Chief Complaint “I can’t sleep.”
HPI: Judy Miller is a 55-year-old woman who is referred by her family medicine physician to a pharmacotherapy clinic for medication therapy management for insomnia. She receives help paying for her medications from medication assistance programs. She has been experiencing long-standing insomnia for approximately 9 months. Specifically, she is having difficulty falling and staying asleep at least four to five times during the week, and then sleeps all day on Sunday. Ms Miller is currently taking temazepam 30 mg daily at bedtime that was recently increased from 15 mg. She said that she started taking valerian root 600 mg 6 weeks ago based on a friend’s recommendation but does not feel any benefit. Additionally, she has been experiencing vivid dreams that she attributes to the valerian root. When she had health insurance, she started cognitive behavioral therapy for insomnia (CBT-I); however, when she lost her insurance, she was only able to complete six out of eight sessions, with last session over 4 weeks ago. She endorsed moderate benefit from CBT-I but still complained of residual symptoms. She is also experiencing depression due to not having any employment and a stress of a partner who recently moved in with her because he could not pay his apartment rent. Her most recent Patient Heath Questionnaire-9 (PHQ-9) result was 20. She admits to being intermittently nonadherent and missing doses of scheduled inhaled medications for COPD and sertraline, olanzapine/fluoxetine, and valerian root one to two times per week. She reports that she is no longer able to see her psychiatrist due to cost of the visits.
PMH: Insomnia for many years COPD Depression Migraine headaches GERD Allergic rhinitis
FH: Mother is alive and well and lives nearby. Father died of MI at age 65.
SH: She is in a new relationship with her partner who recently moved in due to his own financial difficulties. Unemployed, leading to stress at home to pay bills but receives some money from her mother. She smokes approximately five cigarettes per day now but has smoked up to two ppd in the past. She does not drink alcohol. She sees a deacon at her church for counseling regularly. She receives medication assistance for several of her medications from a local agency.
Medications: Temazepam 30 mg PO QHS PRN sleep, Fluticasone/salmeterol DPI 250/50 one inhalation twice daily, Albuterol MDI two puffs Q 6 H PRN SOB, Tiotropium Handihaler one inhalation daily, Sertraline 200 mg PO Q AM, Olanzapine 3 mg/fluoxetine 25 mg PO Q PM, Sumatriptan 100 mg PO PRN for migraine, Atenolol 25 mg PO Q AM for migraine prophylaxis, Ibuprofen 200-400 mg PO Q 6 H PRN for pain/migraines, Tramadol 50 mg PO Q 6 H PRN for pain/migraines, Hydrocodone 5 mg/acetaminophen 325 mg PO Q 4-6H PRN for pain/migraines, Dexlansoprazole 60 mg PO Q AM ,Pseudoephedrine 30 mg PO Q 6 H PRN allergies, Valerian root supplement 600 mg PO QHS
Allergies: NKDA
ROS: Patient reports that she does not sleep at all during the week and only sleeps on Sunday. She also reports some improvement in sleep hygiene based on previous recommendations, such as avoiding eating too close to bedtime and long naps, but she continues to exercise in late evenings and reads and watches television in bed. She has cut back to three cups of coffee throughout the day, reduced from six to eight cups of coffee throughout the day. She continues to experience difficulty going to sleep and staying asleep and reports having had this problem for several years. Additionally, the temazepam does not seem to help much. Due to reports of awakening during the night and risk factors for obstructive sleep apnea (ie, postmenopausal, family history of OSA, GERD, increased BMI), her primary care provider ordered a sleep study that was normal other than some minimal snoring. She has a long history of depression but has never been hospitalized. She currently is not experiencing a “blue mood” or any thoughts of suicide, and her PHQ-9 score today is 20. She has been prescribed sertraline, which she tolerates well, and the combination of olanzapine and fluoxetine to help with her depressive symptoms. Her COPD is secondary to a long history of smoking but is currently controlled on tiotropium, fluticasone/salmeterol, and albuterol PRN. She has experienced migraine headaches for several years and uses sumatriptan and ibuprofen PRN and atenolol daily for prophylaxis. She sometimes uses tramadol and hydrocodone/acetaminophen as well for migraines. Her GERD, which she experiences when she is supine, is currently controlled on dexlansoprazole. She has runny nose, congestion, and itchy eyes in the spring.
PE (from the last visit with her PCP)
General: Obese (per BMI criteria), black woman in NAD who looks her stated age
VS: BP 125/80 mm Hg, P 76 BPM, RR 16, T 37°C; Wt 105 kg; Ht 5′6″
Skin: Normal skin color and turgor, no lesions noted
HEENT: Normocephalic, PERRLA, EOMI
Neck/Lymph Nodes: Supple with normal size thyroid, (-) adenopathy
Lungs: CTA bilaterally
CV: Normal S1, S2; no MRG
Abd: NTND, no HSM
Genit/Rect: Deferred. Last PAP smear was WNL 6 months ago.
Ext: No C/C/E; normal muscle bulk and tone; muscle strength 5/5 and equal in all extremities; normal pulses Neuro: Oriented to person, place, and time; CN II-XII intact; Mini-Mental State Examination results: 30/30
Labs : Na 141 mEq/L K 3.9 mEq/L Cl 105 mEq/L CO2 26 mEq/L BUN 12 mg/dL SCr 0.7 mg/dL Glu 85 mg/dL Hgb 13 g/dL Hct 38% RBC 4.4 × 106/mm3 Plt 236 × 103/mm3 WBC 6.8 × 103/mm3 TSH 3.9 mIU/L Free T4 4.0 ng/dL AST 36 IU/L ALT 32 IU/L LDH 112 IU/L GGT 47 IU/L T. bili 0.6 mg/dL T. prot 7.1 g/dL Alb 4.0 g/dL Lipid panel T. chol 215 mg/dL LDL 100 mg/dL HDL 45 mg/dL TG 160 mg/dL
Assessment:
Insomnia, with poor sleep hygiene and sleep environment, that is inadequately managed with long-term use of benzodiazepine
Depression evidenced by PHQ-9 score of 20
Allergic rhinitis and pseudoephedrine use Migraine headache
GERD
Health maintenance and nonadherence to medication
Multiple stressors and poor access to healthcare
QUESTIONS
Create a list of the patient’s drug therapy problems and prioritize them. Include assessment of medication appropriateness, effectiveness, safety, and patient adherence. Create an individualized, patient centered, team based care plan to optimize medication therapy for this patient’s insomnia and other drug problems. Include specific drugs, dosage forms, doses, schedules, and durations of therapy. Considerations:
1. What subjective and objective information indicates the presence of insomnia? What additional information is needed to fully assess this patient’s insomnia?
2. What nonpharmacologic therapies might be useful for this patient’s insomnia?
3. What are the goals of pharmacotherapy in this case? What feasible pharmacotherapeutic alternatives are available for the treatment of insomnia?
4. What alternatives would be appropriate if the initial care plan fails or cannot be used?
5. What information should be provided to the patient to enhance adherence, ensure successful therapy, and minimize adverse effects?
6. Describe how care should be coordinated with other healthcare providers.
7. What economic, psychosocial, cultural, and ethical considerations are applicable to this patient?
8. What clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects?
9. Develop a plan for the follow¬up that includes appropriate time frames to assess progress toward achievement of the goals of therapy.
10. What concerns are there for dependence and misuse of medications indicated for insomnia? What tools can be used to mitigate these risks?
