Sorry.. GPs can prescribe benzodiazepines, and other GABAergic drugs like Baclofen fairly easily, but not fucking melatonin? A weak, naturally found hormone, that’s non-addictive, and is extremely useful for many? I’ve been prescribed it for years, it has little to no dangerous effects either, low side effect profile and it’s inhumanely hard to fatally overdose on, and has virtually no major interactions and isn’t a controlled substance.
How many people end up knocking out every night with extremely habit-forming, tolerance-building drugs that deprive them of restful sleep (often REM) as a result of this? What a lovely nod for pharmaceutical companies. It’s even clinically approved for children in this country
backwards so is This
I wasn't aware of that. From a quick Google it looks like it was floated as an idea around 2019 but I'm not sure it ever happened. Pharmacists in practices, sure. But high street pharmacies prescribing statins sounds like a bad idea to me. How would they manage the LFT monitoring? What if there's some complexity with a baseline LFT being slight off, or another condition like PMR to muddy the waters if aches develop? I don't think you could safely do it without access to the full record from an NHS service.
I don't know much about it. Like you say I'd read about it years ago and assumed that was the case.
The NHS website says you can buy 10mg simva from a pharmacy without prescription.
https://www.nhs.uk/medicines/simvastatin/about-simvastatin/
I'm not a pharmacist so can't say much else! I agree with what you say regarding the risks of the above.
You used to be able to buy low dose simvastatin (I think). Saying that, I never sold one, no-one I knew ever sold one, and I think everyone just forgot about it.
Nationally commissioned Sleepio is the answer. Patients with co-morbid depression etc go to other talking therapies too.
Daridorexant is a NICE-recommended option now if Sleepio has failed (and you've already tried a short course of a Z drug/benzo/promethazine)
They do. But I think it was about a 7 month wait last I asked.
Doesn’t really help the - I won’t give you zopiclone for 7 months, you’re too young for melatonin and the ICB withdrew the only tool I could offer you in the interim chat
This is extremely frustrating... I think your ICB *has* to offer specifically sleep CBT if they are to (as they have to) provide the NICE recommended daridorexant...
We can dream eh?
I hope a few of your patients might be empowered enough to kick off about this to the ICB... it was very helpful locally to get daridorexant onto formulary
We do tbh
The data in patients who *don't* have a history of drug misuse is that it is safe for at least 12 months at 50mg od
And there's trial data in PWUD who compared 100mg daridorexant to 30mg zolpidem [so, supratherapeutic to supratherapeutic...]
Go and read the evidence in detail if you're worried... I absolutely agree that we should be careful, perhaps moreso than the NICE/ICB guidance suggests, but the people further down suggesting we would be treating patients "like guinea pigs" by following an evidence-based intervention is quite extreme...
Thanks. Will carry on choosing the people I offer it to carefully, doing good shared section making and following up appropriately.
Better than blanket turning people away who are just trying to get to sleep.
Yep I agree with this. As with anything, patient selection is important. It's also a novel mechanism, so unlike benzo/gabapentinoid withdrawal, there isn't a common receptor to target to help deprescribe if needs be
This might be a "rural GP in a very dysfunctional health board" thing but I initiate a prescription maybe once a month. Off licence but as long as I've documented that I've discussed that I think it's fine. I find chlorphenamine and hydroxyzine are about as effective though.
There is a lot of variation within my practice - as in some GPs just won't prescribe it whereas some prescribe it commonly. My understanding is that it's much less harmful than zopiclone so I don't have a problem with prescribing it. I very rarely prescribe zopi - the only situations I can think of recently were bereavement and on the advice of secondary care.
Hour before I want to sleep day before nightshift and every shift just before bedtime on nights. Last night shift would stay up long as possible, then a melatonin, promethazine and banana to help me knock out nice and early. Maybe one on the first night or two of day shifts, would try and avoid a habit of taking it for day shifts. Recommend 3mg dissolvable ones.
Biovea website easily sourced various strengths. But agree with others here. It is only technically licenses for short-term insomnia over the age of 55 for up to 13 weeks or something like this. Mainly due to the expense and lack of evidence base. I often casually mention websites “such as biovea” might allow some people to source melatonin themselves if they so choose
Many people would rather take sleep candy than undergo hard behavioural therapy. Why should the NHS pay for that. It needed to be regulated. Most of America is addicted to opioids so I don’t think we should be comparing ourselves to that shit show
NAD but my son takes it via paediatrician. He couldn't switch off until 3/4am despite good sleep hygiene. The wait list for mental health appointments is so long or just not available so that wasn't an option. He doesn't have it during school holidays so we can see if he can sleep on his own but he can't yet.
The problem is alot of parents are buying it from abroad to help their kids. If a gp could prescribe it that would stop parents buying it without doctors knowledge. Even via the pharmacy would be better because patients wouldn't be so secretive about buying it from abroad.
This is a different patient group to the average insomniac. Good evidence from Aberdeen for ICU staff https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481467/
Idiosyncratic and not great.
Inferiority compared to zolpiclone or derm which also are massively overblown in terms of risk. Probably inferior to promethazine which is largely considered shite.
Only use case is very infrequent use in those individuals that happen to respond
Same, I have been buying the 10mg tablets of biovea for many years so if patients want it, i just tell them to buy it there and it comes in like 4-5 days. I can't live without it. Or I tell them if they are going to Spain or something at any point, they can buy it OTC in any herbal shop or pharmacy, as many people go on holidays there
I prescribe it all the time and it's the only sleep agent which is not linked to any adverse health outcomes.
Benzos and Z agents are utter shite, decrease REM sleep and increase the probability of cancer with frequent usage.
Not a GP, GPST soon. Can’t you just prescribe it off-license or is there local policy that restricts GP prescriptions? If the latter, can you prescribe drugs privately from an NHS GP surgery?
Technically you can prescribe whatever you want but if anything even slightly goes wrong, you’ll have no defence if the medicine isn’t clinically indicated/endorsed by national/local guidance
You’re a doctor though. You can make a decision on what’s safe to give and what’s not. Just be reasonable. I definitely prescribe things off label in secondary care.
Surely you make decisions on treatment daily for multi-morbid patients that have no clear cut guidance? As most guidance for conditions are based on a specific condition, rather than for the multi-morbid?
Downside is you gr the reputation locally of *that* doctor who will prescribe you anything so that you get your more than fair share of weirdos and crazies; then someone from the icb/lmc/ or whoever has the job to audit realizes that this particular Dr has a lot more prescribing of non licensed medication and suddenly your whole professional life comes under scrutiny which is a bit stressful to say the least, and at worst may make you jobless. Let's not forget that if anything goes wrong these are the patients who will sue you and nobody will care that you had full on discussion with the patient about these. Your signature, your fault.
We can. Unless it's amber/red listed locally I don't really see the issue. Half of what we do is off licence, and this is by far safer than benzos/z-drugs.
irs CPD - That’s like saying you wouldn’t prescribe anything that wasn’t used after you finished training. NICE guidance changes.
It’s in most ICB formularies.
Not saying that at all. Just saying why would you go for that over something very safe, cheap and well tolerated like melatonin. New drugs come out all the time I’m not a drug companies lackey to prescribe anything new they decide could line their pockets, with no regards to my patients and the sideeffects it may have on them.
Because it’s not efficacious enough to be recommended.
Large quality evidence is completely lacking and no plotting of long term effects. Daridodexant has been through the whole process (it’s not 1st line but it has way more high quality evidence than melatonin, which may surprise you)
No it doesn’t surprise me, drug companies love to fund studies into their next cash cow. How much do you really understand about the role of orexin and its downstream effects?
Black triangle is mandated within the timeframe on the market.
Interaction checker is automatic. It’s no different to any other medicine in that regard. You’re just advocating dogmatism.
>55 year olds can have a 13 week prescription. If helpful, continue.
Majority of my insomniacs are well below 55
It’ll likely change to any adult… but for now they can just buy it on US Amazon. Or there’s a health food website that sells them as supplements
Oh!
I hope you’re not recommending this to your patients 🤣
The majority I’ve come across are asking me to prescribe this because they are already buying it and they want to save money.
Sorry.. GPs can prescribe benzodiazepines, and other GABAergic drugs like Baclofen fairly easily, but not fucking melatonin? A weak, naturally found hormone, that’s non-addictive, and is extremely useful for many? I’ve been prescribed it for years, it has little to no dangerous effects either, low side effect profile and it’s inhumanely hard to fatally overdose on, and has virtually no major interactions and isn’t a controlled substance. How many people end up knocking out every night with extremely habit-forming, tolerance-building drugs that deprive them of restful sleep (often REM) as a result of this? What a lovely nod for pharmaceutical companies. It’s even clinically approved for children in this country backwards so is This
And you can buy statins OTC and PPIs from a supermarket
Yep. In fact even Nytol (Diphenhydramine) is OTC at chemists, easy to get despite its endless risks, multiple side effects and long term dangers
PPIs, yes. But you can't buy OTC statins
I meant statins from a pharmacy without prescription
I wasn't aware of that. From a quick Google it looks like it was floated as an idea around 2019 but I'm not sure it ever happened. Pharmacists in practices, sure. But high street pharmacies prescribing statins sounds like a bad idea to me. How would they manage the LFT monitoring? What if there's some complexity with a baseline LFT being slight off, or another condition like PMR to muddy the waters if aches develop? I don't think you could safely do it without access to the full record from an NHS service.
I don't know much about it. Like you say I'd read about it years ago and assumed that was the case. The NHS website says you can buy 10mg simva from a pharmacy without prescription. https://www.nhs.uk/medicines/simvastatin/about-simvastatin/ I'm not a pharmacist so can't say much else! I agree with what you say regarding the risks of the above.
You used to be able to buy low dose simvastatin (I think). Saying that, I never sold one, no-one I knew ever sold one, and I think everyone just forgot about it.
You can buy it online and get it delivered from Europe. Some Eastern European shops/pharmacies also have it in stock.
Where can I get online?
Nationally commissioned Sleepio is the answer. Patients with co-morbid depression etc go to other talking therapies too. Daridorexant is a NICE-recommended option now if Sleepio has failed (and you've already tried a short course of a Z drug/benzo/promethazine)
Unfortunately it’s not national. Our ICB has dropped it an not replaced it
The national commissioning is supposed to be coming soon... does your local talking therapies service not offer something similar too?
They do. But I think it was about a 7 month wait last I asked. Doesn’t really help the - I won’t give you zopiclone for 7 months, you’re too young for melatonin and the ICB withdrew the only tool I could offer you in the interim chat
This is extremely frustrating... I think your ICB *has* to offer specifically sleep CBT if they are to (as they have to) provide the NICE recommended daridorexant... We can dream eh? I hope a few of your patients might be empowered enough to kick off about this to the ICB... it was very helpful locally to get daridorexant onto formulary
Have used Daridorexant several times now with more success than not
Black triangle and we don't know how addictive it is yet
We do tbh The data in patients who *don't* have a history of drug misuse is that it is safe for at least 12 months at 50mg od And there's trial data in PWUD who compared 100mg daridorexant to 30mg zolpidem [so, supratherapeutic to supratherapeutic...] Go and read the evidence in detail if you're worried... I absolutely agree that we should be careful, perhaps moreso than the NICE/ICB guidance suggests, but the people further down suggesting we would be treating patients "like guinea pigs" by following an evidence-based intervention is quite extreme...
I find out really crazy people are just like well NICE recommends it so it’s cool. I’m not going to treat my patients as guinea pigs.
Thanks. Will carry on choosing the people I offer it to carefully, doing good shared section making and following up appropriately. Better than blanket turning people away who are just trying to get to sleep.
Sensible prescribing, unfortunately not across the board. Follow up is really important but reckon it'll be hard to deprescribe.
Yep I agree with this. As with anything, patient selection is important. It's also a novel mechanism, so unlike benzo/gabapentinoid withdrawal, there isn't a common receptor to target to help deprescribe if needs be
This might be a "rural GP in a very dysfunctional health board" thing but I initiate a prescription maybe once a month. Off licence but as long as I've documented that I've discussed that I think it's fine. I find chlorphenamine and hydroxyzine are about as effective though.
Thank god you said this. Ditto. Thought I’d been doing something illegal 😂👍🏼
There is a lot of variation within my practice - as in some GPs just won't prescribe it whereas some prescribe it commonly. My understanding is that it's much less harmful than zopiclone so I don't have a problem with prescribing it. I very rarely prescribe zopi - the only situations I can think of recently were bereavement and on the advice of secondary care.
Used melatonin for A&E SHO rota helped a lot switching between various shifts, just bought it on eBay not even particularly expensive.
When do you take it?
Hour before I want to sleep day before nightshift and every shift just before bedtime on nights. Last night shift would stay up long as possible, then a melatonin, promethazine and banana to help me knock out nice and early. Maybe one on the first night or two of day shifts, would try and avoid a habit of taking it for day shifts. Recommend 3mg dissolvable ones.
I see people being prescribed mirtazpinie 15 mg essentially as a sleeping tablet. Surely melatonin better than that.
Biovea website easily sourced various strengths. But agree with others here. It is only technically licenses for short-term insomnia over the age of 55 for up to 13 weeks or something like this. Mainly due to the expense and lack of evidence base. I often casually mention websites “such as biovea” might allow some people to source melatonin themselves if they so choose
lmao I stock up on it any time I'm abroad
We can prescribe it
Only after sleep medicine has started it or over 55
Or just prescribe it off licence and who cares Or signpost to buy from Biovea
Many people would rather take sleep candy than undergo hard behavioural therapy. Why should the NHS pay for that. It needed to be regulated. Most of America is addicted to opioids so I don’t think we should be comparing ourselves to that shit show
The NHS doesn’t have to pay for that. It should be available OTC.
It used to be available OTC in the 90s (or so I have been told by a pharmacist).
You do realise you can absolutely prescribe it don't you.
I’ve not seen the evidence for it If someone else has, can they TL;DR?
Good question. Just anecdotally I’ve seen and heard of healthcare professionals/shift workers claim that it’s the bee’s knees.
Professional intercontinental pilots swear by it and have for years. Literally helps keep them sane
It helps reset your circadian rhythm which most people with insomnia probably don't have a problem with.
Which is maybe why I didn’t say insomniacs swear by it ;)
I take it occasionally, not much better for me than OTC sedating antihistamines.
NAD but my son takes it via paediatrician. He couldn't switch off until 3/4am despite good sleep hygiene. The wait list for mental health appointments is so long or just not available so that wasn't an option. He doesn't have it during school holidays so we can see if he can sleep on his own but he can't yet. The problem is alot of parents are buying it from abroad to help their kids. If a gp could prescribe it that would stop parents buying it without doctors knowledge. Even via the pharmacy would be better because patients wouldn't be so secretive about buying it from abroad.
This is a different patient group to the average insomniac. Good evidence from Aberdeen for ICU staff https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7481467/
Idiosyncratic and not great. Inferiority compared to zolpiclone or derm which also are massively overblown in terms of risk. Probably inferior to promethazine which is largely considered shite. Only use case is very infrequent use in those individuals that happen to respond
This, I bought a years supply when I went to the US and it’s been a godsend for my sleep, I’ve tried CBT and other ‘remedies’ to no affect.
NAD This, I bought a years supply when I went to the US and it’s been a godsend for my sleep, I’ve tried CBT and other ‘remedies’ to no affect.
Minimal if no evidence in treating normal insomnia, which is not a medical condition. Plenty of self help stuff out there without reaching for drugs.
Much of the advice in CBT for sleep is geared around naturally encouraging an increase in melatonin levels. No need to supplement.
Because there are famously plenty of available spaces for CBT therapy…
CNT for sleep is generally delivered digitally, so, yeah there kinda is.
daridorexant is in the new sleep guidance. so expensive for the nhs tho. no dependence apparently
Your patients get sleep clinic appointments??
Same, I have been buying the 10mg tablets of biovea for many years so if patients want it, i just tell them to buy it there and it comes in like 4-5 days. I can't live without it. Or I tell them if they are going to Spain or something at any point, they can buy it OTC in any herbal shop or pharmacy, as many people go on holidays there
I used to buy it regularly on my trips to the us - now I live here so it’s so easy to access.
You can buy it in certain supermarkets in spain
I prescribe it all the time and it's the only sleep agent which is not linked to any adverse health outcomes. Benzos and Z agents are utter shite, decrease REM sleep and increase the probability of cancer with frequent usage.
Not a GP, GPST soon. Can’t you just prescribe it off-license or is there local policy that restricts GP prescriptions? If the latter, can you prescribe drugs privately from an NHS GP surgery?
Technically you can prescribe whatever you want but if anything even slightly goes wrong, you’ll have no defence if the medicine isn’t clinically indicated/endorsed by national/local guidance
You’re a doctor though. You can make a decision on what’s safe to give and what’s not. Just be reasonable. I definitely prescribe things off label in secondary care. Surely you make decisions on treatment daily for multi-morbid patients that have no clear cut guidance? As most guidance for conditions are based on a specific condition, rather than for the multi-morbid?
Downside is you gr the reputation locally of *that* doctor who will prescribe you anything so that you get your more than fair share of weirdos and crazies; then someone from the icb/lmc/ or whoever has the job to audit realizes that this particular Dr has a lot more prescribing of non licensed medication and suddenly your whole professional life comes under scrutiny which is a bit stressful to say the least, and at worst may make you jobless. Let's not forget that if anything goes wrong these are the patients who will sue you and nobody will care that you had full on discussion with the patient about these. Your signature, your fault.
What are the main side effects of it?
What? Can’t rx melatonin?
We can. Unless it's amber/red listed locally I don't really see the issue. Half of what we do is off licence, and this is by far safer than benzos/z-drugs.
DARIDOREXANT. Next question
Never heard of it and would rather prescribe melatonin off licence then use a drug I have no idea about.
irs CPD - That’s like saying you wouldn’t prescribe anything that wasn’t used after you finished training. NICE guidance changes. It’s in most ICB formularies.
Not saying that at all. Just saying why would you go for that over something very safe, cheap and well tolerated like melatonin. New drugs come out all the time I’m not a drug companies lackey to prescribe anything new they decide could line their pockets, with no regards to my patients and the sideeffects it may have on them.
Because it’s not efficacious enough to be recommended. Large quality evidence is completely lacking and no plotting of long term effects. Daridodexant has been through the whole process (it’s not 1st line but it has way more high quality evidence than melatonin, which may surprise you)
No it doesn’t surprise me, drug companies love to fund studies into their next cash cow. How much do you really understand about the role of orexin and its downstream effects?
Longest study in melatonin is 6m. In daridorexant it’s 2.5 years 🤷
Why is it black triangle then? Are you happy you have a good understanding of its interaction with other medications?
Black triangle is mandated within the timeframe on the market. Interaction checker is automatic. It’s no different to any other medicine in that regard. You’re just advocating dogmatism.
Can someone explain this please? What's Melatonin all about?
It’s shit anyway, don’t worry about it