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  • Updated 07.19.2021
  • Expires For CME 07.19.2024

Drug-induced insomnia and excessive daytime sleepiness

Introduction

Overview

Several drugs are associated with sleep disorders. This article starts with a classification of drug-induced insomnia and daytime sleepiness. 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.

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

• Recognition of drug-induced insomnia as well as daytime sleepiness 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.

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. Although levodopa was introduced in the 1960s, reports of levodopa-induced sleep disruptions did not appear until several years later (18).

The information on drug-induced sleep disorders 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 in all instances, 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 (01). “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 insomnia and daytime sleepiness associated with therapeutic use of drugs, but other substances, such as recreational drugs, are not included. Other drug-related sleep disorders such as parasomnias are described in another MedLink Neurology article.

Table 1. Classification of Drug-Induced Insomnia and Daytime Sleepiness

Insomnia due to drugs or other substances

• use of CNS stimulants
• paradoxical effect of hypnotics
• rebound and withdrawal insomnia resulting from sudden discontinuation of hypnotics
• insomnia due to other side effects of drugs, eg, sleep apnea, restless legs syndrome

Daytime sleepiness and drowsiness

• sleepiness as sequel of drug-induced insomnia
• drowsiness due to withdrawal of CNS stimulants
• drowsiness as side effect of drugs
• sleep attacks

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