Ted Williams 03/05/08

Problem #1
Interrupted sleep after 4 hours / Possible Treatments
(pharmacologic vs nonpharmacologic)/Dose / Assessment (Justification) and Goals / Treatment Regimen (Plan) and Patient Education / Monitoring parameters
(drugs and disease states)
Subjective Information
CC: Trouble sleeping over 4 hours.
PMH: MF is a pleasant 82 yo female having trouble sleeping over 4 hours per night. The trouble started in 2003. The patient tried clonidine, but it produced a paradoxical reaction of insomnia and excitability. Patient reads in bed, but has done so for most of her life. MF has no trouble falling asleep, but wakes up consistently after 4 hours. The patient also complains of general fatigue coinciding with her dose of Nifedipine ER.
SH: ex smoker, quit 40+ years ago, light alcohol use (1/wk), limited exercise after a fall last august, but is seeing a physical therapist.
FH: non-contributory
Objective Information
- BP 210/190 (home reading, consistently)
Medications:
Benicar 40mg PO daily
HCTZ 25mg PO daily
Metoprolol Succinate 200mg PO daily
Nifedipine ER 60mg PO daily
Synthroid 88mcg PO daily
Xalatan 0.005% 1 drop both eyes QHS
Azopt 1% 1 drop both eyes QHS
Multivitamin, Ca+D 5 tabs po , / Current Regimen
None
Pharmacologic
- Zolpidem (Ambien) is a selective Alpha-1 GABA Receptor Agonist. Paradoxical arousal has been reported with these medications as well. The different mechanism of action of Zolpidem makes this a reasonable choice. The IR and CR formulations have nearly identical pharmacokinetics, making the IR a good initial choice. Zolpidem is best for patient who have trouble falling asleep. There are no restrictions for glaucoma.
-Eszopiclone (Lunesta) is another selective alpha-1 GABA Receptor Agonist. Like Zolpidem, some paradoxical side effects have been reported. Eszopiclone has been demonstrated to be effective for sleep latency and increased sleep duration, with minimal hangover effects. There are no restrictions for glaucoma.
-Antidepressants are an option for insomnia. Their side effect profile of morning somnolence make them a less suitable first line option.
-Melatonin and Melatonin angonists are useful for circadian rhythm insomnia and sleep latency. The patient has no social history to suggest this is the etiology.
-Benzodiazepines are contraindicated in narrow angle glaucoma.
Non pharmacologic
-The patient has generally good sleep hygiene, with the exception of reading in bed. Although this can be a factor, it seems unlikely that it would suddenly have an effect after 50+ years.
- Adding afternoon light exercise may be helpful in helping adjust her sleep pattern. / Brief HPI/Assessment
Goals
Further, the lack of extended sleep may be contributory to the patient’s refractory hypertension, as their diurnal blood pressure may not be dropping as it should. Eszoplicone (Lunesta) is a good first choice, due to it’s increase in sleep duration without hang over effects. If cost is a concern, then Zolpidem may be a possible option. Therapy should continue for no more than 4 weeks.
Goals:
  • Increase sleep time from 4 hours to 7-8 hours
  • Minimize size effects, esp. paradoxical insomnia
/ Treatment Regimen (Plan)
  • Patient should discuss the use of Eszoplicone (Lunesta) to treat her insomnia
  • Patient should try a short walk in the afternoon, as her osteoarthritis allows.
Education and counseling issues with the patient
  • Sleep pattern changes should occur immediately after beginning Lunesta
  • Therapy should continue for up to 4 weeks only
  • Some patient may feel tired in the AM, which may be a dose-dependent effect
  • Encourage the patient to check their blood pressure upon waking before and after taking Zolpidem to check for changes
  • Patient should not take Eszoplicone if she has had alcohol
/ Therapeutic (Efficacy) Monitoring Parameters
  • Patient should track the number of hours of sleep per night
  • Patient should track her blood pressure in the AM before and after starting Eszoplicone
  • Follow up with Internist 2-4 weeks after initiating therapy
Safety Monitoring Parameters)
Drug-Drug Interactions
  • None

Problem # 2
Hypertension / Possible Treatments
(pharmacologic vs nonpharmacologic)/Dose / Assessment (Justification) and Goals / Treatment Regimen (Plan) and Patient Education / Monitoring parameters
(drugs and disease states)
Subjective Information

Objective Information

/ Current Regimen

Pharmacologic

Nonpharmacologic

/ Brief HPI/Assessment

Goals

/ Treatment Regimen (Plan)
Education and counseling issues with the patient / Therapeutic Monitoring Parameters
Safety Monitoring Parameters
Drug-drug Interactions
Problem # 3
Osteoarthritis / Possible Treatments
(pharmacologic vs nonpharmacologic)/Dose / Assessment (Justification) and Goals / Treatment Regimen (Plan) and Patient Education / Monitoring parameters
(drugs and disease states)
Subjective Information

Objective Information

/ Current Regimen
Pharmacologic
Nonpharmacologic / Brief HPI/Assessment

Goals

/ Treatment Regimen (Plan)
Education and counseling issues with the patient / Therapeutic Monitoring Parameters
Safety Monitoring Parameters
Drug-drug Interactions