Anti-psychotic prescriptions for insomnia on rise
Recently, after morning rounds seeing patients admitted to his hospital through emergency, Dr. David Juurlink tweeted: “Can the next doctor wanting to prescribe Seroquel for sleep, just not?”
Of the roughly 20 patients he had seen that morning, four were prescribed Seroquel, an antipsychotic, for insomnia.
Seroquel and its generics aren’t approved as sleeping pills. Quetiapine, the active ingredient, has been officially approved in Canada for schizophrenia, bipolar disorder and major depression only. Drug-safety experts are growing increasingly alarmed by the drug’s use as a doctor-prescribed nightcap, with a 10-fold increase in quetiapine prescriptions for sleep problems in Canada between 2005 and 2012 alone.
Quetiapine is sedating. Like over-the-counter sleep aids, it makes people drowsy. But it also comes with a multitude of potential side effects, experts say, including an odd sensation of tension and restlessness (akathisia), Parkinson’s-like tremors and movement abnormalities, weight-gain, high blood sugar, new or worsening diabetes and, in rare cases, heart arrhythmia that can cause sudden cardiac death.
A recent Health Canada review linked quetiapine and other “atypical” antipsychotics to an increased risk of sleep apnea — breaks in breathing during sleep.
Juurlink, a clinical toxicologist at Sunnybrook Health Sciences Centre in Toronto, said quetiapine can also cause a particularly nasty complication known as neuroleptic malignant syndrome, a rare but potentially life-threatening reaction to antipsychotics or major tranquillizers.
“Over the last decade, I have seen several patients who have had quetiapine as part of, or one of the contributing causes to NMS,” said Juurlink, whose frustrated tweet last week was a repeat of one he has sent before.
“I’ve certainly seen people who have been diagnosed with Parkinson’s disease that I’m confident were from quetiapine,” he added. “It’s getting to the point now where, when I admit a patient with Parkinson’s, I reflexively look at their other medications to see, ‘Are they on quetiapine?’”
According to drug market research firm IMS Brogan, of the 33 million prescriptions for tranquillizers dispensed by Canadian retail drugstores in 2016, one quarter — 8.3 million — were for quetiapine.
Doctors say the drug is being prescribed in low-dose formulations to people with no underlying psychiatric conditions, the majority for sleep. University of B.C. researchers found 58 per cent of B.C. quetiapine prescriptions in 2010 were for the 25 mg tablet. The dose range for the approved disorders is 150 to 180 mg per day.
“It’s popping up as a patient’s typical medication for insomnia all the time,” says Kamloops emergency physician Dr. Ian Mitchell. “It’s not well supported by any science for use in sleep, it has significant side effects and yet it’s massively prescribed.”
“Seroquel is not benign,” Dr. David Gardner, a professor of psychiatry and pharmacology at Dalhousie University said in an email. “It may be more dangerous than our standard sleeping pills, but without research we cannot know or quantify its risks.”
It’s not clear how antipsychotics have become such a big thing for sleep. But observers point to aggressive marketing and industryfunded “opinion leaders” who’ve described quetiapine as a “mild, not harmful” drug that seems to help with sleep.
Some users swear by it. Others describe feeling spacey and foggy the next morning.
Juurlink said quetiapine might shorten sleep latency — the time it takes to fully fall asleep — by a few minutes. It can also make people less aware of their “nocturnal awakenings” than they might otherwise have been. It’s a potent antihistamine, like diphenhydramine, the active ingredient in Benadryl and other “nighttime” cold remedies.
“But what’s really driving this is a societal expectation that we should all get eight hours of sleep a night, a pill is a way to go about it, and the willingness of some providers to accede to requests for sleeping pills,” Juurlink said.
While quetiapine has proven safe and effective for approved conditions, and most of the side effects have been reported during highdose treatment, side effects such as tardive dyskinesia — abnormal movements of the face and jaw — have been reported with low-dose regimens as well, according to the UBC Therapeutics Initiative.
Abuse of quetiapine is also a growing problem, with people inhaling or injecting crushed or dissolved tablets. Street names for quetiapine include “Suzy Q” and “baby heroin.”