Drug-induced sleep disorders

K K Jain MD (Dr. Jain is a consultant in neurology and has no relevant financial relationships to disclose.)
Originally released August 5, 1999; last updated July 10, 2017; expires July 10, 2020

This article includes discussion of drug-induced sleep disorders, daytime sleepiness, drug-induced insomnia, restless legs syndrome, sleep apnea, and vivid dreams and nightmares. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Several drugs are associated with sleep disorders. This article starts with a classification of various drug-induced sleep disorders and lists drugs associated with each. Some sleep disorders, such as sleepwalking, have been associated with the use of hypnotics for insomnia. Pathomechanism is described when known. This knowledge may help in the modification of drug therapy or alternative medications.

Key points

 

• Several sleep disorders have been reported as secondary to adverse effects of drugs.

 

Excessive daytime sleepiness and insomnia are the most common of these adverse effects but disorders of breathing and movement during sleep may also occur.

 

• Insomnia may occur due to use of prescription or recreational drugs as well as caffeine and alcohol.

 

• Recognition of drug-induced sleep disorders and their distinction from primary sleep disorders and sleep disturbances that occur in neurologic diseases is important for the management of patients.

Historical note and terminology

Sleep disorders, particularly insomnia, and the use of sleep-inducing drugs have been well known throughout medical history. Similarly, sleep disturbances induced by ill-timed use of beverages such as alcohol and coffee, as well as by the desired or undesired effects of recreational drugs, are common knowledge. Drugs are also associated with parasomnias, a category of sleep behavioral disorders in which abnormal events, such as sleepwalking, occur during sleep.

In contrast to the therapy of sleep disorders, little attention was paid to the adverse effects of therapeutic drugs on sleep until the introduction of barbiturates as hypnotics. The long-term use of hypnotics as a cause of drug-induced insomnia was recognized in 1970s. Reports of sleep disturbances associated with other therapeutic drugs also started to appear in the 1970s and 1980s. Nightmares were observed with the initiation or withdrawal of tricyclic antidepressants and with the use of neuroleptic drugs (Strayhorn and Nash 1978). Although levodopa was introduced in the 1960s, reports of levodopa-induced sleep disruptions did not appear until several years later (Sharf et al 1978).

Sleep may be disturbed as a sequel of other drug-induced adverse drug reactions. For example, patients with movement disorders may have difficulty sleeping and patients on diuretics may have to get up frequently at night to urinate. This article describes sleep disorders associated with the use of therapeutic drugs. The information is based on a review of the literature and on reports of adverse reactions received by pharmaceutical manufacturers. The causal relationship is not proven by the usual scientific criteria, but the list of drugs should be considered during investigation of patients with sleep disorders. The International Classification of Sleep Disorders ICSD-3 mentions "sleep disorders resulting from a drug or substance" under the following categories: (1) central sleep apnea; (2) sleep-related hypoventilation; (3) hypersomnia; (4) parasomnia; and (5) sleep-related movement disorders (American Academy of Sleep Medicine 2014). “Drug or substance” can be a prescription medication, recreational drug, caffeine, alcohol, or food item or exposure to an environmental toxin. A practical classification of drug-induced sleep disorders, which reflects how they are reported in the literature, is shown in Table 1. This article is focused on sleep disorders associated with therapeutic use of drugs, and other substances, such as recreational drugs, are not included.

Table 1. Classification of Drug-Induced Sleep Disorders

Excessive sleepiness

 

• daytime sleepiness

Insomnia due to drugs or other substances
Rebound and withdrawal insomnia
Drug-induced sleep-related breathing disorders

 

• snoring
• sleep apnea

Drug-induced sleep-related movement disorders

 

• excessive movements of limbs, restless legs syndrome
myoclonus

Drug-induced parasomnias: sleep behavioral disorders

 

rapid eye movement sleep behavior disorder
• vivid dreams and nightmares
• sleepwalking
• sleep-eating
sleep paralysis
• enuresis
bruxism

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