What medication can be given for insomnia in a 23-year-old female with stage 4 colon adenocarcinoma, lung and liver metastasis, and controlled pain on fentanyl (transdermal fentanyl) 12 micrograms?

From the Guidelines

For insomnia in a 23-year-old female with stage 4 colon adenocarcinoma, lung and liver metastasis, and controlled pain on fentanyl (transdermal fentanyl) 12 micrograms, I recommend starting with a non-benzodiazepine sedative-hypnotic such as eszopiclone (Lunesta) 2-3 mg orally at bedtime, as suggested by the American Academy of Sleep Medicine 1. This medication works by enhancing GABA effects in the brain to promote sleep without significantly affecting respiratory function, which is important given the patient is on an opioid. The choice of eszopiclone is based on its efficacy for both sleep onset and sleep maintenance insomnia, as well as its relatively favorable side effect profile compared to other options. If eszopiclone is ineffective or not tolerated, alternatives include zolpidem (Ambien) 5-10 mg orally at bedtime or zaleplon (Sonata) 10 mg orally at bedtime, as these medications have also been suggested by the American Academy of Sleep Medicine for the treatment of insomnia 1. It's essential to address any underlying causes of insomnia, such as pain breakthrough, anxiety, or depression, and to implement non-pharmacological approaches, including good sleep hygiene practices, cognitive behavioral therapy for insomnia, and relaxation techniques. Regular reassessment of both the insomnia and pain control is crucial, as cancer progression or tolerance to fentanyl could lead to breakthrough pain causing sleep disturbances. Given the patient's complex medical condition, it's also important to consider the potential for drug interactions and to monitor for signs of respiratory depression, especially when combining sedatives with opioids like fentanyl, as cautioned by the Annals of Oncology 1.

From the FDA Drug Label

The effect of eszopiclone on reducing sleep latency and improving sleep maintenance was established in studies with 2100 subjects (ages 18 to 86) with chronic and transient insomnia in six placebo-controlled trials of up to 6 months’ duration. Eszopiclone tablets are used in adults for the treatment of a sleep problem called insomnia. Take eszopiclone tablets exactly as prescribed. Do not take more eszopiclone tablets than prescribed for you.

Eszopiclone can be given for insomnia in a 23-year-old female with stage 4 colon adenocarcinoma, lung and liver metastasis, and controlled pain on fentanyl (transdermal fentanyl) 12 micrograms.

• The patient should take eszopiclone tablets exactly as prescribed by the doctor.
• The patient should not take eszopiclone tablets with or right after a meal.
• The patient should not take eszopiclone tablets unless able to get a full night’s sleep before being active again.
• The patient should be cautious of next-day residual effects, including impaired driving skills and decreased ability to think clearly 2.
• The patient should be monitored for potential side effects, including abnormal thoughts and behavior, memory loss, and anxiety 2.

From the Research

Medication Options for Insomnia

Given the patient's condition, with stage 4 colon adenocarcinoma, lung and liver metastasis, and controlled pain on fentanyl, the following medications can be considered for insomnia:

• Zolpidem: A non-benzodiazepine hypnotic that has been shown to be effective in treating insomnia 3, 4, 5, 6
• Eszopiclone: A non-benzodiazepine hypnotic that has been shown to be effective in treating insomnia and has a favorable profile, but may cause substantial adverse events 6
• Melatonin: A melatonergic receptor agonist that has demonstrated promising outcomes in treating insomnia and comorbid mood disorders 7
• Daridorexant and suvorexant: Dual orexin receptors antagonists that have demonstrated efficacy in treating insomnia and mood symptoms 7

Considerations

When considering medication options, the following factors should be taken into account:

• The patient's age and sex: Zolpidem has been shown to have a higher mean plasma concentration in women than men 4
• The patient's medical history: The patient's cancer diagnosis and metastasis should be considered when selecting a medication
• The patient's current medications: The patient is currently taking fentanyl, which may interact with certain medications
• The potential for adverse effects: Zolpidem has been associated with an increased risk of falls, hip fractures, and complex behaviors such as sleepwalking and hallucinations 4

Pharmacological Treatment

The pharmacological treatment of insomnia in patients with cancer is limited, and healthcare professionals should implement a comprehensive and multidisciplinary pathway from screening to management 3. The treatment of insomnia should involve a multi-disciplinary approach, focusing on implementing behavioral interventions, improving sleep hygiene, managing psychological stressors, hypnotic treatment, and pharmacological therapy 4.