AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,

Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


STUDENT NAME: STUDENT NO.:



Pharmacotherapy Workup NOTES CARE PLAN
PATIENT INITIALS: RR DATE:


MEDICAL CONDITION
lnSCMnlA:

88 ls an 88 year old female (143lbs, 3'4, 8Ml=24.9kg/m
2
, n: 18.3-24.9) who came lnLo Lhe pharmacy for a medlcaLlon
revlew. upon quesLlonlng her, she shares her lnLeresL ln malnLalnlng good healLh and her expresses complalnL ln her
low back paln LhaL seems Lo be boLherlng her sleep. She ls Laklng zoplclone 7.3mg LableL x-1 LableL aL bedLlme as need
basls for lnsomnla slnce 3 years ago whlch ls well LoleraLed(doesn'L experlence mornlng grogglness). She Lakes
zoplclone every day and she rouLlnely Lakes x LableL before golng Lo bed, and Lakes anoLher x LableL lf she wakes up ln
Lhe mlddle of Lhe nlghL around 3 am. 88 has no problem falllng asleep(unable Lo deLermlne wheLher due Lo medlcaLlon
or noL slnce she Lakes lL every nlghL before bedLlme) buL experlences dlfflculLy wlLh malnLalnlng sleep 3-4 nlghLs per
week even wlLh 1/2 and she feels less resLed Lhe nexL mornlng. She Lells you LhaL Lhe nagglng sensaLlon on her lower
back whlch ls boLhersome lnLerrupLs wlLh her golng back Lo sleep, !"#$%&' ! )*+, -.. /01,234 5,6.1 7849 $832 $/$'
8elevanL lab values are wlLhln normal range, eCl8=70ml/mln/1.73m
2
(n>39), AL1=17u/L(n<36). She ls aware of some
sleep hyglene such as avoldlng waLchlng 1v ln bed and avoldlng caffelnaLed drlnks ln Lhe evenlng. She does noL Lake
naps and has seL bedLlme and wake Llme. (8-9am wake Llme and 10-10:30pm bedLlme). 1hls boLhersome back paln ls
only presenLs aL bedLlme or when she slLs for a prolonged perlod. SomeLlmes, she has Lo use poles Lo help allevlaLe Lhe
back paln. She has Lrled 1ylenol and Advll ln Lhe pasL whlch had noL helped aL all. 8ecenLly(slnce 2 weeks ago) she has
been applylng volLaren Lmugel on her lower back before bedLlme whlch has parLlally helped wlLh her low back paln
buL sLlll lnLerrupLs her sleep. She has also Laken up personal yoga once a week for 1 hour whlch also has parLlally
helped wlLh her back problem. She ls Laklng one Lablespoon of llquld calclum and vlLu supplemenL ln Lhe mornlng (=
600mg elemenLal calclum and 400 lu vlLamlnu3) and 2 LableLs of vlLamln u3 1000lu for prevenLlon of osLeoporosls.
Per 8Mu ls 1.03gm/cm
2
, 1 score=0.6 and Z score=2.3 for her femoral lefL neck . !-.. :+;.,<,1,+3+ $1.=.2;3,2 $/$'> 88
has been dlagnosed wlLh hyperLenslon 13 years ago and ls currenLly on ramlprll 10mg Cu. 1hls dose has helped her
conLrol her 8 unLll 3 monLhs ago when lL elevaLed from 140/70 Lo 160/70. !-.. ?@<.1;.2+3,2 $/$' 88. ls compllanL Lo
all her medlcaLlons and supplemenLs and fully undersLands Lhe purpose of Lhese medlcaLlons. She exerclses 30 mlnuLes
4 Llmes a week uslng dumbbells and medlclne ball. She has never smoked and has never used recreaLlonal drugs. She
rarely consumes alcohol(l.e. 1 glass of red wlne every 3 monLhs). She drlnks one cup of coffee and one cup of Lea per
day usually ln Lhe mornlng. Per dleL conslsLs of well balanced meals and a snack. Per usual breakfasL ls bran, flber,
forLlfled soymllk, proLeln powder, flaxseed and frulL(usually x banana) blended lnLo a smooLhle. Per lunch conslsL of
dlnner lefLovers, a slmple sandwlch (Luna or ham wlLh veggles) or a salad. She normally eaLs flsh(l.e. salmon, Luna) or
chlcken wlLh 4 klnds of veggles(e.g. carroLs, beans, broccoll, eLc) for dlnner. She someLlmes snacks on blueberrles or
mufflns. She has recelved lnfluenza and pneumococcal vacclne 10 years ago. !-.. A2B.; 2..C+ 32 ?@<.1;.2+3,2
$/$'She has had surgery and radlaLlon due Lo breasL cancer 11 years ago whlch has been resolved. She also had her
gall bladder removed 40 years ago and had hysLerecLomy performed 33 years ago. She experlenced verLebraLe
compresslon fracLure 7 years ago due Lo fall whlch has healed buL lefL a llngerlng boLhersome sensaLlon ln her low back
paln.
-./0/11#$23
lnsomnla ls a sleep dlsorder LhaL ls characLerlzed by dlfflculLy falllng and/or sLaylng asleep.
1,4
eople wlLh lnsomnla
have one or more of Lhe followlng sympLoms: dlfflculLy falllng asleep, waklng up ofLen durlng Lhe nlghL and havlng
Lrouble golng back Lo sleep, waklng up Loo early ln Lhe mornlng, or feellng Llred upon waklng.
1,4
88 ls sufferlng from
lnsomnla wlLh dlfflculLy malnLalnlng sleep and feellng Llred durlng Lhe day Llme. 88 has chronlc lnsomnla whlch ls
characLerlzed as havlng lnsomnla aL leasL 3 nlghLs per week for 1 monLh or longer(88 experlenced lnsomnla slnce 3
years ago and experlences nocLural awakenlng 3-4 Llmes a week).
1,4
Per lnsomnla ls noL medlcaLlon lnduced(e.g.
buproplon, sLlmulanLs eLc).
1,4
She does however presenL wlLh exLernal cause such as chronlc lower back dlscomforL.
!)C1.++.C 32 401,234 D849 <832 $/$'. 1he back paln prevenLs her from falllng back Lo sleep when she wakes ln Lhe
mlddle of Lhe nlghL,456!789 88 ls llkely experlenclng secondary lnsomnla whlch ls caracLerlzed as sleep dlsLurbance
lnduced by oLher causes(dlsease, paln eLc).
1,4
AlLhough LreaLlng Lhe underlylng cause may reverse lnsomnla,
pharmacologlcal lnLervenLlon may be warranLed unLll Lhe cause ls removed slnce unLreaLed lnsomnla ls asoclaLed wlLh
lncrease rlsk of falls and decreased quallLy of llfe especlally ln elderly.
7
Medlcal lnLervenLlon ls lndlcaLed for moderaLe
Lo severe lnsomnla ln whlch lack of sleep lmpalrs dayLlme funcLlonlng(e.g. Llredness).
1,4,7
88 ls recelvlng medlcal
AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,
Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


lnLervenLlon wlLh zoplclone 3.23mg rouLlnely Laken before bedLlme and furLher Laken agaln ln Lhe mlddle of Lhe
nlghL(usually around 3am) Lo help her fall asleep agaln. Sleep hygelne ls lndlcaLed for lnsomnla as monoLherapy for
mlld lnsomnla and chronlc lnsomnla as ad[uvanL Lherapy Lo pharmacologlcal Lherapy ln moderaLe Lo severe
lnsomnla.
1,4,6,7
88 ls pracLlclng proper sleep hyglene ln some parL. She avolds napplng, caffelnaLed drlnks ln Lhe evenlng
and waLchlng 1v before sleep. Powever, when she does awake ln Lhe mlddle of Lhe nlghL, she sLays ln bed and Lrles
hard Lo fall asleep raLher Lhan removlng herself from Lhe bedroom unLll she feels sleepy agaln. She ls noL aware of
some sleep hygelne Lherapy such as avoldlng fluld lnLake 4 hours before bedLlme or avoldlng exerclse aL leasL 3 hours
before bedLlme.
3
456!7:9
-;<</0=>?/'/113
Zoplclone ls effecLlve as shorL Lerm hypnoLlc Lherapy for lnsomnla.,
8
lL blnds Lo CA8A-A recepLor Lo sLlmulaLe
CA8Aerglc nerves and exhlblLlng hypnoLlc effecL.
8
Zoplclone has been found Lo be effecLlve as an hypnoLlc for Lhe
elderly.
7
lL decrease sleep onseL and Lhe number of nocLurnal awakenlngs and Lherefore lmprove sleep duraLlon and
sleep quallLy.
7,8
1he gerlaLrlc dose for zoplclone ls 3.73mg PS and may be lncreased Lo 7.3mg PS lf rellef ls lnadequaLe
wlLh lower dose.
4,8
ln gerlaLrlc populaLlon, Lhe absoluLe bloavallablllLy of zoplclone was lncreased (94 vs 77 ln young
sub[ecLs) and Lhe ellmlnaLlon half-llfe prolonged (~7 hours).
7
1hls change ln plasma concenLraLlon of zoplclone ln Lhls
populaLlon may be responslble for Lhe reduced gerlaLrlc dose of 3.73mg. Loss of efflcacy due Lo developmenL of
Lolerance has been seen ln hypnoLlc agenLs.
7
Powever, Lhere was an absence of Lolerance wlLh zoplclone for
LreaLmenL perlods of up Lo 4 weeks.
7,8
Also, ezoplclone whlch ls an acLlve lsomer of zoplclone demonsLraLed efflcacy ln
LranslenL and chronlc lnsomnla for over 12 monLhs of use wlLh no evldence of Lolerance developlng.
7,8
CurrenLly 88 ls
Laklng 3.73-7.3mg PS whlch ls an effecLlve dose.
-@#</=23
88 has no conLralndlcaLlon Lo zoplclone such as hypersenslLlvlLy, sleep apnea, myasLhenla gravls, or severe llver
dysfuncLlon.
2,8
88 does noL have lmpalred llver or renal funcLlon LhaL warranLs dose ad[usLmenL.
2,8
(eCl8 =
70ml/mln/1.73m
2
(n>39), AL1=17u/L(n<36) Zoplclone does noL lnLeracL wlLh her currenL medlcaLlon(calclum clLraLe,
vlL u, ramlprll).
2,8
Powever, usual duraLlon of hypnoLlc use ls llmlLed Lo <2weeks accordlng Lo 8C guldellnes.
6
lL can be
conLlnued for anoLher 2-3 Lwo week Lrlals lf prevlous Lrlal does noL lmprove dayLlme lmpalrmenL.
6
ldeally, Lhe duraLlon
of hypnoLlcs should be llmlLed Lo 2-4 weeks or use lnLermlLLenLly (e.g. up Lo 4 Llmes per week) Lo mlnlmlze Lolerance
and dependence.
2,6
rolonged use of zoplclone may lead Lo Lhe developmenL of physlcal and psychologlcal
dependence or abuse.
2,6,8
AlLhough Lhere ls llLLle evldence of dependency especlally wlLh shorL Lerm use, lL should be
cauLloned.
3,7,8
1he rlsk of dependence or abuse ls lncreased wlLh Lhe dose and duraLlon of LreaLmenL
7
, such as ln our
paLlenL who has been on zoplclone for 3 years. She now rouLlnely Lakes x LableL of zoplclone before bedLlme dally. She
feels LhaL she wlll noL be able Lo fall asleep lf she dlsconLlnues Lhe medlcaLlon whlch demonsLraLes dependency.
456!7A9 Zoplclone ls well LoleraLed and cause mlnlmal lmpalrmenL of psychomoLor performance and menLal alerLness
Lhe mornlng afLer a normal bed-Llme dose.
3
lmporLanLly, Lhe drug has been shown Lo have llLLle or no effecL on shorL-
Lerm memory, a funcLlon LhaL ls ofLen lmpalred by earller hypnoLlc drugs parLlcularly ln elderly paLlenLs
3
. 1he drug ls
well LoleraLed by paLlenLs of all ages, and adverse effecLs are lnfrequenLly reporLed, Lhe ma[orlLy of slde-effecLs belng
LasLe dlsLurbance (3.6 ), dry mouLh (1.6 ), poor quallLy of waklng(1 -3), dayLlme sleeplness (0-3), nausea(0-3)
and nlghLmares (0-3).
3
88 has no complalnLs on adverse effecLs due Lo zoplclone and she ls LoleraLlng lL well.
-B("/$/'0/3
88 has no problem adherlng Lo Lhe medlcaLlon. She has no cosL concerns and does noL have dlfflculLy Laklng Lhe
medlcaLlon.
-C'D/= '//(13
PyperLenslon and lnfluenza vacclne ls addressed ln her hyperLenslon C. CsLeoporosls prevenLlon ls addressed ln her
osLeoporosls C. Lower back paln ls addressed ln her lower back paln C.
GOALS OF THERAPY
romoLe sub[ecLlvely sound and resLoraLlve sleep.
8educe sub[ecLlve dayLlme lmpalrmenL assoclaLed wlLh sleep loss.
oLenLlaLe Lhe effecLlveness of behavloural lnLervenLlons.
Mlnlmlze Au8 and dependence from prolonged drug Lherapy
DRUG THERAPY PROBLEM(S) TO BE RESOLVED
4B0=E#F 56!789 88 ls experlenclng lnsomnla (e.g. nocLurnal wakenlng, dayLlme Llredness) secondary Lo dlscomforL ln
her low back and would beneflL from reassessmenL of her low back paln Lherapy. (addressed ln Lower back paln C)
4B0=E#F 56!7:9 88 ls experlenclng lnsomnla (e.g. dayLlme Llredness) secondary Lo noL performlng proper sleep hyglene
and would beneflL from counselllng and educaLlon on proper sleep hyglene.
AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,
Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


4B0=E#FG 56!7A9 88 ls aL rlsk of recelvlng unnecessary drug Lherapy wlLh zoplclone and exposed Lo assoclaLed Au8(l.e.
dry mouLh, Cl upseL, nausea, LasLe dlsLurbance) secondary Lo developlng psychologlcal dependence Lo zoplclone ( 3.73-
7.3mg every day aL bedLlme Laken rouLlnely) and would beneflL from reassessmenL of her lnsomnla Lherapy.


MEDICATION RECOMMENDATION(S)
Zopllcone 7.3mg

(CurrenLly uslng 3.73-
7.3mg qhs)
H9 Cnce Lhe lower back paln ls conLrolled, recommend paLlenL Lo gradually wean off
zoplclone.
6
1aper Lhe dose of zoplclone Lo 3.73mg PS Laken only when necessary and
noL rouLlnely. rlor Lo Laperlng Lhe medlcaLlon, llmlL Lhe Llme ln bed Lo 30 mlnuLes less
Lhan Lhe mean LoLal sleep Llme on medlcaLlon Lo lnduce a modesL degree of sleep
resLrlcLlon.
6
Add 10 mlnuLes Lo Lhe sleep Llme every few days unLll sleep becomes
dlsrupLed, Lhen Lake off 10 mlnuLes Lo asslgn Lhe flnal Llme ln bed.
6














OTHER RECOMMENDATION(S) (E.G., NON-DRUG MEASURES, REFERRALS)
I9 LducaLe and recommend paLlenL psychologlcal and behavloral lnLervenLlon.
1,3,11

J9 Sleep hyglene (aka sLlmulanL conLrol LreaLmenL) should be recommended wheLher on pharmacologlcal Lherapy or
noL.
1,3,7
1ry Lo go Lo sleep aL Lhe same Llme each nlghL and geL up aL Lhe same Llme each mornlng.
3,11
Avold caffelne,
nlcoLlne, and alcohol laLe ln Lhe day.
3,11
CeL regular exerclse.
3,11
Avold exerclslng for aL leasL Lhree Lo four hours before
Lhe Llme you go Lo sleep.
3,11
uon'L eaL a heavy meal laLe ln Lhe day. A llghL snack before bedLlme, however, may help
you sleep
3,11
. Make your bedroom comforLable.
3,11
8e sure LhaL lL ls dark, quleL, and noL Loo warm or Loo cold
3,11
lf llghL
ls a problem, Lry a sleeplng mask.
3,11
lf nolse ls a problem, Lry earplugs, a fan, or a "whlLe nolse" machlne Lo cover up
Lhe sounds.
3,11
lollow a rouLlne Lo help you relax before sleep.
3,11
8ead a book, llsLen Lo muslc, or Lake a baLh.
3,11
Avold
uslng your bed for anyLhlng oLher Lhan sleep or sex.
3,11
lf you do noL fall asleep wlLhln 20-30 mlnuLes, leave Lhe bed
and do someLhlng relaxlng (eg. llsLenlng Lo muslc, readlng, waLchlng 1v) unLll drowsy.
3,11
1hls can be repeaLed as ofLen
as needed. lf you flnd yourself lylng awake worrylng abouL Lhlngs, Lry maklng a Lo-do llsL before you go Lo bed.
3,11
1hls
may help you Lo noL focus on Lhose worrles overnlghL.
3,11


RATIONALE FOR RECOMMENDATION(S)
H9 sychologlcal and behavloral lnLervenLlon, and sleep hyglene have been shown Lo be effecLlve ln LreaLlng chronlc
lnsomnla.
1
WlLh slmple llfesLyle changes, sLlmulus and behavlour conLrol, 88 should be able Lo wean off zoplclone and
resume proper sleep paLLerns wlLhouL drug-Lherapy. SLlmulus conLrol, progresslve muscle relaxaLlon, and paradoxlcal
lnLenLlon are emplrlcally valldaLed by Lhe Amerlcan sychologlcal AssoclaLlon (AA).
10,11
8lofeedback, sleep resLrlcLlon,
and mulLlcomponenL cognlLlve behavloral Lherapy are deemed "probably efflcaclous" by Lhe AA.
10,11
rogresslve
muscle relaxaLlon ls based on Lhe assumpLlon LhaL paLlenLs wlLh lnsomnla have hlgh arousal, and relaxaLlon should
help reduce Lhls arousal .
10,11
ln 16 or 17 sLudles showed LhaL Lhls Lechnlque was shown Lo be more effecLlve Lhan
placebo, walL llsL, and no-LreaLmenL conLrols
10,11
. aradoxlcal lnLenLlon LreaLmenL assumes LhaL performance anxleLy ls
hlnderlng Lhe paLlenL's ablllLy Lo fall asleep
10,11
. 8y havlng Lhe paLlenL Lry Lo "sLay awake," Lhe deslre and anxleLy
surroundlng falllng asleep dlmlnlshes, and gradually dlsappears. lour of 6 sLudles show Lhls approach ls more effecLlve
Lhan conLrol groups.
10,11
CognlLlve behavloral LreaLmenL lnvolves ldenLlfylng Lhe paLlenL's LhoughLs LhaL are lnvolved ln
AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,
Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


lnsomnla, deLermlnlng wheLher Lhese LhoughLs are valld, and replaclng Lhem wlLh less upseLLlng LhoughLs.
10,11
ln an
8C1 LhaL compared C81 (whlch lnvolved sleep hyglene, sleep resLrlcLlon, sLlmulus conLrol, cognlLlve Lherapy, and
relaxaLlon) Lo zoplclone and placebo, parLlclpanLs recelvlng C81 lmproved Lhelr sleep efflclency from 81.4 Lo 90.1
afLer 6 monLhs, whereas Lhere was a decrease from 82.3 Lo 81.9 ln Lhe zoplclone group.
9
1hose ln Lhe C81 group
spenL more of Lhelr sleep ln slow-wave sleep compared Lo placebo and zoplclone, and spenL less Llme awake durlng
Lhe nlghL, Lhough LoLal sleep Llme was slmllar beLween all 3 groups.
9

I9 SLlmulus conLrol LreaLmenL helps Lhe paLlenL develop an assoclaLlon beLween Lhe bed/bedroom wlLh rapld sleep
onseL .
2,11
Caffelne and nlcoLlne are sLlmulanLs and can keep you from falllng asleep Lherefore should be avolded laLe ln
Lhe dayLlme
2,11
. 1ry noL Lo Lake naps durlng Lhe day because naps may make you less sleepy aL nlghL.
2,11
Alcohol can
cause waklng ln Lhe nlghL and lnLerferes wlLh sleep quallLy.
2,11
Lxerclslng close Lo bedLlme may sLlmulaLe you and make
lL hard Lo fall asleep.
2,11
ln a meLa-analysls of 39 sLudles lnvolvlng 2102 paLlenLs LoLal where Lhe prlmary LargeL problem
was sleep-onseL, malnLenance, or mlxed lnsomnla, Lhls Lherapy has been shown Lo decrease sleep laLency from 64 Lo
34 mlnuLes, and Lhe average LoLal Llme awake afLer sleep onseL was shown Lo be reduced from 84 mlnuLes before
LreaLmenL Lo 44 mlnuLes afLer LreaLmenL. lL was also effecLlve as monoLherapy.
13
J9 ldeally, zoplclone should noL be used chronlcally(>4weeks) due Lo posslblllLy of dependency and Lolerance as
menLloned ln nLSA.
2,3,6
lf use ls necessary, lL should be llmlLed Lo lnLermlLLenL use of no more Lhan 4 nlghLs per week.
2,

Cnce Lhe aggravaLlng facLor of lnsomnla such as Lhe low back paln ls properly addressed, 88 may no longer requlre
medlcaLlon Lo help her sleep. 1herefore gradual wlLhdrawal of Lhe medlcaLlon should be recommended. WlLhdrawal
sympLoms, slmllar ln characLer Lo Lhose noLed wlLh barblLuraLes and alcohol (convulslons, Lremor, abdomlnal and
muscle cramps, vomlLlng, sweaLlng, dysphorla, percepLual dlsLurbances and lnsomnla) have occurred followlng abrupL
dlsconLlnuaLlon of hypnoLlcs such as zoplclone especlally ln hlgh dose and prolonged use.
8
1herefore, abrupL
dlsconLlnuaLlon should be avolded and a gradual dosage Laperlng schedule ls recommended ln any paLlenL Laklng Lhe
drug for more Lhan a few weeks.
8
Sleep resLrlcLlon llmlLs Lhe amounL of Llme spenL ln bed hence mlld sleep deprlvaLlon
ls produced, and Lhls gradually resulLs ln more rapld sleep onseL, more efflclenL sleep.
2,11
1herefore, lnlLlaLlng Lhls
Lherapy whlle Laperlng zoplclone can reduce Lhe rlsk of rebound lnsomnla.
2,11

REFERENCES TO SUPPORT RECOMMENDATION(S)
1. Dopp JM, Phillips BG. Chapter 75: Sleep Disorders. In: Dipiro JT, editor. Pharmacotherapy: A Pathophysiological
Approach. 7
th
edition. New York: McGraw Hill Medical;2008.p1191-202.
2. Jensen B, Regier L. Rx-Files: Sedatives. 2010. Saskatoon: Rx-Files Academic Detailing;2010.p.110-1.
3. Procyshyn RM, Barr A. Chapter 5: Insomnia. In: Repchinsky C, editor. Patient Self-Care. 2
nd
ed. Ottawa:
CPhA;2010.p.31-40.
4. Fleming JAE. e-Therapeutics: Insomnia. Accessed on 24MAY2012. Available at: http://www.e-
therapeutics.ca/tc.showChapter.action?documentId=c0006
5.Kerr, J. S., Dawe, R. A., Parkin, C. and Hindmarch, I. (1995), Zopiclone in elderly patients: Efficacy and safety. Hum.
Psychopharmacol. Clin. Exp., 10: 221229. doi: 10.1002/hup.470100309
6.Primary care management of sleep complaints in adults, guidelines and protocols advisory committee, [revised 2004],
[accessed May 23,2012] Available from URL:http://www.bcguidelines.ca/pdf/sleepcomp.pdf
7.Bain K.T. Management of chronic insomnia in elderly persons (2006) American Journal Geriatric
Pharmacotherapy, 4 (2), pp. 168-192.
8. Repchinsky C, editor. Zopiclone In: Compendium of Pharmaceuticals and Specialties [online version (e-CPS)]. Ottawa:
Canadian Pharmacists Association; 2012 [cited 2012 May 20]. Available from: URL: http://e-therapeutics.ca/CPHA/main.htm.
9. Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, Nielsen GH, Nordhus IHJAMA.
Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized
controlled trial. 2006 Jun 28;295(24):2851-8.
10. Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of
insomnia:update of the recent evidence (1998-2004). Sleep. 2006 Nov;29(11):1398-414.
11.Morin C M, Hauri P J, Espie C A, Spielman A J, Buysse D J, Bootzin R R. Nonpharmacologic treatment of chronic
insomnia. Sleep 1999; 22(8): 1134-1156
12. C M Morin, J P Culbert, S M Schwartz Nonpharmacological interventions for insomnia: a meta-analysis of treatment
efficacy. Am J Psychiatry. 1994 Aug ;151 (8):1172-80 8037252 Cit:188


AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,
Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


ACTION:
MD contacted in writing
MD contacted by phone
MD not contacted
Patient as primary contact
Other HC providers contacted
Others contacted:

RECOMMENDATION WAS:
MD accepted pharmacists original recommendation
MD didnt accept recommendation & didnt have an acceptable rationale
Patient accepted recommendation (Patient said she will try to use medication intermittently
along with sleep hygiene suggestions)
MD did not accept recommendation but had an acceptable rationale
Recommendation modified after consultation with MD
Patient did not accept recommendations


MONITORING PLAN

E
F
F
E
C
T
I
V
E
N
E
S
S

OUTCOME PARAMETER MONITORED BY EXPECTED CHANGE DATE
Effectiveness

non-pharmacologlcal measures
expecLed Lo help wlLh paLlenL's sleep.

Sign/symptom:

1) uayLlme 1lredness

2) nocLurnal Awakenlng

3) Sleep LaLency






aLlenL and
pharmaclsL






1) 8educed dayLlme Llredness,
no lmpacL on acLlvlLles of dally
llvlng, no falls

2) uecreased lncldence of
nocLurnal sympLoms

3) MalnLaln sleep laLency = or <
LhlrLy mlnuLes wlLhouL
zoplclone








2 Weeks
Sign/symptom







Laboratory value

N/A






Laboratory value







AdapLed wlLh permlsslon from: 2009 CopyrlghL MedlcaLlon ManagemenL Canada and 2003-2003 eLers lnsLlLuLe of harmaceuLlcal Care,
Clpolle 8!, SLrand LM, Morley C harmaceuLlcal Care racLlce: 1he Cllnlclan's Culde, McCraw Plll, 2004
!"#$ &#'()**+
Copyright 2012 UBC Faculty of Pharmaceutical Sciences


S
A
F
E
T
Y

Safety

non-pharmacologlcal recommendaLlons
for paLlenL are safe. 1aperlng of
Zoplclone should be closely monlLored
Lo prevenL negaLlve ouLcomes.

Sign/symptom:

1) 8ebound lnsomnla

2) WlLhdrawal sympLoms (convulslons,
Lremors, abdomlnal and muscle cramps,
vomlLlng, sweaLlng)









aLlenL and
pharmaclsL








aLlenL should be counseled on
Lhe negaLlve endpolnLs
assoclaLed wlLh Laperlng of
zoplclone and how Lhey should
be dealL wlLh lf lL occurs.









AnyLlme,
usually 1-2
weeks afLer
u/C of
zoplclone
Sign/symptom

3) Au8 of zoplclone (l.e. meLalllc LasLe,
mornlng grogglness, nausea)



aLlenL and
pharmaclsL

unllkely Lo occur as paLlenL has
been uslng medlcaLlon for a
perlod of Llme. Counsel paLlenL
as approprlaLe. Au8's may
surface lf dose changes.


AnyLlme
Laboratory value

N/A






Laboratory value








SIGNATURE: DATE: