Pharmacology/sleeping

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Question
QUESTION: i am 79 with a horrible insommnia problem for   3 months i have taken xanax and lunesta.i weined off xanax down to o5mg i was thinking adding 7.5 remeron to either lunesta or anbien.long term lunesta appears to be safer but a lot of people take ambien for years no problems.is remeron safe with lunesta or ambien?any suggestions will be helpfull.sleepy joe

ANSWER: Question:

i am 79 with a horrible insommnia problem for   3 months i have taken xanax and lunesta.i weined off xanax down to o5mg i was thinking adding 7.5 remeron to either lunesta or anbien.long term lunesta appears to be safer but a lot of people take ambien for years no problems.is remeron safe with lunesta or ambien?any suggestions will be helpfull.sleepy joe

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.

Going forward I would say that Ambien is probably the most practical option because it comes in an inexpensive generic and is not as "dangerous" for long term use as Xanax.  If you have excellent insurance you can continue with lunesta but it usually has a higher copay.  Either of these medications is a good first step.  

If the Ambien (or Lunesta) proves to still be not enough on its own you have a few real good (and inexpensive) options.  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.

I hope that helps you.
Dr. Joshua

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

QUESTION: thanks for the extensive answer,trazodone is not reccomended for folks with high blood pressure.remeron stays in your system over 20 hours and with moderate kidney damage ,remeron is not  kidney friendly/or am i wrong about remeron and kidneys/

Answer
My answer does not change based on what you mentioned.

All drugs carry certain risks with prolonged use (with any use actually).  However, the drugs that I suggested have a tolerable risk benefit ratio.

If you have genuine kidney issues you should be following the instructions of ONLY your NEPHROLOGIST.  If you dont have a Nephrologist you should if you have renal impairment.  

Short of having a nephrologist consult on your medications my answer stands as the best options in my opinion.  

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.

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

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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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