What is the best approach to manage a 51-year-old patient with a history of insomnia and diabetes, currently on Glizide (Gliclazide) and Mounjaro (Tirzepatide)?

Management of Insomnia in a 51-Year-Old Patient with Diabetes on Gliclazide and Mounjaro

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be initiated as first-line treatment for this patient's insomnia, as it is the standard of care with sustained efficacy up to 2 years and is superior to pharmacotherapy for chronic insomnia. 1

Initial Assessment and Evaluation

Before initiating treatment, conduct a thorough evaluation focusing on:

• Duration and pattern of insomnia: Confirm difficulty falling or staying asleep for at least 1 month with resulting daytime impairment 2
• Medication review: While gliclazide and Mounjaro (tirzepatide) are not typically associated with insomnia, assess for any over-the-counter medications, caffeine-containing drugs, or other substances that may disrupt sleep 2
• Diabetes-related sleep disruption: Screen for nocturia, hypoglycemia concerns, and diabetes management needs that may interfere with sleep 2
• Comorbid conditions: Diabetes itself is associated with increased insomnia risk, and patients with insomnia are more likely to have multiple medical problems including diabetes 2

First-Line Treatment: Cognitive Behavioral Therapy for Insomnia (CBT-I)

The American College of Physicians provides a strong recommendation that all patients with chronic insomnia receive CBT-I as the initial treatment intervention. 1 The American Academy of Sleep Medicine designates CBT-I as the standard of care for chronic insomnia in adults of all ages. 1

Key Components of CBT-I

CBT-I combines multiple behavioral interventions that have met evidence-based criteria for efficacy: 2

• Sleep restriction/compression therapy: Limit time in bed to match actual sleep time, consolidating sleep and improving sleep efficiency 2
• Stimulus control: Establish consistent sleep-wake schedules and use the bed only for sleep 2
• Sleep hygiene education: Address behaviors that impair sleep, including frequent daytime napping, excessive time in bed, late evening exercise, insufficient bright light exposure, excess caffeine, evening alcohol, and environmental factors 2
• Cognitive restructuring: Address anxiety and anticipation about poor sleep 2

Implementation Details

• Treatment duration: Typically requires 4-8 sessions over 6 weeks 1
• Delivery format: In-person, therapist-led programs are most beneficial; digital CBT-I is an effective alternative when in-person therapy is unavailable 1
• Expected outcomes: CBT-I produces clinically meaningful improvements sustained for up to 2 years, unlike pharmacotherapy which shows degradation of benefit after discontinuation 1

Common Pitfalls to Avoid

• Do not prescribe hypnotics as first-line treatment: This violates guideline recommendations and deprives patients of more effective, durable therapy 1
• Do not rely on sleep hygiene education alone: While useful when combined with other modalities, sleep hygiene is usually inadequate by itself for severe, chronic insomnia 2
• Counsel patients about gradual improvement: Improvements are not immediate but are sustained over time 1

Diabetes Management Considerations

Current Medication Review

Mounjaro (tirzepatide) should be continued without adjustment for insomnia, as there is no evidence linking it to sleep disturbances. 3 Tirzepatide is administered once weekly subcutaneously and enhances glucose-dependent insulin secretion while reducing glucagon levels. 3

Gliclazide should also be continued, as sulfonylureas are not typically associated with insomnia. 2 However, monitor for hypoglycemia risk, particularly nocturnal hypoglycemia, which can disrupt sleep in patients with diabetes. 2

Sleep-Diabetes Interaction

• Screen for diabetes-related sleep disruption: Assess for symptoms of hypoglycemia during sleep, nocturia, and diabetes management needs (such as glucose monitoring or insulin administration) that may interfere with sleep 2
• Consider referral to sleep medicine: If sleep disorders such as obstructive sleep apnea are suspected (common in 24-86% of people with type 2 diabetes), refer to a sleep specialist 2
• Optimize glycemic control: Poor glycemic control can worsen sleep quality, and disrupted sleep can interfere with diabetes self-management 2

Second-Line Treatment: Pharmacotherapy (If CBT-I Fails or Is Unavailable)

Pharmacotherapy should only be considered after CBT-I has been attempted or when CBT-I is unavailable, using shared decision-making. 1, 4

Preferred Pharmacological Options

If pharmacotherapy becomes necessary:

• Low-dose sedating antidepressants: Trazodone (25-50 mg) or doxepin (3-6 mg) are preferred options 4
• Short-intermediate acting benzodiazepine receptor agonists: Zolpidem (5-10 mg), eszopiclone, or zaleplon may be considered as alternatives 4

Medications to Avoid

• Over-the-counter antihistamines: Lack efficacy data and have potential safety concerns 4
• Herbal supplements: Insufficient evidence for efficacy 4
• Melatonin: Has insufficient evidence to determine efficacy for chronic insomnia 1

Follow-Up and Monitoring

• Reassess sleep patterns: Use sleep logs after 2-4 weeks of CBT-I intervention 5
• Evaluate treatment response: Monitor improvement in sleep efficiency, total sleep time, and daytime functioning 5
• Monitor glycemic control: Ensure that improved sleep does not adversely affect diabetes management, and that diabetes management does not worsen sleep 2
• Consider sleep specialist referral: If insomnia persists despite CBT-I and appropriate pharmacotherapy, or if sleep apnea is suspected 2, 5

Special Considerations for This Patient

At age 51, this patient is approaching the age where sleep architecture naturally changes, but is not yet in the older adult category where additional age-specific considerations apply. 2 The presence of diabetes requires particular attention to:

• Hypoglycemia prevention: Ensure diabetes medications are not causing nocturnal hypoglycemia that disrupts sleep 2
• Nocturia management: Address urinary frequency if present, as this is common in diabetes and disrupts sleep 2
• Cardiovascular risk: Both diabetes and insomnia are associated with increased cardiovascular risk; addressing both conditions is important for overall health outcomes 2