“Only a third of Germans can sleep well,” said Ingo Fietze, M.D., director of the multidisciplinary center for sleep medicine at the Berlin University Hospital Charité. Medscape medical news. So sleep professionals have a lot of work to do. But I can’t do it without the support of my family doctor. But the latter are often not accustomed to sleep disturbances. Medscape spoke to Fietze about why this is so, how it might help patients, and how a new class of sleeping pills could help. I am a sleep doctor who specializes in internal medicine and respiratory medicine.
Medscape: The COVID-19 crisis, the Ukraine war, the energy crisis, inflation, climate change, and many other things have combined to keep people from sleeping in the last few years. Have you observed an increase in the number of patients with sleep disorders?
Fitse: Either way, our phones ring all day and the waiting list is long. However, the number of inquiries by e-mail has increased from all over the country.
Medscape: Why is it in such demand? How common are sleep disorders?
Fitse: No medical condition is more common than sleep disorders. The most common sleep disorders are insomnia on the one hand and snoring and breathing problems on the other. 10% of all adults have severe insomnia requiring treatment. About 17% have sleep apnea that requires treatment.
However, there is a serious shortage of sleep medicine care in Germany. General practitioners have a problem. They don’t know much about sleep. This is related to the fact that in Germany sleep medicine is only taught at individual universities for about five years. Furthermore, there has been no continuing medical education in the sleep field for nearly 30 years. However, with so few sleep specialists and sleepology practitioners, general practitioners must actually treat people with sleep disorders as well.
Medscape: What are the most common causes of chronic sleep disorders?
Fitse: The cause is ultimately always genetic, but is still unknown for all forms of sleep disorders. You may be lacking wakefulness hormones or having too many sleep hormones. Sleep apnea can also be due to predisposition and certain deficiencies. The nerves that control the muscles in your throat don’t work properly during sleep.
Medscape: Melatonin has gotten a lot of hype lately. Patients can get it over-the-counter at pharmacies. What do you think of these self-medication products?
Fitse: Mostly silly, but hats off to the business model. Too little sleep care in Germany promotes promising products while many people suffer from sleep disorders. However, melatonin is only helpful if you have a melatonin deficiency.
Medscape: What about refundable melatonin products and when should I use them?
Fitse: These products are approved for those over the age of 55. In older patients, humans produce less melatonin with age, so it makes sense to try melatonin for two to four weeks. It takes too long.
Medscape: Earlier this year, the European Medicines Agency issued a Marketing Authorization Recommendation for the orexin receptor antagonist daridrexant (see box). The drug has been available on the German market since November. You yourself participated in important research. Could it be a breakthrough in treating insomnia? What kind of patients is it suitable for?
Fitse: If there were enough sleep specialists and doctors practicing sleep medicine, it would be a breakthrough. Orexin receptor antagonists are based on a completely different mechanism of action than known benzodiazepines and his Z drugs. This is why dalidrexant may be recognized as a sleeping drug by neurologists and psychiatrists who see many insomnia patients. It is also an opportunity for many affected people who have hitherto been treated primarily with psychotropic medications.
By the way, benzodiazepines can also lose effectiveness over time. Lower with benzodiazepine agonists (Z drugs). When the effect decreases, use should be discontinued. In home settings, patients often tend to increase their doses on their own due to psychological strain due to the lack of physician supervision during treatment. Orexin receptor antagonists last longer than benzodiazepines. Also, like Z-drugs, there are very few side effects.
Actions of orexin receptor antagonists
Orexin receptor antagonists are a new class of sleep disorder drugs that modulate the overactivity of the arousal system. They induce sleep and have depressive effects. Their mechanism of action differs from benzodiazepines and his Z drugs, which act as GABA-A receptor agonists. Orexin receptor antagonists prevent orexin A and orexin B neuropeptides from binding to their receptors. These neurotransmitters are produced exclusively by neurons in the hypothalamus and are involved in promoting and maintaining wakefulness.
The most common side effects in pivotal studies were headache and drowsiness. However, it can have significant adverse effects. These include coordination problems, worsening depression, suicidal ideation, brief paralysis or hallucinations on sleep onset and waking, and sleepwalking. , no evidence of abuse or withdrawal symptoms has been shown.
Daridorexant (Quviviq, Idorsia Pharmaceuticals) is the only orexin receptor antagonist so far approved in Germany. It can be used by adults with insomnia whose insomnia symptoms persist for more than 3 months and significantly affect daytime activities. The recommended dose is 50 mg once daily, 30 minutes before bedtime.
Also, with the exception of eszopiclone, there are no long-term studies on existing sleeping pills. Meanwhile, he has a 12-month trial on an orexin receptor antagonist. Patients had no adverse effects after stopping the drug.
Only time will tell if I will continue to use conventional sleeping pills in the future and prescribe new ones only when they no longer work, or if I will start using daridrexant immediately as a first-line therapy.
Medscape: There are more and more medical apps, now including sleep disorder apps. Some can be prescribed. In some cases, your health insurance company will cover the cost. What do you think of such apps and, if applicable, who would you recommend them to?
Fitse: It’s worth a try for anyone who doesn’t yet have chronic insomnia but feels their sleep is getting worse. There are no studies on whether this can actually prevent sleep disorders from developing or becoming chronic. At best, it can improve the symptoms of insomnia. A four-week vacation can have exactly the same effect. I think the most important thing for patients is to learn about healthy sleep and sleep disorders first.
Medscape: What do you think is the role of the general practitioner in treating sleep disorders?
Fitse: Our sleep specialists look forward to working with your primary care physician. General practitioners should take advantage of every opportunity for further education on insomnia. Hopefully, the new drug group will soon lead to more training opportunities.
However, it is unlikely that a general physician will self-diagnose “severe insomnia requiring treatment”. But a correct diagnosis is needed before colleagues can prescribe sleeping pills for her over four weeks without fear of objection.
In the past, general practitioners often issued secondary prescriptions as prescriptions. From my point of view, it is outrageous that insomniacs are the only chronically ill patients who have to pay for their own medicines. Therefore, general practitioners should refer patients with suspected severe insomnia to a sleep specialist who can confirm the diagnosis.
Medscape: Do you have a patient that even you, the sleep expert, can’t do a lot of?
Fitse: We can help most patients. But here’s the problem. A psychiatrist has 100 antidepressants at his disposal. Cardiologist says he has 100 antihypertensive drugs. However, he only has four sleeping pills. If we get nowhere we combine two or three sleep aids for this reason. To help them qualify for pension benefits.
Tips to Help Treat Sleep Disorders
Avoid caffeine after 5pm. The body needs up to 7 hours to break it down.
Exercise can improve sleep. Two and a half hours of moderate exercise, such as Nordic walking, is enough for him.
Ventilate your bedroom to ensure adequate oxygen.
The optimal temperature for sleeping is 17°C to 22°C (62°F to 72°F).
Stressful activities like answering emails should be avoided before bedtime.
Evening rituals such as relaxation exercises, reading books, audiobooks, and relaxing music can help you fall asleep.
If the patient is disturbed by snoring or the partner wakes up or goes to bed at different times, it may make sense to sleep in a separate room.
The problem of falling asleep should be dealt with as calmly as possible. If the person is up for a long time, they should get up and do something relaxing, such as reading. Usually the next drowsiness he appears after 90 minutes.
This article was translated from the German version of Medscape.