Addressing Insomnia

SOURCE: Buysse DJ, et al. JAMA 2017;318:1973-1974.

Everyone likely experiences transient sleeplessness sometimes. However, when sustained for at least three nights/week for at least three months (in the absence of factors that predictably would preclude normal sleep, such as excessive stimulants, illicit drugs, load ambient noise, prominent ambient light, restless legs syndrome), the condition merits the diagnosis of insomnia.

The potential consequences of insomnia are obvious even to those who experience an occasional transient sleep disruption: daytime fatigue and difficulty concentrating.

The American College of Physicians recommends cognitive behavioral therapy as preferred initial treatment for insomnia. When insomnia is a major component of depression, there is some advocacy for inclusion of soporific agents (e.g., zolpidem, zaleplon, eszopiclone) as “bridging” sleep agents during the initial titration of antidepressants, with discontinuation once antidepressants have established efficacy (assuming depression-related insomnia is resolving appropriately). Despite the entrenched habits of clinicians and patients for chronic use of sleep agents, evidence supporting this practice is weak. Clinical trials on which currently available sleep agents have been approved generally are short-term. The absence of long-term safety data is a cause for concern. It is suggested that when using soporific agents, short-acting agents are preferred (e.g., temazepam, zolpidem). If possible, intermittent use (three to four nights/week) also is preferred, with intention to taper and discontinue medications after three to four weeks. Ultimately, if cognitive behavioral therapy is insufficient to remedy insomnia, sedative-hypnotic agents must be added sometimes. Consultation with a sleep expert for refractory cases, or for cases requiring more sustained use of medications, is fully appropriate.

The Sticky Wicket of Androgen Receptor Modulators

SOURCE: Van Wagoner RM, et al. JAMA 2017;318:2004-2010.

For those of British or British Colonial heritage, “sticky wicket” probably needs no explanation, referring to the game of cricket as it does. In the United States, the term generally refers to croquet, so stated when a wicket is particularly difficult to pass through.

Enhancement of androgens in the United States is big business. But can consumers rely on internet-advertised products as safe, effective, and containing the stated constituents without adulterants? Van Wagoner et al obtained product samples (44 different products) of androgen receptor modulators sold online and analyzed their contents using the rigorous methods approved by the World Anti-Doping Agency.

Less than half the products tested contained the amount of active product claimed on the label. Almost 20% of the products contained none of the claimed active component. Some products contained substances banned by the World Anti-Doping Agency, and some contained growth hormone secretagogues.

Because many of these products are sold as dietary supplements, they are not subject to the same FDA regulations and surveillance as proprietary pharmaceutical drugs. Since many of the supplements contain substances that either have not been studied in humans or feature little safety data, clinicians should inform potential users about the limitations of such products.

Updated Hypertension Guidelines

SOURCE: Goldfarb IT. JAMA 2017;318:2075-2076.

The most recent American Heart Association/American College of Cardiology (AHA/ACC) hypertension guidelines have created a literature stir, although there remain many clinicians who are not wholly on board with the updated recommendations. Since 1977, when the first National Heart, Lung, and Blood Institute-directed guidance on hypertension was issued, periodic updates have occurred. In 2013, responsibility for cardiovascular disease clinical practice guidelines was transferred to the AHA/ACC, which subsequently released this lengthy and detailed 2017 document.

Perhaps the most novel innovation is the recategorization of systolic blood pressure 130-139 mmHg or diastolic blood pressure 80-89 mmHg as stage 1 hypertension. Previously, this blood pressure zone was labeled prehypertension. The rationale for the new designation is, in part, that previous data indicated as much as a two-fold increase in cardiovascular disease risk when stage 1 hypertension is compared to blood pressure < 120/80 mmHg, coupled with convincing results from recent trials (e.g., SPRINT) that indicate systolic blood pressure levels < 120 mmHg are not only achievable — and, for the most part, safe — but also improve cardiovascular outcomes. Not all major agencies are advocates. For instance, the American Academy of Family Physicians (AAFP) has not endorsed the new guidelines, but instead advocates for the JNC 8 document, which the AAFP suggests provides a more robust evidence base.