Sleep is often disturbed in chronic Lyme disease. Lack of adequate sleep worsens pain, causes fatigue, increases inflammatory cytokines and suppresses the immune system. It appears that in response to infection, the excess inflammatory cytokines produced by the immune system disturb the sleep centers of the brain. A restorative amount of sleep is 7-9 hours of sleep a night. Sleep during the few hours before midnight is most restorative.
Before trying the prescription sleep medicines outlined in this article, be sure to follow the recommendations in Sleep 101: The Basics. It is most important to follow the recommendations on lowering cytokines and sleep hygiene. In addition you may want to try the supplements and herbs recommended in Sleep: The Natural Medicines. The natural sleep medicines may also be used in combination with the prescription medicines listed below.
General RX Approach for Sleep in a Lyme Disease Treatment
People with chronic Lyme can have problems falling asleep, staying asleep, or both. Because of this I break medications into two groups the get you outs and the keep you outs. Medicines in the get you outs are better at getting a person to sleep, and those that are the keep you outs are better at keeping a person asleep.
I usually will start with aget you out even if a person has more of a problem staying asleep. I find that get you outs can often put a person in deep enough sleep that they will maintain sleep through the night.
I also prefer to start first with get you outs because they are short acting and therefore tend to have less of a hangover effect the next day. However many people will require both a get you out and a keep you out sleep medication used in combination.
One final rule I follow is to layer sleep medications together when needed at lower doses. This approach helps avoid side effects that can occur at higher doses of any one sleep medication while getting partial benefit from each medication that together combine for a good night of sleep.
The get you outs are medicines approved for sleep by the Food and Drug Administration (FDA) here in the United States. The medications that are keep you outs are not generally not approved for sleep, but have sleep causing side effects. In medicine we often use medications for “off label” medical problems even when they are not approved for that purpose by the FDA.
The Get You Outs
Zolpidem (Ambien) 10mg .5 to 1.5 30 min before bed. This medication is approved by the FDA for sleep. It is available in generic form. Be aware the general top dose recommended for insomnia is 10mg but in chronic Lyme sometimes more is needed. In addition if the medication works for getting you to sleep but you wake in the middle of the night, then take another .5 pill. Rarely this medication can cause night time sleep walking or even sleep driving!
Zaleplon (Sonata) 10mg .5 to 1 pill 30 min before bed. The medication is approved by the FDA for sleep. It is available in generic form.
Eszopiclone (Lunesta) 2mg or 3mg 1 pill 30 min before bed. This medication is approved by the FDA for sleep. However it is not available in generic form. Because of this insurance companies will often refuse to pay for it. Without insurance coverage it can cost nearly $300 a month.
Alprazolam (Xanax) .5mg 1 to 4 pills 30 min before bed. It is available in generic form. It is approved by the FDA for anxiety disorders, but is very useful for initiating sleep. It is in a family of medications called the benzodiazepines. Because it helps with anxiety I find it very useful when a person has a lot of anxiety about falling a sleep. Be aware it does have addictive potential and that your physician should monitor you for how you are using this medication.
The Keep You Outs
Gabapentin (Neurontin) 300mg 1 to 4 pills 30-60 minutes before bed. Start at 1 pill and increase every 3 nights if needed up to 4 pills. It is approved by the FDA for the management of seizures and for nerve pain. It is available in generic form. I like to use this medication for my patients that have seizure-like or tremor-like disorders in addition to insomnia. I also like to use it as a sleep medication in a person that has nerve pain.
Pregabalin (Lyrica) 50mg to 300mg 30-60 minutes before bed. It is approved by the FDA for seizure management, nerve pain, and fibromyalgia muscle pain. It is not available in generic form and can cost around $250 a month. Because of its cost insurance will often refuse to pay for it for sleep. I think of using this as a sleep medication in a person with nerve pain or who has a lot of muscle pain. It is a modified version of gabapentin and tends to have less side effect problems. So I will also use it if gabapentin works for a person but causes side effects.
Trazadone (Desyrel) 25mg 1 to 4 pills 30-60 min before bed. It is approved by the FDA for depression and insomnia. I rarely use this medication because for most it causes a sleep hangover the next day. I might consider using it in someone with depression. It also can help with nerve pain too.
Clonazepam (Klonipin) 1mg .5 to 3 pills 30-60 min before bed. It is approved by the FDA for anxiety disorders, nerve pain, and restless legs syndrome. It is available in generic form. Like alprazolam above it is a benzodiazepine and does have addiction potential. For this reason most physicians will not prescribe it. However, I find it to be the best keep you out medication. If you take this medication your physician should monitor you for addictive use. I particularly like to use this medication in someone who has sleep anxiety or daytime anxiety. It’s anti-anxiety effect lasts into the day time.
Lamotrigine (Lamictal) 25mg to 200mg 30-60 minutes before bed. It is approved by the FDA for management of manic depression disorder and seizure disorders. It is available in generic form. I like to use this medication when someone has either mild anxiety or mild depression as part of chronic Lyme disease. Although it is not approved by the FDA for these uses it can be helpful.
Quetiapine (Seroquel) 25mg to 200mg 30-60 minutes before bed. It is approved by the FDA for managing schizophrenia and manic depression disorder. It is available in generic form. I find this to be a useful medication when nothing else is working. However it has a lot of side effects including parkinson like symptoms and extreme weight gain. For these reasons I use it as a later resort.
A Get You Out and Keep You Out
Sodium Oxybate (Xyrem) 4.5gm 2 times a night. You must set your alarm 4 hours after the first dose to take the second dose. This is the last resort medication. It is approved by the FDA for narcolepsy. It is also known as the “date rape drug” and is extremely restricted. In the USA it is only allowed to be distributed through one source due to federal law. It is also quite expensive and can cost nearly $600. I find that most insurance companies will not pay for it for insomnia but will cover it if a person has narcolepsy which is a day time disorder where someone falls asleep suddenly even repeatedly throughout the day. However, in spite of all of this, it is an effective sleep medication.
by Marty Ross MD