Newer hypnotics no better for insomnia than short acting benzodiazepines
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《英国医生杂志》
London
The National Institute for Clinical Excellence (NICE) has issued new guidance to the NHS recommending that hypnotic drugs be used for severe insomnia only for short periods and only after non-pharmacological measures have been considered.
Non-pharmacological treatments include cognitive behaviour therapy and relaxation techniques and avoiding stimulants (such as coffee) before bedtime.
NICE does not distinguish between newer hypnotics known as Z drugs (zaleplon, zolpidem, and zopiclone) and short acting benzodiazepines such as loprazolam, lorazepam, lormetazepam and temazepam—recommending that the drug with the "lowest purchase cost" be chosen.
Severe insomnia, like that experienced by Tom Wilkinson in the film In the Bedroom (pictured), should be treated with drugs only for short periods
Credit: KOBAL
The Z drugs were developed to overcome some of the disadvantages of benzodiazepines, such as next day sedation, dependence, and withdrawal.
NICE's appraisal committee came to its decision after finding no compelling evidence of a clinically useful difference between the Z drugs and short acting benzodiazepines in terms of effectiveness, adverse effects, or potential for misuse or dependence.
The guidance is expected to provide cost savings to the NHS, with a possible reduction in the prescribing of hypnotics. NICE notes that in 2002 the NHS spent ￡15.9m ($28.2m; 23.6m) on Z drugs.
However, the guidance does not have the support of the British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders.
The society's representative, David Nutt, professor of psychopharmacology and head of the department of community based medicine at the University of Bristol, said that it was not sensible of NICE to recommend "short acting" benzodiazepines as hypnotics as they are not actually short acting.
For example, lorazepam has an average half life of about 15 hours, meaning it will have significant effects on the brain for at least two half lives (30 hours) after administration, he said. He believes that loprazolam, lormetazepam, and temazepam, which have medium half lives (between eight and 13 hours), will also result in next day effects in many people.
The society told NICE that only drugs with a half life of less than four hours (such as zolpidem and zaleplon) are short acting enough to be considered likely to be free of significant carryover effects the next day. Professor Nutt said that it seems perverse that patients will be forced to run the risk of significant daytime hangover to save a few pence on drug costs. He said pressure will be put on clinicians as a result of the guidance not to use Z drugs.
The society made an appeal against the guidance, but this was rejected by NICE. This is because there were no grounds for appeal, NICE said.
NICE also recommends that hypnotics be prescribed in strict accordance with their licensed indications and that drugs should be switched only if the patient experiences side effects specifically related to that medicine.(Liza Gibson)
The National Institute for Clinical Excellence (NICE) has issued new guidance to the NHS recommending that hypnotic drugs be used for severe insomnia only for short periods and only after non-pharmacological measures have been considered.
Non-pharmacological treatments include cognitive behaviour therapy and relaxation techniques and avoiding stimulants (such as coffee) before bedtime.
NICE does not distinguish between newer hypnotics known as Z drugs (zaleplon, zolpidem, and zopiclone) and short acting benzodiazepines such as loprazolam, lorazepam, lormetazepam and temazepam—recommending that the drug with the "lowest purchase cost" be chosen.
Severe insomnia, like that experienced by Tom Wilkinson in the film In the Bedroom (pictured), should be treated with drugs only for short periods
Credit: KOBAL
The Z drugs were developed to overcome some of the disadvantages of benzodiazepines, such as next day sedation, dependence, and withdrawal.
NICE's appraisal committee came to its decision after finding no compelling evidence of a clinically useful difference between the Z drugs and short acting benzodiazepines in terms of effectiveness, adverse effects, or potential for misuse or dependence.
The guidance is expected to provide cost savings to the NHS, with a possible reduction in the prescribing of hypnotics. NICE notes that in 2002 the NHS spent ￡15.9m ($28.2m; 23.6m) on Z drugs.
However, the guidance does not have the support of the British Sleep Society, a professional organisation for medical and scientific staff who deal with sleep disorders.
The society's representative, David Nutt, professor of psychopharmacology and head of the department of community based medicine at the University of Bristol, said that it was not sensible of NICE to recommend "short acting" benzodiazepines as hypnotics as they are not actually short acting.
For example, lorazepam has an average half life of about 15 hours, meaning it will have significant effects on the brain for at least two half lives (30 hours) after administration, he said. He believes that loprazolam, lormetazepam, and temazepam, which have medium half lives (between eight and 13 hours), will also result in next day effects in many people.
The society told NICE that only drugs with a half life of less than four hours (such as zolpidem and zaleplon) are short acting enough to be considered likely to be free of significant carryover effects the next day. Professor Nutt said that it seems perverse that patients will be forced to run the risk of significant daytime hangover to save a few pence on drug costs. He said pressure will be put on clinicians as a result of the guidance not to use Z drugs.
The society made an appeal against the guidance, but this was rejected by NICE. This is because there were no grounds for appeal, NICE said.
NICE also recommends that hypnotics be prescribed in strict accordance with their licensed indications and that drugs should be switched only if the patient experiences side effects specifically related to that medicine.(Liza Gibson)