What are the treatment options for insomnia in patients with Huntington's chorea?

Treatment of Insomnia in Patients with Huntington's Chorea

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for insomnia in patients with Huntington's chorea, with pharmacological options added only if CBT-I alone is unsuccessful. 1, 2

Non-Pharmacological Approaches

First-Line Treatment: CBT-I

• CBT-I consists of multiple components:
  • Cognitive therapy addressing sleep-related thoughts
  • Behavioral interventions (sleep restriction, stimulus control)
  • Sleep hygiene education
• Delivery methods include individual/group therapy, telephone/web-based modules, or self-help books
• Moderate-quality evidence shows CBT-I improves:
  • Global outcomes (increased remission, treatment response)
  • Sleep outcomes (reduced sleep onset latency, wake after sleep onset)
  • Sleep efficiency and quality 1

Additional Non-Pharmacological Options

• Image Rehearsal Therapy (IRT): Particularly effective for anxiety-related sleep disturbances, with up to 60% reduction in symptoms 2
• Progressive Deep Muscle Relaxation: Can reduce physiological arousal before bedtime 2
• Mindfulness-Based Techniques: Focus on nonjudgmental awareness of thoughts and sensations 2

Pharmacological Approaches (Second-Line)

Add medication only if CBT-I alone is unsuccessful, using a shared decision-making approach that discusses benefits, harms, and costs 1.

Medication Options for Insomnia in Huntington's Disease:

1. For Sleep Onset Insomnia:

   • Zolpidem: 10mg for adults, 5mg for elderly
   • Zaleplon: 10mg
   • Ramelteon: 8mg 2

2. For Sleep Maintenance Insomnia:

   • Doxepin: 3-6mg (low-quality evidence shows improvement in sleep outcomes) 1, 2
   • Eszopiclone: 2-3mg (low-quality evidence shows improvement in global and sleep outcomes) 1, 2
   • Temazepam: 15mg (recommended for both sleep onset and maintenance insomnia) 2
   • Suvorexant: 10-20mg 2

Special Considerations for Huntington's Disease

• Patients with Huntington's chorea commonly experience insomnia, difficulties falling asleep, frequent nocturnal awakenings, and excessive daytime sleepiness 3
• Consider medication interactions with chorea treatments:
  • Many HD patients are treated with VMAT2 inhibitors (tetrabenazine, deutetrabenazine) or antipsychotics for chorea 4, 5, 6
  • These medications may affect sleep patterns and should be considered when selecting insomnia treatments

Treatment Algorithm

1. Start with CBT-I as first-line treatment

   • Allow 4-6 weeks to evaluate effectiveness 2
   • Consider alternative delivery methods if in-person therapy is not feasible

2. If CBT-I is insufficient after adequate trial:

   • Add appropriate pharmacological therapy based on insomnia type (onset vs. maintenance)
   • Start with lowest effective dose, especially in elderly or debilitated patients
   • Monitor for side effects, particularly cognitive impairment which may compound HD symptoms

3. Follow-up within 2-4 weeks to assess effectiveness and side effects 2

Important Cautions

• Avoid long-term use of benzodiazepines and non-benzodiazepine hypnotics when possible

  • FDA warns about cognitive and behavioral changes, driving impairment, and other adverse effects 1
  • These risks may be particularly problematic in HD patients who already have cognitive impairment

• Consider medication burden in HD patients who are often on multiple medications for chorea, psychiatric symptoms, and other comorbidities 4, 7

• Monitor for depression and anxiety which commonly co-occur with HD and can exacerbate insomnia 3

• Melatonin has insufficient evidence to support its use for chronic insomnia disorder 1