What is a good medication for shift worker insomnia (SWI)?

Medication Options for Shift Worker Insomnia

For shift worker insomnia (SWI), the recommended first-line pharmacological treatment is modafinil or armodafinil, which have been specifically FDA-approved for excessive sleepiness associated with shift work disorder. 1, 2, 3

First-Line Pharmacological Options

• Armodafinil reduces sleepiness by approximately one point on the Karolinska Sleepiness Scale and increases alertness by 50 ms in reaction time tests in patients with shift work sleep disorder (moderate quality evidence) 2
• Modafinil shows similar effects on reducing sleepiness and improving alertness in shift work disorder patients (moderate quality evidence) 2, 3
• Both medications are specifically indicated for the excessive sleepiness component of shift work disorder, with documented efficacy in clinical trials 1, 3

Second-Line Pharmacological Options

• Melatonin (1-10 mg) taken before daytime sleep after night shifts may increase sleep length by approximately 24 minutes compared to placebo (low quality evidence) 2, 4
• A randomized, double-blind, placebo-controlled study showed melatonin (3 mg) taken 30 minutes before sleep improved sleep efficiency from 82.1% to 85.5% and decreased sleep onset latency in shift workers with difficulty falling asleep 4
• Caffeine combined with pre-shift naps has shown effectiveness in decreasing sleepiness during night shifts (low quality evidence) 2, 3

Non-Pharmacological Approaches to Consider

• Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the initial intervention for treating insomnia in general, though specific evidence for shift work disorder is limited 5
• Bright light therapy should be explored for all night-shift workers, particularly those with shift work disorder, to help partially re-entrain the circadian clock 3
• Strategic napping before shifts followed by caffeine consumption can improve excessive sleepiness in patients with shift work disorder 3

Treatment Algorithm for Shift Worker Insomnia

1. For excessive sleepiness during work shifts:

   • Start with modafinil (200 mg) or armodafinil (150 mg) taken approximately 1 hour before the start of the night shift 1, 2
   • Monitor for adverse effects including headache, nausea, and blood pressure changes 2

2. For insomnia during scheduled sleep periods:

   • Melatonin (3-5 mg) taken 30 minutes before planned daytime sleep after night shifts 4, 2
   • If ineffective, consider short-term use of non-benzodiazepine hypnotics like zolpidem or eszopiclone 5, 6

3. Combined approach:

   • Implement bright light therapy during night shifts to help reset circadian rhythms 3
   • Strategic pre-shift napping combined with caffeine at the beginning of shifts 2, 3
   • Maintain consistent sleep-wake schedules even on days off when possible 7

Important Caveats and Pitfalls

• Modafinil and armodafinil have been associated with rare but serious skin reactions in post-marketing reports 2
• Hypnotics have limited evidence specifically for shift work disorder and should be used cautiously due to potential for dependence 5, 2
• Over-the-counter antihistamines (diphenhydramine) are not recommended for chronic insomnia management 5
• Trazodone (50 mg) is not recommended despite common use in clinical practice 5
• The effectiveness of pharmacological interventions may be enhanced when combined with behavioral approaches and good sleep hygiene 1, 3