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The American Academy of Sleep Medicine's guideline on drugs for chronic insomnia rates every one of its recommendations as weak, suggests eight drugs and suggests against six more, including melatonin, trazodone, diphenhydramine and valerian. In cancer specifically, the only placebo-controlled trial of temazepam and prolonged-release melatonin randomised 21 people.
The drug evidence in insomnia generally. A guideline from the American Academy of Sleep Medicine reviewed individual drugs rather than classes, using the GRADE framework. Under that system a strong recommendation is one clinicians should follow in most circumstances and a weak one reflects lower certainty. Every recommendation in the guideline is weak, and the panel explains why: publication bias given the funding source for most pharmacological trials, few eligible trials for each individual agent, and heterogeneity in the data.
The drugs it suggests using, each weakly: suvorexant for sleep maintenance insomnia; eszopiclone for sleep onset and maintenance; zaleplon for sleep onset; zolpidem for onset and maintenance; triazolam for onset; temazepam for onset and maintenance; ramelteon for onset; doxepin for maintenance.
The drugs it suggests not using, each weakly: trazodone for either; tiagabine for either; diphenhydramine for either; melatonin for either; tryptophan for either; valerian for either. Melatonin, trazodone and antihistamines are among the things most often taken for sleep, and the guideline's position on all three is that it suggests against them.
In cancer specifically the evidence is thinner still. A three-arm double-blind placebo-controlled trial compared temazepam, prolonged-release melatonin and placebo in people with advanced cancer and an insomnia severity index score above 11. Twenty-one participants were randomised: nine to temazepam, eight to melatonin and four to placebo. The adjusted mean difference in insomnia severity at day 8 against placebo was 9.1 points for temazepam (95 per cent confidence interval 17.5 lower to 0.7 higher) and 9.6 points for melatonin (18 to 1.2 lower). There was no improvement in global quality of life, both agents were well tolerated, and the authors' conclusion ends: "Findings need confirmation with larger patient numbers." Four people on placebo is not a comparison group, and the honest reading is that this trial tells us a properly powered one has not been done.
What this adds up to, without either dismissing the drugs or overselling them. Sedatives work quickly, which is their real advantage and the reason they are prescribed at three in the morning on a ward. They have not been shown in this population to improve quality of life, their benefit in general insomnia is supported only by weak recommendations, and the thing they are usually given instead of has a medium to large effect that lasts six months after the course ends. The sequence the evidence supports is therefore cognitive behavioural therapy for insomnia first, with a short course of a hypnotic alongside or before it where sleep loss is acute and unbearable, rather than a hypnotic as the whole plan.
Two practical cautions that follow from the drugs rather than from the cancer. Benzodiazepines and the related hypnotics impair balance and raise the risk of falls, which matters more where chemotherapy has damaged the nerves in the feet or where bone density has fallen on hormone treatment, both of which have their own records in this front. And they interact with opioids used for cancer pain in the direction of sedation and respiratory depression, which is a conversation to have with the prescribing team rather than a reason to stop anything.
What OnCo could not establish. There is no reliable figure for how many people are taking a hypnotic after cancer treatment that this round could verify from a primary source, which is a gap worth naming given that insomnia affects a third of people 18 months after surgery and the treatment with the best evidence is not widely commissioned.
Hypnotics act on the sleep-generating systems directly, through the GABA-A receptor for the benzodiazepines and the related compounds, through orexin blockade for suvorexant, through melatonin receptors for ramelteon, or through histamine blockade for doxepin and the antihistamines. None of them alters the behaviour and the conditioned arousal that keep chronic insomnia going, which is why benefit tends to stop when the drug stops and why the behavioural treatment outlasts its own course.
Query for this technology: (TITLE:"Sleeping tablets after cancer: what they do and what they do not" OR ABSTRACT:"Sleeping tablets after cancer: what they do and what they do not") AND (cancer OR tumor OR tumour OR oncology OR carcinoma OR lymphoma OR leukemia OR leukaemia OR myeloma OR sarcoma OR melanoma OR glioma). Results are unfiltered search hits about Sleeping tablets after cancer: what they do and what they do not, not a curated reading list.
Shares Early integrated palliative care, Quality of life, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued and the tags rejuvenation, survivorship, psychosocial.
Shares Quality of life, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Placebo, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Placebo, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Quality of life, Survivorship and late effects are neglected, Toxicity and quality of life are undervalued, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Early integrated palliative care, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Cognitive behavioural therapy for insomnia (CBT-I), Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.
Shares Early integrated palliative care, Quality of life, Survivorship and late effects are neglected, HR-positive / HER2-negative breast cancer and the tags rejuvenation, survivorship, psychosocial.