SAN DIEGO – All three main treatments for problem sleepiness can perk patients up, but they differ in cost and side effects, Dr. Milton Erman said at a psychopharmacology congress sponsored by the Neuroscience Education Institute.
Caffeine is the cheapest, most accessible, and most widely used stimulant. The two other treatment options are prescription medications, which are more expensive: modafinil or CNS stimulants (most commonly amphetamines or methylphenidate).
Caffeine tolerance develops rapidly, however, and there's a moderate risk for dependence. Stopping a daily caffeine habit too quickly can trigger a “caffeine headache.” Side effects from regular caffeine use include nervousness, irritability, insomnia, and GI problems, said Dr. Erman of the University of California, San Diego.
“Many of my insomniac patients tell me proudly that they aren't using caffeine” to indicate that caffeine can't be blamed for their insomnia, he said. Ironically, a bit of caffeine in the morning may be just what they need. “The problem with many of these insomniac patients is that they can't get going, get functioning in the morning,” he said. Limited caffeine use in the morning may help them function better.
Use of CNS stimulants also leads to tolerance, and there is a high potential for dependence. Side effects include nervousness, headaches, insomnia, anorexia, GI problems, and mood changes. General CNS stimulants such as amphetamines have a high risk of abuse and hyperactivity because of their broad mechanism of action.
One experimental study of sleep deprivation that compared amphetamines with modafinil treatment to maintain wakefulness suggested that the two drugs are equally potent. In real life, however, “I think amphetamines are more potent,” he said. Patients with narcolepsy who have used amphetamines in the past often aren't satisfied with the effects of modafinil.
Modafinil works more specifically on wakefulness circuits and has fewer side effects than other stimulants. Tolerance is not an issue–it maintains most of its efficacy over time–and use of the drug does not lead to dependence. Side effects include headache, nausea, dry mouth, insomnia, and hyperactivity.
The risk of headache relates to the dosing of modafinil. In early research on the drug, headache appeared primarily in patients who titrated up to a dose of 400 mg/day by the third day. In subsequent research that gave patients 7–9 days to titrate up to 400 mg/day, headache was much less of a problem, Dr. Erman said.
“Modafinil works quite well, particularly if we're not talking about the most severely hypersomnolent patients,” such as narcoleptics who have become accustomed to taking stimulants, he said.
Dr. Erman is a speaker and consultant for, and has received research funding from, the company that makes modafinil, Cephalon Inc. Modafinil is approved to treat sleepiness from shift work, narcolepsy, and sleep apnea.
The most common cause of problem sleepiness is sleep apnea, which occurs in perhaps 10% of the population, he said. Restless leg syndrome can interrupt sleep and lead to daytime sleepiness. Narcolepsy is fairly uncommon. Insomnia can cause excessive sleepiness, but more often, insomniac patients are hypervigilant. “If anything, they are more alert” than they want to be, he said.
Secondary causes of sleepiness include chronic pain and any medical condition that causes pain or discomfort, which may interrupt sleep. Medications used to alleviate pain also can lead to daytime sleepiness because they affect breathing during sleep and increase the risk for sleep apnea.
Check to see if patients who complain of sleepiness are taking drugs that cause sedation or that disrupt sleep, Dr. Erman added, and consider alternative therapies.
Lifestyle issues, such as graveyard shift work, also contribute to excessive sleepiness,. The pace of U.S. culture commonly leads to chronic sleep deprivation that affects daytime function. “As a society, we really haven't dealt with this,” he said.