Examine Case Study: Pharmacologic Approaches to the Treatment of Insomnia in a Younger Adult. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)
Decision #1 (1 page)
Decision #2 (1 page)
Decision #3 (1 page)
Conclusion (1 page)
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.
Assessing and Treating Patients with Sleep Disorders
Insomnia is a sleep disorder that makes a patient have difficulties falling asleep or remaining asleep for a long period of time, especially at night. A person with insomnia finds it hard to sleep during the night. The patient presents symptoms of insomnia. The patient confirms that he has difficulties while trying to sleep.
There are different symptoms of insomnia that the patient is presenting in his description. One of the symptoms is sleeping at work. One of the main symptoms of insomnia is falling asleep during the day, as the body compensates for the sleep lost during the night (Riemann et al., 2017).
The patient confirms that he is becoming unproductive at work as he finds himself sleepy during the day while at work. The daytime sleeping is accompanied by fatigue. There are different causes of insomnia. One of the main causes of insomnia is stress and depression (Hertenstein et al., 2019). The patient confirms that he developed insomnia when he lost his fiancé. Such losses result in psychological stress, which results in insomnia. Mental health is thus a major factor in insomnia treatment.
Insomnia may be chronic or acute. Acute insomnia occurs for a period of one night to few weeks, while chronic insomnia occurs for over three months and may occur over three nights every week (Riemann et al., 2017)).
In this case, the patient is suffering from chronic insomnia as the condition has been progressive for over six months. There are several other aspects of the patient which have to be considered in the decision points. One is his history of opiate abuse, which is an abuse of medication. The patient’s use of alcohol also has to be put into consideration.
Decision Point 1: Trazodone 50-100 mg Daily at Bedtime
Trazodone is one of the most effective medications to prescribe for chronic insomnia cases. Trazodone should be prescribed from 50 mg for adults (WebMD, 2021). Trazodone is a selective serotonin reuptake inhibitor and is known to have low side effects profile (WebMD, 2021). Trazodone works to balance chemicals in the brain.
Thus, it is an effective medication to prescribe to patients who have insomnia, depression, and anxiety. From the description given by the patient, he suffers insomnia out of stress or depression, which resulted when he lost his fiancé. Trazodone would thus be the best treatment option to prescribe at first. The current patient should be prescribed Trazodone s the initial medication for the current intervention.
The other two choices at this point were not selected. Zolpidem has adverse side effects when used on a patient. The patients who use Zolpidem regularly report to having hallucinations at night and waking up to perform activities at night unknowingly (MedlinePlus, 2021).
A patient may thus risk while using Zolpidem as they may wake up and perform dangerous activities like driving unknowingly. The third option was the introduction of Hydroxyzine 50 mg daily at bedtime. Hydroxyzine is an antihistamine that has sedative properties and operates in a similar way to Trazodone, but it is weaker compared to Trazodone (Hertenstein et al., 2019). It also has adverse side effects on patients, and thus, its prescription should not be the first option.
From this decision point, it was hoped that the patient would develop a good sleeping pattern. The patient may also likely develop some side effects like prolonged erection on waking up (priapism). At this decision point, the main ethical issue to consider is the state of the patient and avoid causing more adverse problems than the one the patient reported by selecting the right medication to prescribe.
Decision Point 2: Explain that Priapism is a Side Effect of Trazodone that Should Diminish over Time. Continue Dose
Priapism is one of the side effects of Trazodone. Priapism may not be a very common side effect, but it occurs in some instances among men who are prescribed to Trazodone. Priapism is a form of erection in men which is painful and occurs over a long period of time without sexual stimulation and presents with painful and persistent characteristics (WebMD, 2021).
Patients who experience priapism when Trazodone is prescribed to them may find it more uncomfortable to continue with Trazodone. However, priapism resulting from Trazodone tends to diminish with time, and it is thus not a major reason to worry about the prescription (WebMD, 2021). The other two options were not chosen at decision point 2.
Discontinuation of Trazodone and initiation of therapy with suvorexant 10mg daily at bedtime would not be the best decision to make. When a patient takes suvorexant, they have to remain asleep for not less than seven hours, and waking up before the end of seven hours may result in drowsiness (MedlinePlus, 2021).
This may be challenging for a patient who needs to rest for a shorter time and wake up. The third option, decreasing trazodone to 25 mg daily at bedtime, is not a good option at this point. At this point, the patient is not experiencing adverse side effects which may require a reduction of the dosage by two as in this option.
The main ethical issue here is to patiently explain to the patient and offer him patient education on the side effect to his satisfaction. This will prevent cases of medication abuse as experienced before in the patient medical history. In this decision point, it is expected that the patient experience better sleep over the period and also have diminished cases of priapism. The patient may, however, experience some instances of drowsiness in the morning when they wake up.
Decision Point 3: Continue dose. Explain to paint he may split the 50 mg tablet into half to minimize next-day drowsiness. Follow up in 4 weeks.
Drowsiness is common when using insomnia medication. Drowsiness is a common side effect of trazodone (WebMD, 2021). However, trazodone has a low side effects profile compared to other insomnia medications commonly used. Drowsiness can be mitigated by reducing the 50 mg trazodone by 50% and using it for a period of time to check on its effectiveness (WebMD, 2021). The patient should thus reduce the dosage of trazodone by half and use it for a period of four weeks and then go for a further check-up.
The main intention of reducing the dosage is to reduce the drowsiness side effect. The other two decisions at this point were not considered. Initiating sonata at this point is not a good option. Sonata brings about behaviors of complex sleep that may affect the patient (WebMD, 2021). In this case, prescription of a new medication may not be a good option as trazodone works perfectly with the patient despite the low side effects. Discontinuation of trazodone and introduction of hydroxyzine was also not considered. Many users of hydroxyzine complain of adverse effects of anti choligenic type in the morning (WebMD, 2021). Such effects may affect the progress already made with the patient.
At this point, patent education is the main ethical issue to consider. The patient has to get a proper understanding of how taking half a dose is likely to change the side effects he is experiencing while also maintaining his good sleep. At this decision point, it is expected that the drowsiness will end during the next visit after four weeks, and the patient will have good sleeping habits. The patient is also expected to have no further instances of priapism.
A patient with insomnia experiences a lack of sleep and challenges in maintaining good sleeping patterns. Sleep is important for psychological functionality, and thus, the patient should be treated with urgency. Trazodone is one of the commonly used medications in the treatment of insomnia. Trazodone is majorly used as the first prescription for insomnia cases due to its effectiveness and the few side effects which patients experience when using the medication (WebMD, 2021).
As a result, Trazodone was selected at all decision points, from decision point one to decision point three. A dosage of 50 mg of Trazodone is prescribed as the effective dosage for adult insomnia patients (WebMD, 2021). The side effects which are common with patients of insomnia using Trazodone include drowsiness (WebMD, 2021). Priapism also occurs on some of the male patients using Trazodone and maybe a challenging experience for most men.
As a result, it is important to act on the dosage as a way of reducing the effects of the side effects on the patient. Reducing the dosage helps reduce some of the common side effects. Reducing the 50 mg Trazodone tablet by half helps reduce drowsiness (WebMD, 2021). Drowsiness may be challenging and dangerous for the patient, especially when working as a forklift operator.
Such a side effect may cause an accident. On the other hand, priapism reduces with time as the patient’s body gets used to Trazodone use. As a result, the side effect does not require the patient to change medication at decision point two. The use of Trazodone on the patient would thus be fully effective.
Hertenstein, E., Feige, B., Gmeiner, T., Kienzler, C., Spiegelhalder, K., Johann, A., … & Baglioni, C. (2019). Insomnia as a predictor of mental disorders: a systematic review and meta-analysis. Sleep medicine reviews, 43, 96-105. Retrieved From: https://doi.org/10.1016/j.smrv.2018.10.006
MedlinePlus. (2021). Suvorexant. Retrieved From: https://medlineplus.gov/druginfo/meds/a614046.html
MedlinePlus. (2021). Zolpidem. Retrieved From: https://medlineplus.gov/druginfo/meds/a693025.html
Riemann, D., Baglioni, C., Bassetti, C., Bjorvatn, B., Dolenc Groselj, L., Ellis, J. G., … & Spiegelhalder, K. (2017). European guideline for the diagnosis and treatment of insomnia. Journal of sleep research, 26(6), 675-700. Retrieved From: https://onlinelibrary.wiley.com/doi/full/10.1111/jsr.12594
WebMD. (2021). Hydroxyzine HCL. Retrieved From: https://www.webmd.com/drugs/2/drug-7681/hydroxyzine-hcl-oral/details
WebMD. (2021). Sonata (Zaleplon). Retrieved From: https://www.webmd.com/drugs/2/drug-17532/sonata-oral/details
WebMD. (2021). Trazodone HCL. Retrieved From: https://www.webmd.com/drugs/2/drug-11188/trazodone-oral/details
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