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Obese Patients Especially Vulnerable to Sleeping Pill Risks

sleep disorders, sleeping pills, insomnia, obesity

Between a third and a half of all Americans have insomnia or other sleeping problems, so many turn to medications for relief. As with all drugs, sleeping pills carry risks. A new study reported at an American Heart Association meeting this month finds that obese patients are especially vulnerable, particularly for an increased risk of death.

The use of sleeping pills has increased 23% in the United States since 2006. Most are “sedative hypnotics,” a class of drugs that include benzodiazepines and barbiturates which help to induce and/or maintain sleep. Some of the risks involved in taking these medications are addiction and parasomnia (sleep walking). Sleeping pills are also linked to almost a 5-time greater risk of death and a significant increase in cancer cases.

Robert Langer MD MPH and Daniel Kripke MD have found that some of the risks are greater in patients that are obese. They report that the risk of death tied to sleeping pills is nearly double for those with a body mass index (BMI) greater than 30, even when they are prescribed 18 or fewer pills over the course of a year.

The findings are based on a study of electronic medical records from Scripps Health outpatient clinic visits including almost 40,000 patients between 2002 and 2006. Just over 10,500 patients had been prescribed sleeping pills, including Ambien (zolpidem) and Restoril (temazepam) for an average of 2.5 years and almost 23,700 patients who had not been prescribed the drugs served as controls.

Obese patients in the study (average BMI was 38.8), the risk of death was 8.1 times higher among those who were prescribed the smallest number of pills (18 or fewer annually) when compared to similar controls. For those taking the largest amount of pills (132 or more in a year), the mortality rate was 9.3 times higher among the obese.

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Men appeared to be particularly vulnerable. They were twice as likely to die as women who received sleeping pill prescriptions, after accounting for other factors.

Those who are obese are at a greater risk for sleep apnea, a disorder characterized by an interruption in breathing during sleep. Obstructive sleep apnea, the most common type, is caused by a blockage of the airway, usually the soft tissue in the back of the throat which collapses during sleep. Men, being overweight – particularly with a large neck (17 inches or more in men, 16 or more in women), and those over 40 are at greater risk.

If left untreated, sleep apnea can lead to high blood pressure, stroke, heart failure, heart attack, diabetes, or depression.

"It is important to note that our results are based on observational data, so even though we did everything we could to ensure their validity, it's still possible that other factors explain the associations," said co-author Lawrence E. Kline, D.O., medical director of the Viterbi Family Sleep Center. "We hope our work will spur additional research in this area using information from other populations."

Dr. Kline suggests trying alternative methods of inducing and maintaining sleep before resorting to medication. At the Scripps’ Clinics Viterbi Family Sleep Center, clinicians focus on cognitive therapy that teaches patients to better understand the nature of sleep. For example, some people suffering from insomnia might require less than the eight hours of sleep commonly recommended for each night.

Patients also can benefit from practicing good sleeping habits such as sticking to a sleep schedule, creating a bedtime ritual, and ensuring the room is comfortable and conducive to sleep. When insomnia results from emotional problems such as depression, doctors should treat the psychological disorder rather than prescribe sleeping pills that could prove to be harmful, Dr. Kripke said.

American Heart Association's Epidemiology and Prevention | Nutrition, Physical Activity and Metabolism 2012 Scientific Sessions in San Diego.
Kripke DF, Langer RD, Kline LE. Hypnotics’ association with mortality or cancer: a matched cohort study. BMJ Open, 2012;2:e000850 DOI: 10.1136/bmjopen-2012-000850



Sleep apnea, or more specifically, obstructive sleep apnea (OSA) is the underlying problem. When a person with undiagnosed OSA takes a sleeping pill or any respiratory depressant for his/her insomnia, their apneas are prolonged resulting in worsening of their hypoxemia (low blood oxygen). Cardiac arrest and death results. Physicians should never prescribe a sleeping pill or any respiratory depressant to a patient without knowing whether they have OSA or not.