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Trouble Sleeping or Insomnia
or, "What should I do if I am having a hard time falling asleep or staying asleep?"

Side effects from medications are pretty common, but fortunately they are generally pretty mild and can be remedied with relatively easy treatments.  As medicine makes progress in the treatment of HIV and AIDS, the newer medications are generally easier to take and less sickening than some of the older treatments.  Additionally as more and more treatments are found, it becomes easier and easier to find treatments that suit all patients much better.

The most important thing to do about side effects is to report them to your healthcare provider promptly and completely.  If your healthcare provider is aware of your symptoms and problems, your provider can provide recommendations about treatments and changes in your treatment that can decrease or even eliminate the symptoms that you are dealing with.  Please note that the information below should not come before the advice of your healthcare provider because only that person knows all of your medications and all of your conditions.

Trouble Sleeping
Possible Causes
HIV Drugs
Other drugs
other antidepressant drugs
other prescribed stimulant drugs (e.g Ritalin, Provigil, etc.)
reaction to situations
altered sleep cycle (e.g. recent hospitalization)
excess alcohol use
cocaine/crack use
amphetamine use (crystal meth)
liver failure (hepatic encephalopathy)
stopping sleeping pill use (rebound)
caffeinated beverages consumed late in the day
lack of exercise
excess snoring or sleep apnea
Explanation and Possible Solutions
If you are taking efavirenz, this drug MAY cause anxiety, sleeplessness, nightmares, and depression.  It may be reasonable for you to ask to speak to your healthcare provider about alternatives so that you can see what things are like OFF of efavirenz and better be able to tell if other problems are causing the sleep disturbance.  If efavirenz is absolutely necessary for your therapy, using a mild sleeping aid such as temazepam (Restoril), zolpidem (Ambien), or zaleplon (Sonata) may help.  However, all sleeping aids such as these alter your sleep cycle and make you dependent upon the sleeping aid.  If you do not take the sleeping aid after you have been taking it for a while, your ability to sleep may be even further impaired ("rebound" insomnia.)  Gabapentin (Neurontin) is also used for its sedative qualities; gabapentin does not produce dependence or rebound insomnia, and this drug does not appreciably alter your sleep cycle.  Gabapentin can make you feel a little groggy in the morning, and it may impair your memory a bit.  Older sleeping pills such as barbiturates and flurazepam (Dalmane) should be avoided.  Over the counter melatonin may also be tried.  Melatonin may stimulate vivid dreaming.

Stimulant drugs such as antidepressants can also frequently lead to sleep problems.   The sleeping aids mentioned above should be considered if the particular medication you are using is otherwise doing a good job or there are no good substitutes.

Elimination of caffeinated beverages such as coffee, tea, cola beverages, and energy drinks 4-6 hours prior to your bedtime is always a good idea. 

Regular exercise is thought by many experts to be critical to good sleep.  Basically if you do not tire yourself out each day, you should not expect to sleep as well as if you do.  A fast walk, a slow jog, bicycling, or any activity that gets your heart rate up for 15-30 minutes per day will greatly increase your chances of sleeping well.

If snoring is a problem, you may be suffering from sleep apnea.  Consult with your healthcare provider immediately.

Pain will also prevent sleep or restful sleep due to frequent awakenings.  Consult with your healthcare provider.

Depression and other significant mental health problems may also cause problems with sleep.  Consult with your healthcare provider.

Frequent awakenings due to the need to urinate can also make restful sleep less likely.  Try not drinking much fluid for at least 2 hours before you retire to bed and don't drink during the night.  In males the prostate gland can prevent complete emptying of the bladder.  As a result the bladder fills up more rapidly, and the need to urinate is more frequent which may interrupt sleep.  Consult with your healthcare provider if this problem persists.

If you are having trouble sleeping, avoid lying in bed while you are not sleeping.  Get out of bed and read or watch television.

Sleep is definitely a rhythmic or cyclical activity.  One usually sleeps at a certain time each day or night.  Occasionally the sleep cycle may become disturbed due to longer and longer daytime naps, a hospitalization where one stayed (and slept) in the bed most of the time, or if someone stays up later and later due to new interests or television viewing.  While this is not necessarily harmful to your health, it can put you "out of sync" with the rest of the world and the people that you live with if you are sleeping while everyone else is awake.  If one wants to re-synchronize with the world or with one's family, then the cycle must be slowly adjusted back to normal.  Consider trying going to sleep 30-60 minutes earlier or later each day until the cycles are matched again.

Sleep and the normal sleep cycle are definitely impaired by alcohol and drugs such as cocaine, crystal methamphetamine, and heroin.   It is said that a sign of true "recovery" from dependence on these drugs is normal, restful sleep.

 Do not stop any medications that you think may be causing the problems sleeping until you have spoken with your healthcare provider.  If you absolutely MUST stop a suspected antiretroviral medication, stop all of your antiretroviral medications at the same time.  Do not stop just the suspected medication or you might lose the effectiveness of the remaining drugs.  This warning does not apply to medications that are not antiretrovirals.


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