Sedative hypnotics

[ViewsAskew]

As I am re-reading The Clinical Management of Restless Legs Syndrome, I was surprised at how strongly the authors make the case....against using this class of drugs as a first-line treatment.

First, this is the class that contains benzodiazepines such as clonazepam (Klonopin), temazepam, ativan, etc.

Here are some quotes:
"Most RLS experts use these drugs sparingly to treat RLS symptoms, for which they are not approved, but rather to treat the insomnia associated with RLS (for which most are approved)."

"Another concern about the use of sedative hypnotics (especially with their daytime use or with the bedtime use of long-acting ones that may spill over into the next day) is that they have the potential for worsening daytime RLS symptoms and increasing the risk of accidents from activities that require vigilance."

During this part of the book, they make points regarding some early RLS studies related to these drugs. They make two points regarding why those studies were flawed and draw the conclusion that the study results (that this class of drugs helps RLS) may not be accurate. Their concerns are related to placebo effect and sleep disruption. The studies looked at sleep disruption, not a decrease of RLS symptoms. Since these drugs definitely address sleep disruption, it may be that the study measured the wrong thing and erroneously conclude the they help RLS.

They do go on, however, to say the following, "However, the goal of physicians is to make patients feel better. If these drugs do accomplish this goal for RLS sufferers, they should be considered, especially when other drugs have not been helpful."

"After years of not sleeping well, they [the long term RLS sufferer] typically develop a conditioned insomnia. The use of sedative-hypnotic drugs may be invaluable to break this cycle."

When they talk about choosing a drug, they are clear about what to look for, "However, when choosing a sedative hypnotic, it is generally best to select one that has a quick onset to promote sleep initiation and a relatively short half-life to prevent daytime sleepiness or drowsiness that in turn may promote increased RLS symptoms."

"For chronic daily use, the nonbenzodiazepines are far more preferred due to their decreased side effect profile and markedly decreased risk of tolerance and dependence."

[Aiken]

One important thing to understand about the hypnotics is that they can induce a form of amnesia for part of the duration of action. Therefore, the patient may think they've been asleep for several hours, when in fact they woke up into a fog after half an hour and tossed and turned for most of the time afterward. They don't remember with their mind, but their body knows it didn't get enough rest.