Do complaints of insomnia stress you out? Well, never fear. In this episode our guest is Dr. Karl Doghramji, Professor of Psychiatry, Neurology and Medicine and the Medical Director of the Sleep Disorders Center at Thomas Jefferson University Hospital in Philadelphia. With his help we deconstruct the “dread pirate” insomnia (as I call it) so you can dominate it in your daily practice.
Dr. Doghramji reports recent relationships with Merck (stock) and consulting work for Merck, Xenoport, Jazz, Inspire, Teva and Pfizer. He has a current research grant from Inspire.
*Pathophysiology: Likely biological, neurobehavioral and psychological hyperarousal. Possible genetic component.
*Depression, anxiety or PTSD may be their primary disorder. Many insomniacs unaware of their depression. Need a high index of suspicion.
*Sleep apnea is probably cause in 10-20% of patients who present with insomnia.
*GERD can present with insomnia and night time awakenings as its primary symptom.
*CBT works as well as pharmacotherapy and has lasting potential even 1-2 years after discontinuation of therapy.
*High yield nonpharmacologic therapy: Get up at the same time every morning. Don’t sleep in, even if bedtime or sleep onset was delayed.
*Melatonin: It’s effect depends on time administered (see below). It’s not as safe as you think (insulin resistance, low sperm count)
1. Administer very low dose (under 3 mg) four to five hours prior to bed for delayed sleep phase (usually occurs in teens).
2. Administer higher dose (3-5 mg) one hour before bed for sleep initiation (adults with fragmented sleep).
*Agents for sleep initiation: zaleplon, zolpidem, ramelteon
*Agents for sleep maintenance: zolpidem ER, eszopiclone, doxepin (low dose of 3mg or 6mg), gabapentin (off label)
*Suvorexant (orexin antagonist) treats both sleep initiation and maintenance: Start 10 mg and go up 5 mg every few weeks to max 20 mg daily. Orexins are deficient in narcolepsy. Orexins seem to mediate a switch system between arousal and sleepiness.
*Doxepin, gabapentin and ramelteon have very lose risk for abuse.
*Off-label use of diphenhydramine for sleep is not recommended ("dirty drug"). Trazodone and mirtazapine also have uncertain benefit.
*Mirtazapine 7.5 mg is the dose for insomnia (more sedating). Lower dose favors histamine receptor.
Links from the Show:
1. This is one possible site for online CBT
2. Melatonin associated with impaired glucose tolerance
4. This site below has easy to understand information on sleep related disorders and links to videos explaining sleep hygiene. You can also download sleep logs, get info.
5. Review on use of mindfulness and meditation for insomnia.
In this episode our guest is Dr. Robert Dickson a Pulmonologist from the University of Michigan who studies the respiratory microbiome. We discuss how the lung microbiome differs in health, chronic illness and acute disease states like pneumonia, sepsis and ARDS. The lung microbiome has the ability to predict frequency of exacerbations and even severity and progression of certain lung diseases. We’ll explore all of this plus Dr. Dickson’s new paper published last month in Nature Microbiology, which had the surprise of finding gut bacteria in the lungs during critical illness. Please enjoy this wide ranging discussion
Dr. Dickson did not report any disclosures.
1. The lungs are constantly bombarded by microbes and the largest host to microbe interface in the body where bacteria come within millimeters of the blood stream.
2. The lung microbiome is altered in both acute and chronic diseases
3. The lung microbiome is altered by antibiotics, corticosteroids, PPIs and probably lots of other things we are just beginning to discover.
Links from the Show:
Dr. Dickson’s latest article reporting gut bacteria in the lungs during critical illnesses.
Dickson, R et al. Enrichment of the lung microbiome with gut bacteria in sepsis and the acute respiratory distress syndrome. Nature Microbiology 1, Article number: 16113 (2016). doi:10.1038/nmicrobiol.2016.113
A link to Dr. Dickson’s podcast discussing the role of microbiome and the care and treatment of critically ill patients.
Dr. Dickson’s recent publication in The Lancet.
Five clinical pearls on the Pulmonary microbiome
Robert P. Dickson and Gary B. Huffnagle. The Lung Microbiome: New Principles for Respiratory Bacteriology in Health and Disease. PLoS Pathog. 2015 Jul; 11(7): e1004923. Published online 2015 Jul 9. doi: 10.1371/journal.ppat.1004923 PMCID: PMC4497592
A comprehensive review of the Pulmonary Microbiome field