alan g. pocinki, m.d. ehlers-danlos national foundation learning conference july 22-23, 2011

Alan G. Pocinki, M.D. Ehlers-Danlos National Foundation Learning Conference July 22-23, 2011

Overview Autonomic nervous system (ANS) regulates all body processes, including sleep ANS dysfunction is very common in the hypermobility syndromes, and underlies many of its symptoms The most common type of sleep disorder seen in the hypermobility syndromes appears to have an autonomic basis

Basics of the ANS Sympathetic nervous system: fight or flight, the accelerator Parasympathetic nervous system: rest and digest, the brake

Adrenaline Concept of adrenaline reserve Central paradox: the lower the reserves, the more exaggerated the stress response, or The more tired you get, the harder it is to sleep

Treatment of Autonomic Dysfunction Better sleep Address underlying problems: Dehydration Low blood sugar Emotional stresses Pain Fatigue

Restoring Autonomic Balance Better sleepquantity and quality Adequatereallypain control Adequate salt and fluid Avoid hypoglycemia Minimize emotional stresses (realistic goals, not negative, guilty Dont push through fatigue Take breaks, time outs

Your suggestion to ratchet down my level of busy- ness [by taking frequent short breaks] to facilitate relaxation is great. Its helpful and enjoyable. Its good to have doctors orders to relax and read a book for a few minutes in the middle of the day!

Non-Restorative S leep Frequent arousals and awakenings Little or no deep sleep Normal Sleep Non-Restorative Sleep

Treatment of Sleep Disorders Good sleep hygiene Comfortable mattress Dark and quiet Elevate head of bed Medication regimen Multiple medications with complementary effects usually needed Finding the right combination can be a frustrating trial and error process Home sleep monitor can be helpful in assessing response

Treatment of Sleep Disorders: Medication Beta blockers Clonidine Alpha blockers Benzodiazepines Analgesics Muscle relaxants Other agents Trazodone, amitryptiline, doxepin Neurontin, Lyrica Sleeping pills Antidepressants

Beta Blockers Propranolol Start with 10 mg at bedtime Increase by 10 mg every 4-5 days until fewer awakenings, side effects, or no further benefit Switch to long-acting if needed Take some earlier to offset second wind Often need smaller daytime dose as well

Other Beta Blockers Metoprolol Start with half a 25 mg tablet (tartrate) Increase by half a tablet every 4-5 days Add long-acting (metoprolol succinate) if needed Nadolol Safest in asthma Start with 20 mg Increase by 20 every 4-5 days Consider smaller daytime dose Carvedilol Start with 3.125 mg Increase by one tablet every 4-5 days Add smaller AM dose if needed

Clonidine Start with 0.1 mg Increase by 0.1 mg no sooner than one week No more than 0.3 mg Consider long-acting clonidine (Nexiclon XR)

Alpha Blockers Prazosin best studied, shown to reduce nightmares in PTSD, where a hypersensitivity to adrenaline triggered many of their nightmares. In a VA study, 75- 80% of PTSD patients stopped having nightmares. Usual dose is 4mg Can worsen orthostatic intolerance Not clear if combination alpha-beta blockers (e.g. carvedilol) are as effective, but probably not.

Benzodiazepines All have beneficial properties: Sedative Anti-anxiety Muscle relaxant Anti-movement, anticonvulsant Anti-adrenaline But also potential problems: Impair cognition, motor performance Depress mood, respiration Cause or worsen fatigue Tolerance Dependence Withdrawal

Some Common Benzodiazepines Clonazepam Longest-lasting, most likely to have residual effects Also effective for restless leg, PLMS Diazepam Typically lasts about 8 hours Probably best muscle relaxant Temazepam Typically lasts about 7 hours Capsule limits dosage adjustment Lorazepam Typically lasts about 6 hours Metabolized differently (less variability, interactions)

Analgesics Anti-inflammatories NSAIDs: Naproxen, Meloxicam, Celebrex Prednisone Tramadol, short- and long-acting Narcotics, short- and long-acting, patches Cymbalta, Savella Neurontin, Lyrica Lidoderm Flector, Voltaren Gel, Pennsaid

Muscle Relaxants Cyclobenzaprine Shown to improve sleep quality in fibromyalgia Has analgesic, sedative, muscle relaxant properties Soma Less sedating, but probably more analgesic effect, especially with narcotics Skelaxin Less sedating, some can tolerate daytime doses Tizanidine More sedating, high margin of safety Baclofen Potent, use for severe painful spasm only

Other Agents Trazodone Probably most effective at increasing deep sleep Low dose, 50-150 mg, most people take 50 Amitryptiline Also increases deep sleep, especially with pain Start at 10 mg, most people take 20-40mg Doxepin Enhances sleep more at lower doses 10 mg tablet, liquid, or Silenor 3 mg, 6 mg DDAVP (Desmopressin)?

Sleeping Pills Zolpidem, short- and long-acting Doesnt reduce arousals or improve sleep architecture Onset/maintenance, e.g. until other meds effective Retrograde amnesia Zolpidem usually lasts 5 hours, ER about 7 Lunesta Doesnt reduce arousals or improve sleep architecture Occasionally helps with sleep onset and maintenance, e.g. until other medications become effective Usually lasts about 7 hours Zaleplon Good for sleep onset, especially getting back to sleep Lasts 2-3 hours, no cognitive impairment

Antidepressants SSRIs often cause shallower sleep, more dreams Prozac worst, Lexapro best Lowest effective dose, consider liquid formulations Cymbalta sleep neutral if taken in AM Tricyclics generally improve sleep, but often cause daytime sedation Wellbutrin impairs sleep if taken late in day, so take once-daily (XL) form early in day or consider AM only dosing of twice a day (SR) form

DO YOU HAVE ANY DATA?

ONLY THE TWO- LEGGED KIND!

I think your diagnosis was spot on! I had the prescription for the beta blockers filled immediately and... taking it appears to make a significant difference in my quality of sleep. I am already starting to feel more refreshed in the morning.

Summary The most common type of sleep disorder seen in the hypermobility syndromes appears to be characterized by excessive sympathetic activity at night Medications to suppress, offset, or block this excess activity are effective in improving sleep, measured both by polysomnography and symptoms Replenishing autonomic reserves, minimizing daytime stresses, and improving daytime autonomic balance also help improve sleep, which in turn improves daytime function, which in turn improves circadian rhythms and sleep, which ..

alan g. pocinki, m.d. ehlers-danlos national foundation learning conference july 22-23, 2011

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