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ADD and Insomnia in Male Patient

A male patient, 30, came into the clinic complaining of being unable to fall asleep. He did not have a history of insomnia, but had recently been placed on medications for Attention Deficit Disorder (ADD). Now he is having a hard time sleeping. Would you introduce a sleep medication? Do you have any concerns about doing so? Why or why not?

  • from Doctor Unite 2 months 2 weeks
    No sleep medication as the cause is stimulant induced insomnia. Moreover, the prevalence of physical sleep disorders in ADD/ADHD are very high, particularly OSA/UARS or RLS/PLMD. The patient needs a sleep study
  • from Doctor Unite 2 months 2 weeks
    I would consider extending your day with more work that benefits you to just tire yourself. eventually, you will get tired or use up those stimulants.... Most of the time , we dont use this strategy because we feel like we are already busy with daily activity. Some people are really busy and i can see it but most population, they are really not that busy. So i would do that first, then taking the medicine earlier so starting your day earlier, good sleeping habits and maybe adding hypnotic as last option
  • 2 months 3 weeks
    Assuming that after performing a full history and physical, and that, if there are no other contributing factors, I would consider the following. I would first discuss shorter acting ADHD treatments, lower medication doses if possible, discuss taking the medication earlier in the day, and would review progressive muscle relaxation and deep breathing to assist with sleep onset. If all of that has failed for one reason or another, I would consider starting a medication to assist with sleep onset. I would consider a sedative hypnotic like zolpidem, a short acting benzodiazepine, an alpha 2 agonist like clonidine, an anticholinergic heavy medication like trazodone or some TCAs. If this doesn’t seem helpful, I would consider a trial of an orexin antagonist like lemborexant or suvorexant. Of course, this is all assuming that the patient feels the need to treat the ADHD remains a higher priority than the insomnia.
  • 2 months 3 weeks
    I would consider changing/ stopping rthe AD medication before adding any sleep medication.
  • from Doctor Unite 2 months 3 weeks
    Many of the ADD meds can induce insomnia if taken close to bedtime. In addition to HPI I would inquire about the ADD medication first, modify timing and then if the insomnia persist initiate CBT-I and pharmacotherapy.
  • from Doctor Unite 2 months 3 weeks
    I absolutely agree that defining the cause of the insomnia is crucial. Aside from doing a physical exam, I would query him regarding any other episodes of sleep disorder. Many of the stimulant agents used to treat ADD can cause insomnia, but an agent like Strattera is less often associated with this symptom. If he was given Strattera and these symptoms started, I would want to know about any history of bipolar disorder since SSRI's ( of which Strattera is one) can induce manic episodes. Immediate release stimulant agents might be best assuming all history and physical parameters are normal. The medication would peter out of the system faster than long acting agents. If sleep disruption still persists, a separate management plan, possibly including medications would be needed to control the insomnia.
  • from Doctor Unite 2 months 3 weeks
    he is young healthy why mot treat both
  • from Doctor Unite 2 months 3 weeks
    I would not prescribe a sleep medication. If the ADD medication is a stimulant type it may be that this medication is cause of the insomnia. It may be illustrative to wean off the present ADD medication and start something like Strattera. I would also, of course, do a complete social/sleep hygiene history to check for other stimulant use and use or abuse of substances. A sleep hygiene discussion is an often neglected component of review of systmems.
  • from Doctor Unite 2 months 3 weeks
    I would consult with the psychiatrist who prescribed the stimulant and consider other treatment options for ADHA
  • 2 months 3 weeks
    As many have already stated, I would re-evaluate the ADD treatment first, befire any other workup. There are non-stimulant choices, and meds without significant insomnia. The alpha 2 agents, Clonidine and Guanfacine would seem to me to be better options, perhaps a trial on Amoxetine as well. Failures in treatment usually lead me to reassung the patient, including lifestyles and behaviors. Genetic testing may be necessary.
  • from Doctor Unite 2 months 3 weeks
    Need to start with a full complete history and physical exam and review of past medical history. Most obvious starting point is to find out what med was Rx for his ADHD. If it was a stimulant, it the most likely cause of the insomnia. If it was a stimulant, no need to order a sleep aid. the focus would be on titrating down the dose of the stimulant. Adding another med to treat a known side effect of a med is not a wise choice, as any additional med could have unwanted side effects as well.
    Need to take a full social history including OTC meds and herbs and alcohol intake and any illicit drugs or marijuana. Need to try non pharmaceutical changes to improve the likelihood of attaining quality sleep - diet restrictions, exercise, set time to go to be every night etc.
  • from Doctor Unite 2 months 3 weeks
    Would do a thorough physical exam, and check with the other medications that he is taking.
  • from Doctor Unite 2 months 3 weeks
    I agree with many comments here- After PE and full history completed- and WNL, then I'd look at sleep history and consider an immediate release ADD med before adding anything for sleep
  • from Doctor Unite 2 months 3 weeks
    As many have commented before me, it is hard to provide an appropriate answer w/o knowing more information; as aforementioned, what dose of ADD med did he receive; what type, short or long acting; multiple dose? when did he take his dose; what other things are involved; what about sleep quality; sleep hygiene; is it trouble falling asleep, or staying asleep or both; any other co-morbidities such as OSA, RLS? Energy drinks, caffeine mentioned above;
  • 2 months 3 weeks
    I would evaluate how well current dose of stimulant is working for control of ADD. If the PDMP, personal history and D&A history is unremarkable, then consideration for changing to an immediate release form of the stimulant can be discussed. At the very least, taking medication early in day for long acting formulations, augmented with immediate release formulation in afternoon could alleviate any insomnia. Given that insomnia was not present prior to the stimulant, it is likely the stimulant is the etiology. Clonidine is good option as long as they are not already on an antihypertensive and it could off set any increase in blood pressure or heart rate...or over activation that might accompany a stimulant. Melatonin, non hypnotic medications, non addicting sleep medications are options to explore. Sleep hygiene, cell phone off etc.
  • from Doctor Unite 2 months 3 weeks
    I agree with another doc above - add Clonidine @HS before any sleep meds.....
  • from Doctor Unite 2 months 3 weeks
    I would obtain further history about current sleep regimen, sleep hygeine, phone use, time of medication administration. Would encourage early AM ADHD medication usage. This might include setting an alarm, taking medication and falling back asleep for another 1-2 hours. After trialing non-pharmaceutical measures, would re-examine after 2-4 weeks. At that time, would consider lower risk medications like melatonin, magnesium, zinc. I do not believe pharmaceutical sleep aids are a great long term solution for most patients, but would consider a very short course if all the above not providing any improvement.
  • from Doctor Unite 2 months 3 weeks
    ADD meds frequently cause insomnia especially if taken too late in the day. I would not add any meds for sleep. Assume of course sleep hygiene and other causes of insomnia has been ruled out.
  • 2 months 3 weeks
    It would help to know which med he is on. First I would have him try it earlier. Then I would have him try it later. Then I would try a lower dose of the same med. Then I would him try the immediate release. Then I would switch to another med. If the same thing continued, I would use what they use in children who have ADHD-induced or ADHD med-induced insomnia. Clonidine is a very safe med. It does not lower blood pressure in a normotensive individual. The dose would start at 0.1mg and could advance if needed to 0.4mg. It would have helped to know the name of the med he was originally put on and his starting dose. Many times docs start adults on too high a dose "because they are bigger." Treating ADHD patients is an art honed by experience.
  • from Doctor Unite 2 months 3 weeks
    I would not add a med for sleep since their efficacy wanes quickly and many are habituating especially in patients with ADD. Adjust ADD med either by dose or timing.
  • from Doctor Unite 2 months 3 weeks
    I would consider a different long acting stimulant and make sure pt is taking it early, Also no caffeine past 11 am, check other medications that could affect sleep including OTC's. If symptom cont consider strattera
  • from Doctor Unite 2 months 3 weeks
    The stimulant medication for his ADHD is probably the main issue and would not be addressed by simply treating the sleep issue. Is it necessary to take a stimulating ADHD medication or can it be taken once a day upon arising to allow for more restful sleep? Routine sleep hygeine issues, such as diminished caffeine and exercise late in the day are helpful, too, of course.
  • 2 months 3 weeks
    if patient is on long acting form of stimulant maybe switch to IR form, stress medication be taking first thing in AM, if patient feels medication effective, may augment with sleeping medication, or consider lower the dosage of current medication
  • 2 months 3 weeks
    I would make sure if he is on stimulants that he is not getting the last close to bed time as it can interfere with sleep.Also if possible switch him to non stimulant agent for his ADD.Using sleep might be needed for short duration if required.
  • from Doctor Unite 2 months 3 weeks
    Insomnia started with relation to start medications for ADD, subsequently that medication most probably main reason for insomnia.
    Time and dose of that medication should be adjusted to be sure that stimulating effect will be stopped 2 hours before scheduled bed time. Longevity and quality of response to stimulant are different for different patients, dose and time should be adjusted for that particular patient.
    I would not consider any additional sleeping aids including otc or melatonin at the present time.
    I will evaluate sleep schedule and habits to see any changes which could be related to start of ADD medication and if necessary discuss with patient ways to correct it (e.g patient started to watch tv in bedroom which he did not do before).
  • from Doctor Unite 2 months 3 weeks
    Assuming he is using ADD medication appropritely and there were no other identifiable psychosocial factors, I would suggest melatonin and or diphenhydramine.
  • from Doctor Unite 2 months 3 weeks
    A full history including social issues is in order; what type of add med is used? May be able to adjust dose of medication to improve sleep, or change to less stimulating med. Also may try non-pharmacological sleep hygiene measures and otc sleep aids.
  • 2 months 3 weeks
    I would obtain additional information about caffeine consumption during the day. Otherwise, changing the stimulant would be my first option.
  • from Doctor Unite 2 months 3 weeks
    Change the timing or the dose of ADD, then re-evil. If problem persists may consider sleep aids
  • from Doctor Unite 2 months 3 weeks
    Switch to shorter acting ADD med or take time release med earlier. Or change to nonstimulant ADD agent. Would not add med to reverse adverse effect of ADD drug
  • from Doctor Unite 2 months 3 weeks
    As noted above by other physicians, obviously The beginning of treatment of ADD and being newly placed on medications can affect someone’s sleep and create insomnia. Important questions which were not discussed, how long has the patient been on the new medications, how long did the sleep deprivation begin after he was placed on the new medications? also, what else is going on in this patient’s life? Has anything else changed? Relationship issues? Something else that would also cause additional psychiatric issues to create insomnia? Is the medication making him nap during the day and not sleep at night? So obviously there are lots of other additional variables to take into account, more than I mentioned here.
  • 2 months 3 weeks
    Usually, my experience is that patients with ADD actually report improved sleep pattern on an ADD medication due to the their symptoms improvement. I would question if misusing mediations(ie adderall tablet form) and would move to vyvanse or adderal xr. Also do to high comorbidity such as depression,, substance abuse and bipolar as well as high number do have issues with tobacco dependence and caffeine excess( these would all need to be rule in or out)
  • from Doctor Unite 2 months 4 weeks
    After taking a detailed history a newer agent like Belsomra or Day vigo might help...I would also consider Silenor
  • from Doctor Unite 2 months 4 weeks
    I would not add on additional sleep medications such as benzodiazpine in a patient already not able to sleep and on a stimulant who had no previous history of sleep problems. It is likely the ADD medication that is affecting his sleep pattern, in a patient with not previous history and thus would attempt to adjust that first. Sleep medication would has issues of adding on another unneccesary controlled substance that can lead to unnecessary long term dependence on top of ADD medication such as Adderral in a young patient.
  • from Doctor Unite 2 months 4 weeks
    Clearly a full history is needed before prescribing any other medicines. Also social history including illicit drug use. My concern is that add medications are often stimulants and may interrupt normal healthy sleep just by their action. What type of add Med was started? What time taken ?

    After these questions are addressed I would first consider milder possibly otc sleep meds first primarily magnesium or melatonin
  • from Doctor Unite 2 months 4 weeks
    Would do a full exam and history/diary of his sleep routine. Find out what is giving him a hard time sleeping. The ADD medicine will make him tired throughout the day. Is he drinking caffeine or energy drinks to try to stay awake. Maybe adjust the ADD medicine which could also causes drowsiness as a side effect. I do know know if adding another medicine to address his sleep issues would help the problem or maybe even create another issue of sleeping during inappropriate times.