Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night
BACKGROUND
This week, we examine a 31-year-old male who presents to the office with a chief complaint of insomnia.
SUBJECTIVE
Patient is a 31-year-old male. He states that his insomnia has gotten progressively worse over the past 6 months. Per the patient, he has never been a “great sleeper” but is now having difficulty both falling asleep and staying asleep at night. The problem began approximately 6 months ago after the sudden loss of his fiancé. The patient states this is affecting his ability to perform his job, which is a forklift operator at a local chemical company. The patient states he has used diphenhydramine in the past to sleep but does not like the way it makes him feel the morning after. He states he has fallen asleep on the job due to lack of sleep from the night before. The patient’s medical record from his previous physician states that he has a history of opiate abuse, which began after he broke his ankle in a skiing accident and was prescribed hydrocodone/apap (acetaminophen) for acute pain management. The patient has not received a prescription for an opiate analgesic in 4 years. The patient states recently he has been using alcohol to help him fall asleep, approximately four beers prior to bed.
MENTAL STATUS EXAM
The patient is alert and oriented to person, place, time, event. He makes good eye contact and is dressed appropriately for time of year. He denies auditory/visual hallucinations. Judgement, insight, and reality contact are all intact. Patient denies suicidal/homicidal ideation and is future oriented.
Decision Point One
Select what you should do:
Zolpidem: 10 mg daily at bedtime
Trazodone: 50–100 mg daily at bedtime
Hydroxyzine: 50 mg daily at bedtime
RESULTS OF DECISION POINT ONE
• Patient returns to clinic in 2 weeks.
• Patient states the medication “knocked him out” but felt he slept well.
• His new girlfriend was concerned as he woke up in the middle of the night and cooked breakfast, yet the patient has no recollection of the occurrence.
• Patient states that the medication helps him sleep especially well when taken with a beer right before bedtime. Patient denies auditory/visual hallucinations and is future oriented.
Decision Point Two
Select what you should do next:
Explain that priapism is a side effect of trazodone that should diminish over time. Continue dose
Discontinue trazodone. Initiate therapy with suvorexant 10 mg daily at bedtime
Decrease trazodone to 25 mg daily at bedtime
Decrease zolpidem to 5 mg daily at bedtime
RESULTS OF DECISION POINT TWO
• Patient returns to clinic in 2 weeks.
• Patient states his episodes of “nighttime activity” has greatly decreased.
• His girlfriend told him that one time in the 2 weeks he got up and was getting ready to go for a drive.
• Patient denies auditory/visual hallucinations and is future oriented.
• Patient states that he likes the way the zolpidem helps him sleep and “is good with continuing to take it if most of the time I sleep through the night undisturbed.”
•
Decision Point Three
Select what you should do next:
Maintain dose. Patient to return in 4 weeks for follow up appointment
Discontinue zolpidem 5 mg tablets. Initiate therapy with Intermezzo 5 mg sublingual tablet nightly at bedtime, as needed. Follow up in 4 weeks
Discontinue zolpidem. Initiate therapy with trazodone 50 mg nightly at bedtime. Instruct patient he may take up to 100 mg if 50 mg is ineffective. Follow up in 4 weeks
•
• Guidance to Student
• Zolpidem is a medication that has a host of negative side effects. It should not be the first choice of therapy due to these side effects. Caution must be exercised if prescribing this medication to a patient. The patient should be instructed not to mix the medication with alcohol or any other medication unless first speaking with their provider.
• In this case, the patient is experiencing complex sleep behavior. It is prudent as the patient’s healthcare provider to discontinue this medication and prescribe something different.
• Trazodone is a selective serotonin reuptake inhibitor that is a much safer choice. In adults you will want to start with 50mg at bedtime and titrate up as needed.
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