The adult patient developed insomnia due to metoprolol, is there B-blocker less associated with causing insomnia?Initial Q: the adult patient developed insomnia due to metoprolol, is there B-blocker with less insomnia? 49 years old man has a myocardial infarction medications history : aspirin clopidogrel lisinopril metoprolol atorvastatin acetaminophen
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- Answered 28 Sep 2019 Conflict of interest declaration: None I found little information on this topic and there seems to be contradictory messages! As I am not qualified to comment untangle this, I will simply report the pertinent articles I’ve found in date order. Also, the question listed the other drugs the person is taking – I have not taken that in to account as, again, I am not qualified to explore potential interactions. The 1985 article “Beta-blockers and sleep: a controlled trial”  reports: “Analysis of physiological records confirmed subjects' reports that waking was increased by the lipophilic drugs… …Although atenolol had no effect on subjective measures of sleep this hydrophilic drug also reduced REM frequency, suggesting that either it has some central effect, or that REM reduction is due to a peripheral 'shielding' effect.” Twenty four years later (2009) “Insomnia and chronic heart failure”  reported: “More than two decades ago, Kostis demonstrated that orally administered beta-blockers adversely affected sleep continuity and wakefulness in 30 healthy men. Lipophilic beta blockers, particularly pindolol, had more adverse effects, and were also more likely to be associated with reduced REM sleep.” The 2013 article “Risk of insomnia attributable to β-blockers in elderly patients with newly diagnosed hypertension”  concludes: “The use of bisoprolol and atenolol was associated with the lowest risk of insomnia in elderly patients, as compared to propranolol. β-Blockers with high selectivity in β(1)-receptors and/or low lipophilicity were associated with a lower risk of insomnia.” Another 2013 article “Systematic review of genuine versus spurious side-effects of beta-blockers in heart failure using placebo control: recommendations for patient information”  questions the link between beta-blockers and insomnia: “At least 6 so-called side-effects are less common on beta-blocker than placebo, including depression (reduced by 35%, p<0.01) and insomnia (by 27%, p=0.01).” The 2017 article “Insomnia in Patients with Comorbid Medical Problems”  states: “Beta-specific adrenergic blocking agents reduce sympathetic tone to the pineal gland and have been shown to suppress night time melatonin and worsen sleep quality. However non-selective beta blockers like carvedilol (alpha-1 blocking) and nebivolol do not appear to suppress melatonin synthesis." Finally, and not in date order, is a trial I incidentally found. The papers often mention the effect of beta-blockers on melatonin production. There may be more, but this is shared for information (there may be others which may be contradictory) and I appreciate it’s not part of the actual question. The trial is “Repeated Melatonin Supplementation Improves Sleep in Hypertensive Patients Treated with Beta-Blockers: A Randomized Controlled Trial”  concludes: “n hypertensive patients treated with beta-blockers, 3 weeks of nightly melatonin supplementation significantly improved sleep quality, without apparent tolerance and without rebound sleep disturbance during withdrawal of melatonin supplementation (in fact, a positive carryover effect was demonstrated). These findings may assist in developing countermeasures against sleep disturbances associated with beta-blocker therapy.” References 1) https://www.ncbi.nlm.nih.gov/pubmed/2865152 2) https://link.springer.com/article/10.1007/s10741-008-9102-1 3) https://www.ncbi.nlm.nih.gov/pubmed/22813717 4) https://www.internationaljournalofcardiology.com/article/S0167-5273(13)00996-0/pdf 5) https://link.springer.com/chapter/10.1007/978-3-319-41400-3_11 6) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3443766/