Pharmacotherapy of Insomnia.

Insomnia remains a common clinical concern that is associated with negative daytime consequences for patients and represents a significant public health problem for our society. Although a variety of therapies may be employed to treat insomnia, the use of medications has been a dominant approach. Regulatory agencies have now classified insomnia medications into 4 distinct pharmacodynamics classes. Medications with indications approved for insomnia treatment include benzodiazepine receptor agonists, a melatonin receptor agonist, a selective histamine receptor antagonist, and a dual orexin/hypocretin receptor antagonist. Both pharmacodynamic and pharmacokinetic advances with hypnotic medications in recent years have expanded the pharmacopoeia to allow personalized treatment approaches for different patient populations and individual sleep disturbance patterns.

Zolpidem's use for insomnia.

Zolpidem is a short-acting non-benzodiazepine hypnotic drug that belongs to the imidazopyridine class. In addition to immediate-release (IR) and extended-release (ER) formulations, the new delivery forms including two sublingual tablets [standard dose (SD) and low dose (LD)], and an oral spray form have been recently developed which bypass the gastrointestinal tract. So far, Zolpidem has been studied in several clinical populations: cases poor sleepers, transient insomnia, elderly and non-elderly patients with chronic primary insomnia, and in comorbid insomnia. Peak plasma concentration (Tmax) of zolpidem-IR occurs in 45 to 60min, with the terminal elimination half-life (t½) equating to 2.4h. The extended-release formulation results in a higher concentration over a period of more than 6h. Peak plasma concentration is somewhat shorter for the sublingual forms and the oral spray, while their t½ is comparable to that of zolpidem-IR. Zolpidem-IR reduces sleep latency (SL) at recommended doses of 5mg and 10mg in elderly and non-elderly patients, respectively. Zolpidem-ER at doses of 6.25mg and 12.5mg, improves sleep maintenance in elderly and non-elderly patients, respectively, 4h after its administration. Sublingual zolpidem-LD (5mg) and zolpidem oral spray are indicated for middle-of-the-night (MOTN) wakefulness and difficulty returning to sleep, while sublingual zolpidem-SD (10mg) is marketed for difficulty falling asleep. With their array of therapeutic uses and their popularity among physicians and patients; this review describes the clinical pharmacology, indications and uses, identifying withdrawal symptoms, abuse and dependence potentials, and adverse drug reactions are discussed.

Melatonin and Human Cardiovascular Disease.

The possible therapeutic role of melatonin in the pathophysiology of coronary artery disorder (CAD) is increasingly being recognized. In humans, exogenous melatonin has been shown to decrease nocturnal hypertension, improve systolic and diastolic blood pressure, reduce the pulsatility index in the internal carotid artery, decrease platelet aggregation, and reduce serum catecholamine levels. Low circulating levels of melatonin are reported in individuals with CAD, arterial hypertension, and congestive heart failure. This review assesses current literature on the cardiovascular effects of melatonin in humans. It can be concluded that melatonin deserves to be considered in clinical trials evaluating novel therapeutic interventions for cardiovascular disorders.

Understanding cardiac "echo" reports. Practical guide for referring physicians.

OBJECTIVE: To help referring physicians extract clinically useful information from transthoracic echocardiography (TTE) reports, highlighting current practice and innovations that are reflected with increasing frequency in reports issued by echocardiac laboratories. QUALITY OF EVIDENCE: Echocardiography is an established science. The field has a large body of literature, including peer-reviewed articles and textbooks describing the physics, techniques, and clinical applications of TTE. MAIN MESSAGE: Transthoracic echocardiography is a basic tool for diagnosis and follow-up of heart disease. Items of interest in TTE reports can be categorized. In clinical practice, TTE results are best interpreted with a view to underlying cardiac physiology and patients' clinical status. Knowing the inherent limitations of TTE will help referring physicians to interpret results and to avoid misdiagnoses based on false assumptions about the procedure. CONCLUSION: A structured approach to reading TTE reports can assist physicians in extracting clinically useful information from them, while avoiding common pitfalls.