Elaine Zablocki

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 recommends that healthy adults sleep seven to nine hours per day. However, many people aren't getting the sleep they need. The Centers for Disease Control  and Prevention recently reported that 30% of workers sleep less than six hours per day. 

Many different situations can lead to short or interrupted sleep, including predisposing factors such as anxiety, depression and worry about sleep; precipitating factors such as stressful life events, medical or psychiatric illness; shift work; and prescription or nonprescription drugs. 

More recently, a class of medications called benzodiazepine receptor agonists has been developed. They include Ambien (zolpidem), Lunesta (eszopiclone), and Sonata (zaleplon).  

"Benzodiazepine receptor agonists, benzodiazepines, the melatonin agonist ramelteon and low doses of the antidepressant doxepin are effective and generally safe for treatment of insomnia," says Mark Abramowicz, MD, editor-in-chief of

 The Medical Letter on Drugs and Therapeutics

, a non-profit newsletter that critically appraises drugs.  

The benzodiazepine receptor agonists are not structural benzodiazepines, but bind to benzodiazepine receptors. All act rapidly to decrease sleep latency and do not affect deep sleep; the primary differences between them are in their duration of action. 

"However, these agents may impair performance in the morning, including driving," says Dr. Abramowicz. "Complex sleep-related behaviors may occur without conscious awareness."   

Over-the-counter sleep aids containing antihistamines such as Benadryl (diphenhydramine) are widely available.  

"Over-the-counter antihistamines marketed as sleep aids are not recommended," he says. "They can cause next-day sedation, impairment of performance skills such as driving, and troublesome anticholinergic [dry eye and/or dry mouth] effects."   

A wide variety of psychiatric medications, are commonly prescribed for insomnia even though they are not FDA-approved for this condition. The most common are antidepressants such as trazodone (Desyrel, and others), mirtazapine (Remeron) or amitriptyline (Elavil, and others).  

"There is little evidence that these agents are effective in treating insomnia not associated with depression," Dr. Abramowicz says.  

Articles

Symptoms of insomnia can be treated with several different drugs, but be aware of side effects.

Insomnia symptoms can indicate underlying medical conditions

Asthma affects one in 12 people in the United States and was once considered a condition of hyperactive airways.   

"Now we think of it more as a chronic inflammation, and this has changed our understanding of the appropriate treatment," says Michael Sherman, MD, senior vice president and chief medical officer for Harvard Pilgrim Health Care. "We now recognize the critical importance of taking ongoing maintenance medications, such as inhaled corticosteroids to suppress airway inflammation."  

Low daily doses of an inhaled corticosteroid (ICS) suppress airway inflammation and reduce the risk of exacerbations, according to Mark Abramowicz, MD, editor of 

The Medical Letter on Drugs and Therapeutics

Asthma is one of the most common chronic diseases of childhood.  About 1 in 10 children (10%) and 1 in 12 adults (8%) had asthma in 2009.  

"For children with mild intermittent asthma, an inhaled short-acting beta-2 agonist (SABA) should be used as needed," says Dr. Abramowicz. "For mild, moderate or severe persistent asthma, ICSs are the preferred long-term treatment for control of symptoms. ICSs do not, however, alter the underlying severity or progression of the disease."  

Medications prescribed for children must match their ability to understand and control the device used to deliver the medication.  

"In young children, a SABA or an ICS may best be delivered through a metered-dose inhaler with a valved holding chamber and face mask or mouthpiece, or through a nebulizer," says Dr. Abramowicz. "Dry powder inhalers are not suitable for use in young children, who cannot reliably inhale rapidly or deeply enough to use them effectively."  

Asthma medications for children must match a child's ability to understand and control treatment of symptoms.

Children need extra help to control asthma symptoms

	Two of the major causes of blindness in the United States are glaucoma and age-related macular degeneration (AMD). However, medications are available for both conditions that substantially limit their effects, especially when treatment is started early.  

In glaucoma, the fluid inside the eye doesn't drain normally, so excess pressure builds up within the eye. As this goes on, the structure of the eye is damaged, resulting in blurred vision, a narrowed field of sight and eventual blindness. While anyone can develop glaucoma, those at highest risk include African Americans over age 40, those with a family history of glaucoma, and anyone over age 60.  

It is important for patients to receive regular checkups, including a dilated eye exam.  

The early stages of glaucoma typically affect peripheral vision, and patients don't experience any symptoms. Even though they have increased eye pressure, they don't feel it.  

"By the time people come in because they are actually noticing vision problems, at that point they have sustained major damage to the optic nerve," Dr. Iwach says.  

Once the early stages of glaucoma are identified during a routine eye exam, ophthalmologists do have effective medications to reduce pressure within the eye. Beta-blockers used to be the first line treatment for glaucoma, and they are still used under certain circumstances.  

"The problem with beta-blockers is they are systemic medications, which tend to exacerbate asthma and chronic obstructive pulmonary disease, limit the maximal heart rate, and lead to depression," says Mark Packer, MD, an ophthalmologist in private practice in Eugene, Ore., and an associate clinical professor at Oregon Health Sciences University.  

Starting in the mid-1990s, prostaglandin analogs, which do not affect systemic bodily functions, became the first line choice for treatment of glaucoma.  

"They offer once-a-day dosing, which is by far the most convenient and also has the highest compliance rate," Dr. Packer says. "In addition, the absence of systemic side effects is of great importance." 

Treatment for glaucoma starts out with one of the prostaglandin analogs, and if needed a second medication may be added.  

"Treatment of glaucoma is all about the target pressure," says Dr. Packer. "Let's say that some damage has occurred at the current pressure, so as a starting point, we think the pressure should be 20% lower. Generally speaking, we first try a prostaglandin and then try other medications to see their effect. The period for maximal efficacy is usually about two to four weeks, and then we check the pressure in the eye again." 

"This disease is potentially blinding, and yet it has no symptoms in its early stages," says Dr. Packer. "The treatment regimen is complex. Sometimes the patient has to do the first drop, than wait five minutes to do the second drop. Patients with arthritis may have problems squeezing the bottle." 

Drug compliance programs should be considered for glaucoma patients. 

Two of the major causes of blindness in the United States are glaucoma and age-related macular degeneration (AMD), which often can be controlled with medication.

Treatment of glaucoma begins

INFLAMMATORY BOWEL DISEASE (IBD) includes ulcerative colitis and Crohn's disease, two distinct conditions with similar symptoms, in which the intestines become inflamed, probably as a result of the body's immune reaction mobilized against intestinal tissue. Ulcerative colitis affects the colon and the rectum, while Crohn disease's may affect any portion of the gastrointestinal tract (most often the small intestine and/or the colon.) Symptoms typically include diarrhea, abdominal pain, nausea and vomiting, fever and weight loss. Sometimes there are associated complaints such as arthritis or skin problems. 

Most patients have sporadic symptoms. About 20% to 25% have frequently relapsing disease, or chronically active disease. Drugs to treat IBD include mesalamine (a substance that helps control inflammation), antibiotics, corticosteriods, and immunosuppressants. 

 "For patients with mild to moderate disease, initial treatment would depend on their specific condition," says Bruce Sands, MD, MS, vice chair of the American Gastroenterological Association Institute. "A person with moderate disease might have diarrhea three or four times a day, and some degree of urgency and belly pain, but they can take in adequate nutrition, and they are able to function in daily life."  

These medications are biologic substances that can locate and bind to the specific molecules involved in causing inflammation. Today, three TNF inhibitors are approved by the FDA for treatment of moderate to severe Crohn's disease that has not responded to other drugs: Cimzia (certolizumab pegol), Humira (adalimumab), and Remicade (infliximab). 

"TNF inhibitors were a completely different type of agent that could produce a response in patients who had been refractory to all existing therapies," says Dr. Sands. "Before the advent of TNF inhibitors, I had patients who were completely homebound by the disease. Not every patient responds, and some have a partial response, but in many cases patients were able to return to work and a normal lifestyle."  

These medications have side effects, which may include the risk of infection or rare cases of lymphoma, says Dr. Sands. When patients have mild symptoms, typically those medications are not recommended.  

For the 15% to 20% of patients who don't respond to initial treatment, tumor necrosis factor inhibitors can reduce inflammation

Elaine Zablocki

Articles

Insomnia symptoms can indicate underlying medical conditions

Children need extra help to control asthma symptoms

Treatment of glaucoma begins

Biologics can treat some cases of inflammatory bowel disease