失眠药物怎么选?这篇文章讲透彻了!

2022-02-16 Oranhgy 神经新前沿

人的一生有三分之一的时间是在睡眠中度过,睡眠作为我们最重要的事之一,可有些人睡得好,有些人却睡不好。成年人的世界里,越长大越容易失眠。

人的一生有三分之一的时间是在睡眠中度过,睡眠作为我们最重要的事之一,可有些人睡得好,有些人却睡不好。成年人的世界里,越长大越容易失眠。现如今,有 10%~15%的成年人符合失眠诊断,且呈慢性化病程,近半数严重失眠可持续10年以上。

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失眠的定义

根据《中国失眠症诊断和治疗指南》,失眠症是以频繁而持续的入睡困难和(或)睡眠维持困难并导致睡眠感不满意为特征的睡眠障碍。失眠症分为慢性失眠症、短期失眠症及其他类型的失眠症。失眠症的治疗包括心理治疗、药物治疗、物理治疗、中医治疗和综合治疗等。今天我们说说药物治疗方面。

药物治疗

临床上,药物治疗的目标是缓解症状,增加有效睡眠时间,改善睡眠质量;改善失眠相关日间损害;避免自短期失眠障碍向慢性失眠障碍的演变;减少失眠相关躯体疾病或精神障碍风险。常用治疗药物分为苯二氮卓类受体激动剂(BzRAs)、褪黑素受体激动剂类催眠药物、有镇静作用的抗抑郁药物、以及其他处方药和分处方药物等。

1、BzRAs:包括苯二氮卓类药物和非苯二氮卓类药物。

A.苯二氮卓类药物

目前临床上最常用的一种镇静、催眠和抗焦虑药物。根据起效及作用时间长短分为短效、中效和长效三种。
 
苯二氮卓类药物对不同类型的失眠症起到良好的治疗作用, 但其所产生的副作用, 尤其对老年人群的影响不容忽视。常见不良反应包括口干、乏力、便秘、视力模糊、宿醉作用、药物耐受性、依赖、戒断反应、认知功能损伤等。
B. 非苯二氮卓类药物
 
目前国内临床常用的有唑吡坦、右佐匹克隆、扎来普隆。
 
a) 唑吡坦:适用于短期治疗入睡困难者,最常见副作用是头痛、头晕和嗜睡,进而可导致跌倒,目前未被批准长期使用。
 
b) 右佐匹克隆:对入睡困难和夜间维持睡眠困难、早醒等不同类型的睡眠障碍都有效。该药最常见的不良反应是味觉不适和头痛。
 
c) 扎来普隆:是一种超短效药物,其半衰期很短,也就是说在短时间内其深度就会降到初始值的一半。它比较适合入睡没有问题、但是清醒过早的人,可将他们的睡眠时间延长2-3小时。扎来普隆不良反应与剂量有关,主要为头痛、嗜睡、眩晕,大剂量单次用药可致语言能力下降、记忆力减退。
 
2、褪黑素受体激动剂和褪黑素
 
雷美替胺为褪黑素MT1和MT2受体激动剂,用于治疗以入睡困难为主诉的失眠及昼夜节律失调导致的失眠症。褪黑激素在人体中天然存在,可向身体发出睡眠信号。褪黑素属于非处方类药物,可用于调整时差和治疗失眠,但不作为常规用药。
 
3、具有镇静作用的抗抑郁药
 
不以血清素为作用目标的抗抑郁药大多有镇定效果,可用于治疗失眠症状,尤其适用于抑郁和(或)焦虑伴发失眠症的治疗。
 
A. 三环类抗抑郁药物

阿米替林能够缩短睡眠潜伏期、减少睡眠中觉醒、增加睡眠时间、提高睡眠效率,但其同时减少慢波睡眠,不同程度减少快波睡眠,且不良反应多,如抗胆碱能作用引起的口干、心率加快、排尿困难等。因此,不作为失眠的首选药物。小剂量的多塞平(3-6mg/天)因有专一性抗组胺机制可以改善成年和老年慢性失眠患者的睡眠状况,具有临床耐受性交好,无戒断效应的特点,近年来国外已作为失眠治疗的推荐药物之一。
 
B. 选择性5-色胺再摄取抑制剂(SSRIs)
 
虽无明确催眠作用,但可以通过治疗抑郁和焦虑障碍而改善失眠症状。部分SSRIs延长睡眠潜伏期,增加睡眠中的觉醒,减少睡眠时间和睡眠效率,减少慢波睡眠。
 
C. 5-羟色胺和去甲肾上腺素再摄取抑制(SNRIs)
 
包括文拉法新和度洛西汀。因可治疗抑郁和焦虑状态而改善失眠。
 
D. 其他抗抑郁药物
 
小剂量米氮平(15-30mg/天)能缓解失眠症状;小剂量曲唑酮(25-100mg/天)具有镇静效果,可以用于治疗失眠和催眠药物停药后的失眠反弹。
 
4、食欲素受体拮抗剂
 
苏沃雷生是一种高选择性食欲素受体拮抗剂,是该类药物中第一个获得FDA批准用于治疗失眠的药物。苏沃雷生通过阻断食欲素受体促进睡眠,可以缩短入睡潜伏期,减少入睡后觉醒时间,增加总睡眠时间。
 
5、其他处方药
 
A. 加巴喷丁
 
是一种癫痫药物,有镇定效果。可用于对其他药物治疗无效、对BzRAs禁忌的患者,对酒精依赖患者戒断后的焦虑性失眠、睡眠时相前移者有效,可用于治疗慢性疼痛性失眠;
 
B. 喹硫平(指南)
 
第二代抗精神病药,可以拮抗组胺、多巴胺D2和5-HT2受体,小剂量(12.5~25.0 mg)主要发挥抗组胺作用;该药通常不用于没有明显精神疾病的患者,除非其他药物治疗失败;
 
C. 奥氮平(指南)
 
第二代抗精神病药,可拮抗5-HT2A/2C、5-HT3、5-HT6受体、多巴胺D1、D2、D3、D4、D5受体、胆碱能M1~M5受体以及组胺H1受体,主要通过拮抗组胺H1受体发挥镇静作用,可用于治疗矛盾性失眠。
 
6、非处方药物
 
如抗组胺药、抗组胺药-镇痛药合用,许多失眠患者将此类药物用于失眠的自我治疗。对于这类药物的有效性和安全性的证据非常有限,不推荐用于失眠的治疗。
 
药物治疗调整
 
对于推荐的治疗剂量无效,或对药物产生耐受性或严重不良反应等情况,应逐步更换药物,首选苯二氮受体激动剂或褪黑素受体激动剂,逐渐添加新的药物并增加剂量,于 2 周内完成更换药物过程。常用药物减量方法一种是减少药物剂量,一种是减少用药次数,即持续给药变为间断给药。
 
终止药物治疗
 
长期服用安眠药,尤其服用安眠药剂量较大者切忌突然停药,突然停药可能会出现反跳或戒断症状。
 
参考文献:
唐启盛,孙文军,曲淼. 中国民族医药治疗成人失眠的专家共识[J]. 北京中医药大学学报.2022.1. Vol.45 Iss.1.
中国成人失眠诊断与治疗指南(2017 版),中华神经科杂志,2018 52(5):324-335
http://www.lg.gov.cn/bmzz/wjj/xxgk/qt/cjwt/content/post_2797260.html

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    2023-04-30 NOpainDr.guo 来自河南省

    总结的还是比较全面的,学习了

    0

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    2022-02-18 ms3000001362015616

    学习

    0

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    2022-02-16 ms4000000143541694

    学习了

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