the treatment plan should be individualized based on the patient's specific needs and medical history. Key considerations include:
• The patient's specific cardiac condition and potential interactions with other medications
• The risk of respiratory depression and the need for careful monitoring
• The importance of starting with the lowest effective dose and titrating as needed
• The need for ongoing assessment and adjustment of the treatment plan to ensure optimal outcomes.

From the FDA Drug Label

Zolpidem tartrate is used in adults for the short-term treatment of a sleep problem called insomnia (trouble falling asleep).

• Zolpidem can be given to a patient in the cardiac care unit (CCU) for insomnia 2.
• The patient should be warned against driving and other activities requiring complete mental alertness if zolpidem is taken, especially if the patient has less than a full night of sleep remaining (7 to 8 hours) 2.
• Zolpidem may cause serious side effects, including getting out of bed while not being fully awake and doing an activity that the patient does not know they are doing 2.

From the Research

Medication Options for Insomnia in the Cardiac Care Unit (CCU)

• Non-benzodiazepine hypnotics such as zolpidem, zolpidem-controlled release, zaleplon, zopiclone, eszopiclone, and the melatonin receptor agonist ramelteon are generally well tolerated and have favorable safety profiles compared to older benzodiazepines and barbiturates 3.
• These medications can be considered for patients in the CCU with insomnia, but it is essential to weigh the benefits and risks, including the potential for dependence and abuse.
• Short-acting benzodiazepines, such as lorazepam and triazolam, can also be used to treat insomnia, but their use should be carefully monitored due to the risk of adverse effects, particularly in elderly patients 4.

Non-Pharmacological Interventions for Insomnia

• Non-pharmacological interventions, such as cognitive behavioral therapy for insomnia (CBT-I), relaxation techniques, exercise, massage, acupressure, aromatherapy, music, eye mask, and earplugs, can be effective in improving sleep quality in patients with insomnia 5, 6.
• These interventions can be particularly useful in the CCU setting, where patients may be experiencing stress, anxiety, and discomfort that can disrupt sleep.
• A systematic review and meta-analysis found that non-pharmacological interventions can significantly improve sleep quality, reduce pain intensity, and alleviate anxiety in post-operative cardiac patients 6.

Patient Preferences and Education

• Patients' preferences and attitudes towards non-pharmacological interventions for insomnia should be considered, and educational programs can help inform patients and healthcare providers about the benefits and risks of different treatment options 7.
• Female patients and those taking short-acting benzodiazepines may be more willing to try non-pharmacological interventions, and patients who are interested in these therapies often prefer massage therapy, sleep hygiene, music, and relaxation techniques 7.