New AASM guideline on shift work disorder leans on low-cost fixes, steers clinicians away from benzodiazepines

Nurses, factory workers and police officers have one thing in common: Their schedules often run against the body’s natural clock, particularly when shifts rotate. Some develop shift work disorder (SWD), which the Sleep Foundation describes as “a circadian rhythm sleep disorder” that “can affect people who work overnight, early morning, rotating, or other nontraditional schedules.”

In the United States, 20% of workers are employed outside the typical 9 a.m. to 5 p.m. workday. About 27% of adult shift workers have SWD, according to a meta-analysis cited in the new guideline from the American Academy of Sleep Medicine (AASM). The guideline, published in the Journal of Clinical Sleep Medicine, is the group’s first update to its treatment recommendations since 2007.

For payers, clinicians and patients, many of the recommendations rely on inexpensive, widely available options.

What the AASM recommends for shift work disorder

A task force of experts in sleep and circadian medicine developed 19 recommendations, and only a handful involve prescription drugs.

For adults with SWD who have excessive sleepiness, the guideline suggests modafinil or armodafinil taken 30 to 60 minutes before a night shift. They are the only FDA-approved medications for excessive sleepiness in patients with SWD.

Other recommendations to reduce sleepiness include:

• Caffeine before or during the night shift
• Bright light during the night shift
• A nap before the night shift
• Eating only a snack, or nothing, rather than a full meal during the night shift
• Clockwise rotating schedules (days, then evenings, then nights) rather than counterclockwise
• Combining caffeine with bright light, or a nap with caffeine

To help patients sleep during the day, the guideline suggests:

• Cognitive behavioral therapy for insomnia (CBT-I)
• Melatonin, for daytime sleep after a night shift, for the switch back to nighttime sleep, and before a nap ahead of the first night shift
• Ramelteon and other melatonin receptor agonists
• Suvorexant (Belsomra) and other dual orexin receptor antagonists

The guideline recommends against triazolam and other benzodiazepines. The task force concluded that the risks, including falls, misuse, dependence and withdrawal, outweigh the benefits.

Low-cost options for shift work disorder

Many of the options cost little or nothing, and the guideline rated modafinil and armodafinil as low cost because both are available as generics. A 30-day supply of generic armodafinil starts at about $32 for cash-paying patients, according to Drugs.com, compared with about $474 for a 30-day supply of Belsomra. The task force noted that suvorexant involves moderate costs to patients.

Access to CBT-I may be limited by a shortage of trained providers, financial constraints and the time needed to complete a full course of treatment, according to the guideline.

“There is no one-size-fits-all solution for shift work disorder,” Kenneth P. Wright Jr., Ph.D., a professor at the University of Colorado Boulder and lead co-author of the guideline, said in a news release. “Our recommendations reflect the reality that patients have different schedules, symptoms, and constraints, and clinicians need flexible, evidence-based strategies to help them function safely and sleep effectively.”

Limits of the evidence

All of the recommendations are conditional, and most are based on low or very lowcertainty evidence. Modafinil and armodafinil were the only treatments supported by moderate certainty evidence. Much of the evidence came from laboratory studies of healthy adults or from shift workers who had not been formally diagnosed with SWD.

Shift work has been linked to cardiometabolic disease, weight gain and cancer, but none of the studies reviewed examined whether these treatments reduce those long-term risks. The effect of wake-promoting medications on real-world accident rates also has not been studied.

“More research is needed into interventions that can both target acute symptoms and mitigate long-term health risks,” the authors wrote.