Optimizing Medication Regimens for Sleep Disturbance

We did not prescribe the medicines ourselves but we gave advice, so the final responsibility remained with the prescribing physician. Many patients had been prescribed mirtazapine, nortriptyline or quetiapine to help them sleep. All three increase—like SSRIs—the QTc interval, the first two of which also carry a risk of a serotonergic syndrome. We recommended first phase out those three. The SSRI often helps people sleep better. If not, we recommend promethazine syrup (first generation phenothiazine), a sedative Histamine1 (H1) antagonist instead. To avoid a possible slightly improvement of the effect of the SSRI^{40 (link)}, we kept the doses as low as possible (5 mg to 15 mg at night). Many people used desloratadine (H1 antagonist) because of allergies and theoretically that may also improve the effect of an SSRI. Omeprazole (CYP2C19 inhibitor) increases the serotonin level. But we stopped increasing the SSRI if there were too many side effects and backed off if necessary. People who used omeprazole (n = 5), received: venlafaxine 37.5 mg; paroxetine 10 mg; citalopram 2 × 20 mg; escitalopram 5 mg. Aspirin and diclofenac (increasing risk of bleeding) were also advised to greatly reduce or phase out. Use of solifenacin and salmeterol (fluticasone) (both increase QTc interval) could not be tapered and were combined with fluvoxamine 100 mg and 75 mg, respectively.