Sonata use in commercial driving

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Kdantin

Sonata use in commercial driving

Post by Kdantin » Wed Jan 09, 2019 7:52 am

It seems that some physicians are prescribing sonata for insomnia to their patients who are commercial drivers due to the shorter half life and the fact that the FDA did not add warnings to the labeling as with ambien and lunesta. Of course, the examiner has to consider many factors when evaluating a driver with a sleep disturbance but i was wondering if any of you handle sonata use differently than other hypnotics?



Robert Swotinsky MD
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Re: Sonata use in commercial driving

Post by Robert Swotinsky MD » Sun Jan 13, 2019 8:10 pm

...i was wondering if any of you handle Sonata use differently than other hypnotics?
I do not typically disqualify drivers based on prescriptions for bedtime use of short-acting hypnotics. For thoroughness, an inquiry into concurrent prescriptions for benzodiazepines could be informative. The prescriber is probably prescribing the Ambien or Sonata at a rate of 1 per day; but, it's not unusual for patients on these drugs to also be prescribed benzos, and once they're combining sedatives the risk becomes more apparent.

One could also inquire about the nature of the "sleep disturbance," but this seems unlikely to be informative.

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Re: Sonata use in commercial driving

Post by Robert Swotinsky MD » Mon Jan 14, 2019 3:29 pm

You are referencing page 3 of a report published in 1991, commissioned by DOT, see https://www.fmcsa.dot.gov/sites/fmcsa.d ... psych1.pdf

I believe the heirachy of authority is:

#1 regulations, i.e., 49 CFR 391.41(b) and the Medical Advisory Criteria
#2 guidelines, e.g., FAQs, 2014 Medical Examiner Handbook
#3 panel reports commissioned by DOT, particularly the more recent ones
#4 texts, newsletters, etc. (I have it on good authority that the authors of those texts and newsletters occasionally make mistakes.)

The 1991 panel report does recommend that short-acting sedatives for short periods of time are acceptable. btw, zolpidem was approved for use in the United States in 1992. If the zolpidem was short-acting (not extended release) and prescribed at no more than 5 mg qhs (as FDA recommended in 2013), I'd be ok with qualifying the driver. I do understand that zolpidem and other sleeping meds are intended for short term treatment, and that is probably where the two week time frame comes from. Long term treatment may not be supported as effective by medical science, but I don't think that long term treatment makes the person more impaired.

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Re: Sonata use in commercial driving

Post by Robert Swotinsky MD » Tue Jan 15, 2019 5:40 am

Good point! That more recent handbook from FMCSA does address hypnotic medications like zolpidem. The handbook can be viewed at several web site links, including: http://www.occ-doc.net/FMCSA_Medical_Ex ... 4MAR18.pdf The section we are discussing is:
Anxiolytic and Sedative Hypnotic Therapy
Anxiolytic drugs used for the treatment of anxiety disorders and to treat insomnia are termed sedative hypnotics. Studies have demonstrated that benzodiazepines, the most commonly used anxiolytics and sedative hypnotics, impair skills performance in pharmacologically active dosages.
The effects of benzodiazepines on skills performance generally also apply to virtually all nonbenzodiazepines sedative hypnotics, although the impairment is typically less profound. However, barbiturates and other sedative hypnotics related to barbiturates cause greater impairment in
performance than benzodiazepines. Epidemiological studies indicate that the use of benzodiazepines and other sedative hypnotics are probably associated with an increased risk of automobile crashes.

Waiting Period
No recommended time frame
You should not certify the driver until the medication has been shown to be adequate/effective, safe, and
stable.

Decision
Maximum certification — 2 years

Recommend to certify if:
The driver uses:
• Hypnotic, if the medication is:
o Short-acting (half-life of less than 5 hours).
o The lowest effective dose.
o Used for a short period of time (less than 2 weeks).
• Non-sedating anxiolytic.

Recommend not to certify if:
The driver:
• Uses a sedating anxiolytic.
• Has symptoms or side effects that interfere with safe driving.
Zolpidem is intended for use as a hypnotic, not a sedating anxiolytic. Long term use of zolpidem as a hypnotic (qhs) arguably falls in neither the "certify" or "not to certify" category. The risk is that some patients take zolpidem not just to sleep but also to relieve their anxiety. A sizable fraction also take benzodiazepines for the same reason. The thorough medical examiner may be advised to get records from the treating MD and/or usual pharmacy to indicate (a) how much zolpidem per month is being purchased, (b) is it immediate or extended release, (c) is it dosed at greater than FDA's recommendation of 5 mg/day immediate release for women/10 mg/day for men, and (d) what other meds the pt is taking.

greghomd

Re: Sonata use in commercial driving

Post by greghomd » Wed Sep 11, 2019 6:15 pm

I hear from drivers that tolerance excuses long term use, but see Am J Public Health. 2015 August; 105(8): e64–e69. Zolpidem after 360 days still carried an increased hazard ratio = 1.76 (1.21, 2.55). Trazodone carried a 1.27 risk after 360 days. I counsel drivers about good sleep hygeine and recommend CBT , but generally follow the 2013 recommendations for zolpidem.

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