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

Biologics can treat some cases of inflammatory bowel disease

CHF is a common condition. About 5 million people in the United States have heart failure, resulting in about 300,000 deaths each year. Many patients experience acute episodes involving trips to the emergency room. Heart failure is one of the most common reasons people are admitted to the hospital, and the most common reason for readmission. Between 29% to 47% of elderly heart failure patients are readmitted for that condition within three to six months after an initial hospitalization. 

Various medications are used to control CHF: ACE (angiotensin-converting enzyme) inhibitors; ARBs (angiotensin receptor blockers); beta-adrenergic blockers; aldosterone antagonists; vasodilators; diuretics; and digitalis. 

In general, patients with heart failure with left ventricular problems should take both an ACE inhibitor and a beta-blocker, and usually a diuretic as well. ARBs are recommended for patients who cannot tolerate ACE inhibitors. 

"No data are available showing that any ACE inhibitor is more effective than any other for treatment of heart failure or in its effects on symptoms or survival," says Mark Abramowicz, MD, editor of 

, a non-profit newsletter that critically appraises drugs. "The ACE inhibitors shown in the chart have been shown in clinical trials to be effective in recommended doses in improving outcomes."  

Candesartan and valsartan are the only ARBs approved by the FDA for treatment of heart failure. "Many 

 consultants believe that all ARBs could be effective for this indication, but effective doses are best established for candesartan and valsartan," says Dr. Abramowicz. 

Most patients with CHF experience fluid retention. Diuretics relieve these symptoms, although their effect on survival is unknown. However, patients who consume large amounts of sodium or who take nonsteroidal anti-inflammatories (which block diuretics) may continue to retain fluids.  

Group Health, with about 600,000 members in Washington state and northern Idaho, has developed a sophisticated transition program to aid members who have been treated in the hospital for CHF.  

"This goes far beyond discharge planning," says Barbara Wood, director of complex care management, who is responsible for both hospital-based care management and clinic-based case management. "We coach them based on the four pillars of transition." 

The pillars were developed by Eric Coleman, MD, at the University of Colorado Health Sciences Center. 

Dr. Coleman's work emphasizes four specific areas of patient self-management: medications; use of a dynamic patient-centered health record; timely primary care/specialty care follow up; knowledge of red flags that indicate a worsening in their condition and ways to respond.  

Group Health patients have at least one meeting with a nurse while they're still in the hospital to discuss their medications and appointments needed for continuing care. They talk about warning signs to watch out for once they're back home and receive a discharge packet with detailed information related to their condition.  

"We talk with them about their new medications, and the fact that they may need to throw out some older medications," says Wood. "It's not uncommon for us to help them call and schedule follow-up appointments right there from the hospital room." 

Within 24 to 48 hours after discharge, a case manager specializing in heart failure calls the patient for follow up. The nurse completes an over-the-phone assessment, and if the patient needs medication adjustments and continued monitoring, he or she is admitted to Group Health's chronic heart failure case management program. Nurses with advanced training in care management call the patient as often as needed, perhaps once a week, perhaps once a day.  

"With a patient who is quite unstable, the nurse may call in the morning and then talk to them again in the afternoon," Wood says.  

Nurse case managers in the program offer the patient education about diet and exercise. They work within the cardiologist's office, which facilitates needed medication changes.  

"We try to set it up so when the patient comes in to see the doctor, they also meet the nurse case manager," Wood says. "We find, especially with our senior citizens, that if they meet the nurse and have at least one face-to-face conversation, the telephonic work goes much more smoothly." 

Group Health data for those in case management for CHF shows there has been a substantial decrease in readmission rate during the 12-month period after hospitalization for this condition.  

"We believe our hospital transition management program has been very effective in contacting patients and getting them involved in case management," Wood says. "We expect the transition program will show significant results in reducing the number of readmissions within 30 days of discharge."   

This article is based on information supplied by The Medical Letter (

 a non-profit organization that publishes newsletters offering critical appraisals of new drugs and comparative reviews of older drugs. The Medical Letter is completely independent of the pharmaceutical industry. It is supported entirely by subscription sales and accepts no advertising, grants or donations. Institutional site license inquiries can be sent to 

Elaine Zablocki has been reporting on healthcare for more than a dozen years. 

Group Health cuts CHF readmission rate with care transition program, while patients stick to diet, exercise and medication plans

ACE inhibitors, ARBs control CHF

These hospitals and health plans are influenced by a shifting combination of circumstances. For many, historic traditions of community service are a strong motivator. Others are responding in part to Congressional calls for increased community benefit activities. Some healthcare systems report that an investment in these community services can lead to lower costs for expensive functions, such as emergency room services.  

Sutter Medical Center in Sacramento is one example. It is based just a mile from the state capitol building in a low-income neighborhood. A few years ago, the hospital staff observed that when homeless patients were released, they often went right back to the streets, followed by needless complications and readmissions. Together with other hospitals, Sutter formed a partnership with the Salvation Army called the Interim Care Program, which sets aside beds at the Salvation Army shelter so discharged patients can receive follow-up healthcare services after an acute care episode.  

"One of the best aspects of this program is while they are there, they also have access to other services," says Thomas C. Gagen, Sutter's CEO. "They receive assistance in applying for health coverage and housing. If someone is a substance abuser, they have access to those services as well."  

About 40% of the population entering the program is uninsured, but 100% have healthcare coverage when they leave. About 77% move into some form of housing upon discharge.  

Sutter Medical Center also noticed that some patients were using the emergency room frequently-as often as 40 visits in a single year-and a substantial proportion of those high users were homeless. To address the frequent use of costly emergency room services, Sutter partnered with a community clinic called The Effort, which offers primary care to people in downtown and midtown Sacramento. The program is called T3, which stands for "Triage, Transport and Treat."   

When someone arrives at the emergency room, there is a triage process. If they need acute care they are admitted to the hospital. However, if they actually need primary care, a case manager from The Effort comes to the emergency department immediately to start care for a longer-term basis.  

"This is a vital aspect of the program," says Gagen. "We don't ask them to make an appointment the next day because in general this population probably wouldn't keep the appointment."  

The Effort deals with primary care medical needs and helps the patient achieve a more stable life situation. Gagen recalls one case in particular, where a mentally unstable person could not pay his outstanding traffic tickets. There were seven warrants out for his arrest, and he ended up living on the street.  

"When we found out that the precipitating factor was so minor, we were able to find a way to pay off those tickets and get him stabilized," Gagen says. "We were able to get him into housing, and now he's a member of society again."   

T3 has been in existence for about two years and has served 85 people. Recently, the city and county opened up small apartments to house formerly homeless people; now 49 of those people have been placed in housing.  

"They pay rent based on their ability to pay," he says. "There are continuing case management services at the complex, and we expect most of them will find work in the community."   

Sutter Medical Center has invested almost a half million dollars in getting T3 up and running, and that investment has yielded significant results. For example, there's been a 54% reduction in emergency department usage. For clients who've been involved in the program for more than six months, emergency room use has dropped by 65%. 

"We've also seen a reduction in hospital bed days for this population by about 35%. About 80% of these clients have reduced their substance abuse significantly." Gagen says. "These efforts do benefit the hospital economically, and we also look on these services as part of our commitment to serve the community."   

If you help patients and members address challenges in their basic life needs, they will better attend to their healthcare and avoid costly events