Pharmacology/sleeping

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QUESTION: dr cappuccilli,i am 79 and have bad insommnia for years.currently i take 2mg lunesta and 1mg xanax for sleep.lately the lunesta is not working.my doc suggestes ambien or remeron.between ambien and remeron which has less side effects and is generally safer/

ANSWER: Ok - first (and you have probably already tried these things) you need to address "sleep hygeine" that involves taking steps to making yourself and your environment more suitable for sleeping.  Go to the following link at the Mayo Clinic for tips on sleep hygeine :

http://www.mayoclinic.com/health/sleep/HQ01387

That being said medications are a necessity for some people even with perfect sleep preparations.  Working your way off the Xanax is a very good idea for two reasons.  First, Xanax is in a class of drugs that we can become physically dependent or addicted to and the longer we use them daily the worse the risk is for this type physical NEED becomes.  Second, these types of medications have diminishing returns - that means that over time they will not work as well as they once did.

Remeron (mitazapine) is a good option and pretty well tolerated and safe for most patients.  Trazadoone is a mild anti depressant that is primarily used for sleep problems.  It is a better option than Remeron for most patients because it is cheaper and you get the dual benefit of mood enhancement during the day and the sleep at night.  Finally, there is a class of older anti-depressants called Tri-cyclic anti-depressants.  These are also beneficial for mood during the day and used primarily in patients with sleep problems.  Again - the dual benefit of these makes them a better option than Remeron and they are older medications which means they are also dirt cheap.

Ambien is a good medication and very safe - however - I would try the ones listed above first because they are not controlled substances, they are less likely to cause physical dependence and they are all cheaper than Ambien (even the generic) on most insurance plans - or in terms of cash payments.


I hope that helps you.
Dr. Joshua


---------- FOLLOW-UP ----------

QUESTION: have read articles that lunesta can be used over a year with very mild side effects compared with remeron which is loaded with side effects

Answer
There are no completely "safe" drugs. Lunesta may have a lower side effect profile (and that is debatable) however it carries the risk of physical dependance that remeron (mirtazapine) does not.  Also, Remeron has been in the market much much longer so the full side effect profile is available because of years of observation and reporting.  Lunesta is a far newer drug so there simply isn't enough data to know what protracted daily use of Lunesta will result in.  In my opinion the risk of addiction / physical dependance is more than the benefits it offers over remeron (if remeron works for you).

Finally, Remeron is cheap - like dirt cheap and Lunesta is expensive (very) so for most patients Remeron is a better monetary option.

Hope that helps.

Dr Joshua

Pharmacology

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Dr. Joshua Cappuccilli

Expertise

I can answer most questions involving medication use, side effects, adverse effects, interactions and how drugs relate to specific disease states. No one can answer all questions; I will respond as such if I cannot provide an answer. I will provide resources / references for the information that I use to formulate the answer given.

Experience

I am a Doctor of Pharmacy currently practicing in Florida in a retail pharmacy.

Organizations
California Phamacist Association American Pharmacy Assocaition

Education/Credentials
BA University of South Florida PharmD University of Florida APhA Medication Therapy Management certification

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