How can drowsiness be managed?

Management of Drowsiness

For medication-induced drowsiness, switch from first-generation antihistamines to second-generation antihistamines, as first-generation agents cause significant performance impairment even without subjective awareness of sedation. 1

Medication-Induced Drowsiness

First-Generation Antihistamines

• Avoid first-generation antihistamines (diphenhydramine, hydroxyzine, chlorpheniramine) as they cause drowsiness, performance impairment, and cognitive dysfunction even when patients deny feeling sedated 1
• Drivers taking first-generation antihistamines are 1.5 times more likely to be responsible for fatal automobile accidents, and workers experience impaired productivity and increased occupational accidents 1
• The common practice of dosing first-generation antihistamines only at bedtime still causes significant daytime drowsiness and performance impairment due to prolonged plasma half-lives and persistent end-organ effects 1
• Second-generation antihistamines (cetirizine, loratadine, fexofenadine) are strongly preferred as they produce minimal or no drowsiness, performance impairment, or anticholinergic effects 1

Cardiovascular Medications

• Adjust timing of medications that cause fatigue by administering diuretics and β-blockers at bedtime rather than during the day to avoid daytime drowsiness 1
• Review and de-escalate cardiovascular medications (digoxin, amiodarone, mexiletine) that may contribute to fatigue and drowsiness 1

Sedative-Hypnotics and Benzodiazepines

• Avoid benzodiazepines (lorazepam, diazepam) due to cognitive impairment, increased fall risk, and daytime sedation, particularly in older adults 1, 2
• Zolpidem and eszopiclone should be prescribed with caution as they cause cognitive impairment, increase fall risk, and produce next-morning impairment even at FDA-reduced doses 1
• Older adults are particularly vulnerable to psychomotor impairment, falls, fractures, and subdural hematomas from sedating medications 1

Excessive Daytime Sleepiness from Sleep Disorders

When Drowsiness Indicates Underlying Sleep Pathology

• Evaluate for obstructive sleep apnea (OSA) if patients report excessive snoring, gasping for air, observed apneas, or unexplained daytime drowsiness, particularly in head and neck cancer patients where OSA is prevalent 1
• Consider polysomnography for patients with sleep-disordered breathing or periodic limb movement disorder 1
• Treat primary sleep disorders with CPAP or BiPAP rather than stimulants alone 1

Pharmacologic Management of Refractory Daytime Sleepiness

• Methylphenidate 2.5-5 mg orally with breakfast is the first-line stimulant for refractory daytime sedation, with a second dose at lunch if needed (no later than 2:00 PM) 1
• Modafinil 200-400 mg daily is effective for excessive sleepiness in narcolepsy, obstructive sleep apnea (despite CPAP use), and shift work disorder, with onset of action within 1-2 days 1, 3
• Alternative options include dextroamphetamine and caffeine for refractory daytime sedation 1

Drowsiness from Insomnia Treatment

Avoiding Sedation While Treating Insomnia

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is first-line treatment and does not cause daytime drowsiness, unlike pharmacologic agents 4, 2, 5
• If pharmacotherapy is necessary, low-dose trazodone 25-50 mg at bedtime has lower risk of next-day sedation compared to benzodiazepines or Z-drugs 4, 2, 5
• Low-dose doxepin 3-6 mg at bedtime is an alternative with minimal anticholinergic effects and less daytime impairment 4, 2

Critical Pitfalls to Avoid

• Never assume patients are aware of their impairment: Performance deficits from first-generation antihistamines occur even when patients deny drowsiness 1
• Avoid combining sedating medications: Concomitant use of alcohol, sedatives, or antidepressants with antihistamines dramatically worsens performance impairment 1
• Do not use AM/PM antihistamine dosing strategies: Combining second-generation antihistamines in the morning with first-generation agents at night still produces significant daytime impairment 1
• Reassess regularly: Document sleep patterns with sleep logs after 2-4 weeks to objectively track whether interventions are reducing drowsiness without causing rebound effects 4, 2