Despite the importance of good quality sleep for nearly every aspect of health, more than one-third of adults get less than the recommended seven hours of sleep per night. This may be for many reasons. For some, the culprit may be sitting in their medicine cabinet. Studies have calculated that the use of just one medication increases the risk of insomnia by 66%.
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Overview of Medication-Induced Sleep Disturbances
By altering sleep architecture and sleep quality, medications hold the potential to cause sleep-related side effects that include insomnia, daytime sleepiness, and nightmares (25).
Sleep architecture is the pattern and structure of sleep stages throughout the night. It consists of three stages of non-rapid eye movement (NREM) sleep followed by rapid eye movement (REM) sleep. Each stage serves different functions, including physical healing, memory consolidation, and emotional processing. (41)
Sleep quality refers to the characteristics of sleep that determine its effectiveness and the degree to which individuals feel rested upon waking. Subjective measures of sleep quality include:
- Sleep latency: the time it takes to fall asleep
- Frequency of nighttime awakenings
- Sleep duration: the amount of time a person sleeps
- Sleep efficiency: the proportion of time that is actually spent sleeping
Why does this matter? In a systematic review and meta-analysis of 16 studies, including over one million men and women, short sleep duration was associated with a greater risk of all-cause mortality. Sleep deprivation alters cognitive functioning, increasing the propensity to engage in risky behaviors and the incidence of workplace and motor vehicle accidents. Poor sleep has also been linked to the development and progression of chronic diseases, including heart disease, diabetes, anxiety, depression, neurodegenerative diseases, and obesity.
1. Beta-Blockers
Beta-blockers are a class of medications primarily used to treat cardiovascular conditions, such as high blood pressure and arrhythmias (irregular heartbeats). They work by blocking the action of beta-adrenergic receptors to lower blood pressure and heart rate and improve blood flow. (3)
How They Affect Sleep:
Beta-blockers may reduce your natural levels of melatonin by inhibiting beta-1 adrenergic receptors (14). Melatonin is a hormone that helps regulate the normal wake-sleep cycle and induces sleepiness at night. If a beta-blocker suppresses natural melatonin production, it can lead to difficulties falling or staying asleep.
Beta-blockers may also interrupt sleep by causing nightmares in up to one-third of patients taking them.
Management Strategies:
You should never reduce your dose or discontinue a beta-blocker without talking to a doctor. Sometimes, your doctor may lower the dose or prescribe an alternative medication with similar actions. (17, 18)
Taking beta-blockers earlier in the day can minimize their impact on sleep. Avoiding stimulating activities, like high-intensity exercise, before bed may also help you fall asleep. (17, 18)
Studies have shown that taking 0.3-2 mg of melatonin before bed can improve sleep patterns and quality in elderly patients with insomnia (14).
2. Corticosteroids
Corticosteroid medications mimic the effects of cortisol to reduce inflammation. They are prescribed for a wide range of medical conditions, including autoimmune diseases, allergic reactions, lung disease, and skin conditions. (27)
How They Affect Sleep:
Cortisol and cortisol-mimicking drugs have stimulatory effects on the nervous system, leading to increased alertness and other physical symptoms that can interfere with the ability to relax and sleep, such as rapid heart rate and feelings of anxiety.
Management Strategies:
Steroids are generally prescribed for short courses, and sleep disturbances resolve once the treatment course is completed (17).
However, some individuals may require prolonged corticosteroid use. Insomnia is reported by more than 60% of chronic steroid users, and the incidence increases as the dose does. For individuals requiring long courses of corticosteroids:
- When possible, take steroid medications in the morning to minimize their impact on sleep.
- Discuss lowering the dose or alternative treatment options, such as non-steroidal anti-inflammatory drugs (NSAIDs), disease-modifying antirheumatic drugs (DMARDs), and biologic therapies.
- Complementary and integrative therapies, such as acupuncture, mindfulness-based stress reduction (MBSR), or cognitive-behavioral therapy for insomnia (CBT-I), may help alleviate sleep disturbances and improve sleep quality.
3. SSRI Antidepressants
Selective serotonin reuptake inhibitors (SSRIs) are a class of antidepressant medications commonly prescribed to treat depression and anxiety disorders. SSRIs work by increasing the levels of serotonin, a neurotransmitter involved in mood regulation, in the brain. (32)
How They Affect Sleep:
In addition to mood, serotonin helps to regulate the sleep-wake cycle and influences sleep architecture (21, 26). Therefore, medications that modulate serotonin levels can suppress REM sleep and increase sleep latency and the number of nighttime awakenings (33).
However, the effects of SSRIs on sleep are a little more complex, as there are also reports of this class of medication causing increased drowsiness with their use (2).
Management Strategies:
If your SSRI is making it hard to fall asleep or making you tired during the day, talk to your doctor about the following management strategies:
- Reducing the dose
- Modifying the time of day at which you take your medication. For example, if your SSRI causes insomnia, take it in the morning. Conversely, if it makes you drowsy, take it at night before bed.
- Switching to another SSRI or class of antidepressant that has a different side effect profile on sleep
In addition to pharmacotherapy, alternative treatment options for anxiety and depression may be considered. These may include psychotherapy, exercise, light therapy, and mindfulness-based practices. Evidence-based complementary therapies have been shown to alleviate the severity of symptoms associated with anxiety and depression, enabling patients to gradually decrease their reliance on antidepressant medications.
4. ACE Inhibitors
Angiotensin-converting enzyme (ACE) inhibitors are a class of medication that works by inhibiting the activity of ACE, which regulates blood pressure and fluid balance in the body. ACE inhibitors are commonly prescribed to treat and manage symptoms of cardiovascular diseases, diabetes, and kidney disease. (1)
How They Affect Sleep:
ACE inhibitors may cause a dry, persistent cough in up to 30% of patients who take them. The mechanism underlying ACE inhibitor-induced cough involves the accumulation of a protein called bradykinin, which irritates the respiratory tract. Coughing episodes at night can interfere with falling and staying asleep. (4)
Management Strategies:
The only effective treatment for ACE inhibitor-induced cough is cessation of the medication. This should only be done under the guidance of a healthcare provider. Discontinuation of the ACE inhibitor should resolve the cough within 1-4 weeks. Your doctor will likely switch you to an alternative class of antihypertensive medication called an angiotensin receptor blocker (ARB). ARBs provide similar cardiovascular benefits to ACE inhibitors but are less likely to cause cough. (11)
5. Decongestants
Decongestants relieve nasal congestion, often associated with conditions such as the common cold, allergies, and sinusitis. They decrease nasal swelling and congestion by stimulating alpha-adrenergic receptors to narrow blood vessels and reduce blood flow in the nasal passages. They can be administered topically or orally. (16, 22)
How They Affect Sleep:
As many as 25% of patients taking oral decongestants experience insomnia and irritability. This is because the activation of alpha-adrenergic receptors in the central nervous system is stimulating, producing symptoms like fast heart rate, high blood pressure, and racing thoughts. This heightened state of arousal interferes with winding down, relaxing, and falling asleep.
Management Strategies:
When possible, take decongestants earlier in the day. This allows more time for the medication's stimulating effects to wear off before bedtime, which may result in fewer sleep disturbances.
Doctors may also recommend non-stimulating alternatives for those who need a decongestant closer to bedtime. Alternative options include steroid nasal sprays, oral or nasal antihistamines, and nasal saline sprays. (17)
Consulting With Healthcare Professionals
Sleep-related side effects of medications should never be ignored. Given the importance of sleep for overall health, patients are always encouraged to discuss sleep problems with a doctor. While you should never alter a medication regimen on your own, management strategies to address medication-induced sleep disturbances include adjustments to medication timing and dosage or exploring alternative treatment options that have fewer sleep-related side effects.
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Key Takeaways
- Medications can disrupt sleep by interfering with normal sleep architecture and causing side effects that negatively impact sleep quality.
- Taking medication should never come at the cost of losing sleep because sleep deprivation is associated with an increased risk of chronic disease and mortality.
- Patients who experience medication-induced sleep disturbances should discuss these concerns with a healthcare provider to explore management strategies that address their medical needs and sleep quality.
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