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CONTINUING PROFESSIONAL DEVELOPMENT
COUNSELLING IN PRACTICE
What are the side effects of the medicine
that I am on?
Fluoxetine (Prozac) is a selective serotonin re-uptake inhibitor (SSRI) that has a long half-life (due to active metabolite norfluoxetine).5
Common side effects of fluoxetine include nausea, diarrhoea, insomnia, dry mouth, headache, anxiety, and weight changes. Less frequently, people taking fluoxetine may experience nose bleeds, sedation, confusion, and hypotension. In rare cases, hepatic failure and raised liver enzymes as well as
seizures may be observed.6
Insomnia (as well as anxiety and nervousness) is
reported as a side effect in
10–15%
of people taking fluoxetine,
with these effects
leading to drug discontinuation in 5%
of people taking fluoxetine.7 Insomnia is more likely to be
experienced if fluoxetine is taken in the evening as opposed to in the morning.8
What can I do to relieve my symptoms?
Symptoms of insomnia can be relieved by a number of methods. Fluoxetine is less likely to cause insomnia if administered in the morning, so changing the dose timing could be beneficial.
While dose timing of fluoxetine may be the most likely reason for insomnia symptoms, insomnia can also be caused by some medical conditions, stress and lifestyle factors (inadequate sleep hygiene).1 Non-pharmacological treatment options (e.g. sleep hygiene measures and cognitive behavioural therapy) may be helpful.3
Sleep hygiene measures allow healthy sleep
habits to develop. These techniques include not taking afternoon naps, trying not to engage in mentally stimulating activities close to bedtime, and reducing stress associated with sleep routines.9 Sleep restriction may also assist in developing a sleeping pattern. Sleep restriction involves reducing allocated sleeping time to the amount of hours currently being slept. For example, if the time in bed is from 10 pm to 6 am, but sleep is only occurring for three of those hours, then sleep is restricted to three hours physically in bed each night only, and increased in 30-minute intervals from there until a desired sleep pattern is achieved.3
Doxylamine (Restavit) and diphenhydramine (Unisom) are Schedule 3 sedating antihistamines and may assist sleep. Caution should be taken in recommending these medicines to the elderly, patients already taking antidepressants (especially monoamine oxidase inhibitors (MAOIs) and
tricyclic antidepressants [TCAs]), or patients with acute asthma. Caution should also be taken in recommending sedating antihistamines if combined with other medicines that may cause sedation.
The combination of sedating antihistamines with alcohol and other respiratory depressants is not recommended. Continuous use for more than 7–10 days is also not recommended.7
Box 1. Sleeping problems Self Care Fact Card – dos and don’ts
SELF CARE
P Sleeping ‘DOs’
• Remember that your sleep needs may change over time.
• Sleep in a darkened, quiet room with plenty of fresh air.
• Use a comfortable, supportive mattress and pillow.
• Use clean bedding suitable for the weather.
• Allow yourself time to wind down and relax before bedtime.
• Learn and use relaxation techniques to manage stress.
• Get enough exercise during the day to feel physically tired each night.
• Spend at least 30 minutes outdoors each day to help set your body clock.
O Sleeping ‘DON’Ts’
• Don’t nap during the day, especially after 3 pm. Keep sleep for bedtime.
• Don’t work or watch TV in your bedroom. Keep your bedroom for sleeping, relaxing and sex.
Don’t have pets or equipment with lights or noise in the bedroom.
• Don’t exercise close to bedtime.
• Don’t have a heavy meal close to
bedtime.
• Limit your daily amount of caffeine.
• Limit your daily amount of alcohol. • Go to bed at the same time each
night and get up at the same time each day (this trains your body to develop a regular sleep cycle).
• Have a calming bedtime routine such as:
- a warm bath or shower
- a warm milk drink or a light
snack
- listening to peaceful music and/
or reading for a while - slow, deep breathing.
• Don’t drink a lot of fluid in the evening (to help limit night time visits to the toilet).
• Don’t have caffeine close to bedtime.
• Don’t drink alcohol close to bedtime (alcohol can affect sleep quality).
• Don’t smoke (especially close to bedtime).
Reference: Sleeping problems10
Australian Pharmacist January 2017 I ©Pharmaceutical Society of Australia Ltd. 39