What are the treatment options for insomnia and tachycardia?

Treatment of Insomnia and Tachycardia

Insomnia Treatment: Start with CBT-I, Not Medications

Cognitive Behavioral Therapy for Insomnia (CBT-I) must be initiated as first-line treatment before any pharmacological intervention for chronic insomnia. 1, 2, 3

Why CBT-I First

• CBT-I provides superior long-term efficacy compared to medications, with sustained benefits lasting up to 2 years without risk of tolerance, dependence, or adverse effects 2, 3, 4
• The American Academy of Sleep Medicine and American College of Physicians both designate CBT-I as the standard of care for all adults with chronic insomnia, including older adults and those with comorbid conditions 1, 3
• Improvements are gradual but durable, addressing the underlying mechanisms that perpetuate insomnia rather than just suppressing symptoms 2, 3

Core CBT-I Components to Implement

Multicomponent therapy must include at least three of these elements: 1, 3

• Stimulus control therapy: Go to bed only when sleepy, use bed only for sleep and sex, leave bedroom if unable to sleep within 15-20 minutes, maintain consistent wake time 3
• Sleep restriction therapy: Initially limit time in bed to match actual sleep duration (creating mild sleep deprivation to consolidate sleep), then gradually adjust based on sleep efficiency thresholds 3
• Cognitive therapy: Target maladaptive beliefs about sleep using structured psychoeducation, thought records, and behavioral experiments 3
• Relaxation training: Progressive muscle relaxation, diaphragmatic breathing, or guided imagery 1, 4

Critical caveat: Sleep hygiene education alone is ineffective as monotherapy and should only serve as an adjunct to other CBT-I components 1, 3

CBT-I Delivery Options

• Individual therapy (most effective, with incremental odds ratio of 1.83), group sessions, telephone-based programs, web-based modules, or self-help books all show effectiveness 2, 3
• Standard format: 4-8 sessions over 6 weeks with trained CBT-I specialist 3
• Brief Behavioral Therapy for Insomnia (BBT-I): Abbreviated 1-4 session version emphasizing behavioral components when resources are limited 3

Pharmacological Treatment Algorithm (Only After or Alongside CBT-I)

If CBT-I alone is insufficient after 2-4 weeks, add pharmacotherapy as a supplement—never as a replacement—while continuing behavioral interventions. 1, 2, 4

First-Line Pharmacological Options

For sleep onset difficulty: 2

• Zolpidem 10 mg (5 mg in elderly ≥65 years) 2, 5
• Zaleplon 10 mg 2
• Ramelteon 8 mg (particularly appropriate for patients with substance use history as it's non-DEA-scheduled) 2, 4

For sleep maintenance difficulty: 2

• Eszopiclone 2-3 mg 2
• Temazepam 15 mg 2
• Low-dose doxepin 3-6 mg 2
• Suvorexant (orexin receptor antagonist) 2

For both sleep onset and maintenance: 2

• Eszopiclone 2-3 mg 2
• Zolpidem 10 mg (5 mg in elderly) 2, 5
• Temazepam 15 mg 2

Second-Line Options

When first-line agents fail or contraindications exist: 1, 2

• Sedating antidepressants (trazodone, amitriptyline, mirtazapine) especially when comorbid depression/anxiety is present 1, 2
• Alternative benzodiazepine receptor agonists 1
• Daridorexant or lemborexant (newer orexin receptor antagonists with favorable safety profiles) 2, 6

Critical Safety Considerations

All hypnotics carry significant risks that must be discussed with patients: 2

• Daytime impairment, complex sleep behaviors (sleep-driving, sleep-walking), falls, fractures, and cognitive impairment 2
• Elderly patients (≥65 years) require lower doses (e.g., zolpidem maximum 5 mg) due to increased sensitivity and fall risk 2
• Use the lowest effective dose for the shortest duration possible, typically less than 4 weeks for acute insomnia 2
• Combining multiple sedative medications significantly increases risks 2

Medications NOT Recommended

Avoid these agents due to lack of efficacy data or problematic side effects: 2, 3, 4

• Over-the-counter antihistamines (diphenhydramine, hydroxyzine): lack efficacy data, cause daytime sedation and delirium risk especially in elderly 2, 4
• Trazodone: not recommended by American Academy of Sleep Medicine for sleep onset or maintenance insomnia 2
• Antipsychotics (quetiapine, olanzapine): should not be used as first-line due to metabolic side effects 2, 4
• Herbal supplements (valerian) and melatonin: insufficient evidence of efficacy 2
• Long-acting benzodiazepines: increased risks without clear benefit 2

Tachycardia Management Considerations

When insomnia coexists with tachycardia, the treatment approach must address both conditions while avoiding medications that worsen cardiac symptoms.

Key Principles

• Evaluate for underlying causes: anxiety disorders, hyperthyroidism, cardiac arrhythmias, medication side effects, or excessive caffeine/stimulant use 1
• CBT-I is particularly valuable as it addresses anxiety and arousal without cardiovascular effects 3
• Avoid stimulating medications and substances that can exacerbate tachycardia 3

Medication Selection When Both Conditions Present

If pharmacotherapy is needed alongside tachycardia: 2

• Ramelteon 8 mg is preferred as it has no cardiovascular effects and no abuse potential 2
• Low-dose doxepin 3-6 mg for sleep maintenance (minimal cardiac effects at this dose) 2
• Avoid medications that can worsen tachycardia or interact with cardiac medications 1

If comorbid anxiety and depression are present (common with both insomnia and tachycardia): 2

• Sedating antidepressants like mirtazapine are safe for cardiac patients and aid sleep 2
• Sertraline has lower QTc prolongation risk than citalopram/escitalopram 2

Common Pitfalls to Avoid

• Never use benzodiazepines or benzodiazepine receptor agonists as first-line without attempting CBT-I 1, 2, 3
• Never prescribe sleep medications long-term without periodic reassessment (every few weeks initially, then every 6 months) 1, 2
• Never rely on sleep hygiene education alone—it must be combined with other CBT-I components 1, 3
• Never use doses appropriate for younger adults in elderly patients without age-adjusted dosing 2
• Never fail to screen for underlying sleep disorders (sleep apnea, restless legs syndrome) if insomnia persists beyond 7-10 days of treatment 2, 4

Monitoring and Follow-Up

Reassess patients every 1-2 weeks initially to evaluate: 2, 4

• Efficacy on sleep latency, sleep maintenance, and daytime functioning 2
• Adverse effects including morning sedation, cognitive impairment, and complex sleep behaviors 2
• Sleep diary data should be collected before and during treatment 1

Long-term monitoring: 1

• Continue follow-up every few weeks until insomnia stabilizes or resolves 1
• Then reassess every 6 months, as relapse rate for insomnia is high 1
• Attempt medication tapering when conditions allow, facilitated by concurrent CBT-I 4