Sleep agents in ICU

Q: Trazadone is now used with increasing frequency in ICU as a sleep aid. Trazadone is a 

 A) Melatonin receptor agonist 
B) Serotonin modulator 
C) Nonbenzodiazepine benzodiazepine receptor agonist 
D) Second-generation antihistamine 
E) Barbiturate


Answer: B

Sleep disturbance in ICU is a major problem. Non-pharmacological interventions play a major role, but very frequently requires pharmacological interventions.

Trazadon is a serotonin modulator and has shown to be very effective. 

 Another very effective and increasingly used medicine is melatonin receptor agonists like ramelteon, which is found to be of particular help in older patients as a sleep aid and an anti-delirium agent.

Zolpidem, eszopiclone/zopiclone, and zaleplon are nonbenzodiazepine benzodiazepine receptor agonists. They were introduced in ICU with a lot of fanfare but fastly lost the attraction with increasing reports of high association with delirium and other cognitive issues. 

 Antihistamines are around for a long time, and expect to stay despite their anticholinergic effects!

 Barbiturates are not ideal to be used as a sleep aid in ICU.


#pharmacology


References:  

1.  Kanji S, Mera A, Hutton B, et al. Pharmacological interventions to improve sleep in hospitalised adults: a systematic review. BMJ Open 2016; 6:e012108. 

2. Hatta K, Kishi Y, Wada K, et al. Preventive effects of ramelteon on delirium: a randomized placebo-controlled trial. JAMA Psychiatry 2014; 71:397. 

3. Doroudgar S, Chou TI, Yu J, et al. Evaluation of trazodone and quetiapine for insomnia: an observational study in psychiatric inpatients. Prim Care Companion CNS Disord 2013; 15. 

4.  Richards K, Rowlands A. The impact of zolpidem on the mental status of hospitalized patients older than age 50. Medsurg Nurs 2013; 22:188. 

5.  Kolla BP, Lovely JK, Mansukhani MP, Morgenthaler TI. Zolpidem is independently associated with increased risk of inpatient falls. J Hosp Med 2013; 8:1. 

6. Vande Griend JP, Anderson SL. Histamine-1 receptor antagonism for treatment of insomnia. J Am Pharm Assoc (2003) 2012; 52:e210.