Medications for Shift Work Sleep Disturbances
Modafinil is the first-line medication recommended for treating shift work sleep disturbances due to its established efficacy in improving alertness and reducing sleepiness in individuals with shift work sleep disorder. 1
First-Line Pharmacological Options
Modafinil: Recommended as first-line therapy for excessive sleepiness associated with shift work sleep disorder with typical doses ranging from 200-400 mg taken before the shift. For elderly patients, starting at 100 mg and titrating up weekly is recommended. Common side effects include nausea, headaches, and nervousness. 1
Armodafinil: An alternative first-line agent that reduces sleepiness by approximately one point on the Karolinska Sleepiness Scale and improves alertness in patients with shift work sleep disorder. 1, 2
Second-Line Pharmacological Options
Traditional stimulants: Methylphenidate or dextroamphetamine can be used for refractory daytime sedation, starting at 2.5-5 mg orally with breakfast. If needed, a second dose can be given at lunch (no later than 2:00 pm). 1
Caffeine: Can be used judiciously, with the last dose given no later than 4:00 pm. When combined with pre-shift naps, caffeine has been shown to decrease sleepiness during night shifts. 1, 2
Melatonin for Sleep Improvement
Melatonin: Low-quality evidence suggests melatonin (1-10 mg) taken after night shifts may increase daytime sleep length by approximately 24 minutes compared to placebo. 2, 3
Melatonin therapy (3 mg taken 30 minutes before sleep) has been shown to improve sleep onset latency and sleep efficiency in shift workers with difficulty falling asleep. 3
However, tolerance to melatonin's sleep-promoting effects may develop after the first day of administration, requiring further investigation. 4
Behavioral Approaches to Complement Medication
Maintain good sleep hygiene and a regular sleep-wake schedule allowing adequate time for sleep. 1, 5
Avoid heavy meals throughout the day and alcohol use. 1
Two short 15-20 minute naps, one around noon and another around 4:00-5:00 pm, may help alleviate sleepiness. 1, 5
Consider bright light therapy to partially re-entrain the circadian clock, particularly for night shift workers. 5
Monitoring and Follow-up
More frequent follow-up is necessary when starting medications or adjusting doses. 1
Monitor for adverse effects of stimulants, including hypertension, palpitations, arrhythmias, irritability, or behavioral manifestations such as psychosis. 1
Regularly reassess functional ability as medications like modafinil generally improve but do not eliminate sleepiness. 1
Important Considerations and Precautions
Individuals with shift work sleep disorder are at increased risk for gastrointestinal and cardiovascular diseases, as well as safety concerns due to excessive sleepiness. 6
For elderly patients or those with cognitive impairment, avoid benzodiazepines as they can cause decreased cognitive performance. 1
When using zolpidem, exercise caution due to the risk of next-morning impairment. Lower doses are recommended by the FDA (5 mg for immediate-release products and 6.25 mg for extended-release formulations). 1
Occupational counseling may benefit patients who are still employed, with recommendations to avoid shift work if possible. 1