Clinical Manual for Management of the HIV-Infected ... - myCME.com

8–14 | Clinical Manual for Management of the HIV-Infected Adult/2006
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Wake up at the same time each day regardless of
total hours of sleep.
Have a dark, quiet, comfortable environment
conducive to sleep.
If unable to fall sleep after 15-20 minutes, the
patient should get up, go into another room for
nonstimulating activity in dim light (such as
reading), and not go back to bed until sleepy.
The patient should discontinue use of caffeine,
central nervous system stimulants, alcohol, and
tobacco, with tapering if necessary to avoid
withdrawal symptoms.
Teach or refer the patient for relaxation techniques.
Pharmacotherapy
The following options are available:
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Antihistamines, such as diphenhydramine or
hydroxyzine 25-50 mg at bedtime (be aware of
anticholinergic adverse effects).
Sedating antidepressants such as trazodone 25-
50 mg at bedtime, or amitriptyline 10-50 mg
at bedtime. Check for drug interactions with
antiretroviral agents and other medications.
Mirtazapine (Remeron) is a newer antidepressant
with fewer drug interactions that may be used at low
dosages (7.5-15 mg) for insomnia.
Sedative hypnotics, such as triazolam (Halcion)
0.125-0.25 mg at bedtime as needed; temazepam
(Restoril), 15 mg at bedtime; and newer agents
such as zolpidem (Ambien), eszopiclone (Lunesta),
zaleplon (Sonata). Because of addictive potential
and problems such as amnesia and confusion, these
should be used only for short-term management
(5-7 days).
Note that protease inhibitors and nonnucleoside
reverse transcriptase inhibitors may raise blood
concentrations of many benzodiazepines. If
benzodiazepines are used, they should be started
at low dosages, and other central nervous system
depressants should be avoided. Consult with a
clinical pharmacist before prescribing.
Midazolam (Versed) and triazolam (Halcion) are
contraindicated with all protease inhibitors and
delavirdine and efavirenz.
Consult with a skilled mental health clinician if
problems persist or depression is suspected.
Patient Education
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Behavioral interventions can help to reduce
insomnia.
Patients should report new or worsening symptoms
to their health care provider.
References
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Darko DF, McCutchan JA, Kripke DF, et al.
Fatigue, sleep disturbance, disability, and indices of
progression of HIV infection. Am J Psychiatry. 1992
Apr;149(4):514-20.
Lee KA. An overview of sleep and common sleep
problems. ANNA J. 1997 Dec;24(6):614-23, 677;
quiz 624-5.
Norman SE, Chediak AD, Kiel M, et al. Sleep
disturbances in HIV-infected homosexual men. AIDS.
1990 Aug;4(8):775-81.
Uphold CR, Graham MV. Clinical Guidelines in
Adult Health. 2nd ed. Gainesville, FL: Barmarrae
Books; 1999:95-99.
Weiss RE. Neuropsychiatric Complications of HIV
Infection. In: Buckley RM, Gluckman SJ, eds. HIV
Infection in Primary Care. Philadelphia: Saunders;
2002:192.