Welcome back to our weekly diabetes advice column Ask D'Mine, written by longtime type 1 and diabetes author Wil Dubois. Here, you can ask all the burning questions about life with diabetes that you may not want to ask your doctor.

This week, Wil's addressing the relative safety of taking sleeping pills when you have diabetes.

{Need help navigating life with diabetes? Email us at AskDMine@diabetesmine.com}

 

 

Sadie, type 1 from Canada, writes:I have diabetes and was wondering about sleep aids. I was using trazodone and didn’t like it. Now I’m using a low dose doxepin and my blood sugar has gone down. Was the trazodone making it higher?

 

Wil@Ask D’Mine answers: First a word from my sponsor. Oh. Wait. I don’t have a sponsor. OK, a word of “common” medical wisdom, then: Sleep aids for T1s are generally frowned upon. Why? Are they bad for our blood sugar? Maybe. Maybe not. More on that in a bit. Instead, the general uneasiness about sleep aids for our kind is that too sound of a sleep could lead to a permanent state of slumber, if you take my meaning.

Yep. Docs get worried about their malpractice insurance payments when writing a prescription that might result in a type 1 sleeping through a nocturnal low blood sugar, not responding, and kicking the bucket. So the more common approach is to try to address PWD sleep issues in a more organic OTC way. A while back we talked about the use of the naturally occurring melatonin as an alternative to prescription sleep aids, or even trying grocery store medicine-aisle options like Tylenol PM or Advil PM to kick-start a good night’s sleep. 

Other diabetes sleep specialists focus on the environment first: Cut caffeine at mid-day, don’t exercise before bed, remove all electronic distractions from the bed chamber, etcetera, etcetera, etcetera. All of these actions fall under the category of good sleep hygiene, a concept that’s been around since the 1970s, and recently updated with all manner of apps like Sleep Cycle, to help people track and improve their sleep patterns.

If all of those actions fail, then the normal medical approach is to look toward what are called sedative hypnotic sleep aids, such as Ambien or Lunesta, at the lowest possible doses. But that’s minor league stuff compared to what you are taking. The two sleep aids that have been prescribed for you are, well, powerful medicine. Meds that most docs would tremble to prescribe to someone with type 1, so I need to be clear with our other readers that the following analysis is to answer your question, not to suggest a course of treatment that they should ask their doctors if it’s right for them.

But wait a sec, why is this even a problem? Does having diabetes make it harder to get a good night’s sleep?

As a matter of fact, yes, it does. Sleep issues are a real problem for D-folks, with various studies showing that the majority of people with diabetes suffer from some form or another of insomnia. The reasons are wide-ranging: Sleep apnea, neuropathy, restless leg syndrome, nocturia, leg camps…

And don’t even get me started on nocturnal alarm fatigue with continuous glucose monitoring systems.

And with research showing us that sleep disturbance can eff’ with glucose even in “healthy” individuals, can you imagine what it does to us?

Now, with that background established, on to your question about Traz and Dox. Both of which, by the way, like all drugs in their classes, carry a suicide risk black box warning.

Trazodone is a sedative and antidepressant classified as an atypical antidepressant, which basically means it doesn’t really work like anything else, so we need to be careful about not making any parallel assumptions like we might do when looking at most medicines within a class. It’s generally prescribed for depression, anxiety, and pain. It can also be used to treat neuropathy, and some limited research shows it may even work better than gabapentin. Because drowsiness is a side effect of the drug, it’s also prescribed "off label" as a sleep aid. In fact, in the last year, a full third of insomnia prescriptions were for trazodone, even though it has never been approved for insomnia treatment, and is not included in the treatment guidelines from the American Academy of Sleep Medicine. (Who also diss melatonin—along with tryptophan and valerian, two other popular alternative sleep aids.)

Looking at the data on trazodone, there’s no mention whatsoever of any side effects related to blood sugar, although interestingly, I found one study of 100 type 2s taking trazodone that actually showed improved glucose control. Whoa! Isn’t that a lot of PWDs on a med we’re not generally supposed to take? Yes it is, but remember that these people are type 2s, and apparently less than a quarter of them were using basal insulin, and none, as far as I can tell, were using fast-acting insulin—so the risk profile of severe nocturnal hypos is different than it would be for you or me. So does what little data we have suggest that trazodone might actually lower blood sugar, the opposite of your experience? Probably not, the study’s author felt that improved sleep was the causative agent in the improved blood sugar, not the drug itself.

So is there any evidence of trazodone raising blood sugar as you suspect? Nothing scientific and controlled, but I did find some folks reporting high blood sugars that they attribute to trazodone. Now, that’s all anecdotal, but sometimes where there’s smoke there’s fire. Of course, other times it’s just people blowing smoke.

On the other hand, the med you’re having a better experience with definitely has a darker side when it comes to blood sugar. 

Doxepin, sold under the brand names Silenor, Prudoxin  and Zonalon, is classified as a nerve pain and antidepressant med, but is also used to treat sleep disorders, along with alcohol withdrawal anxiety, manic-depressive conditions, and irritable bowel syndrome.

That’s quite a resume for one drug. 

Unlike trazodone, doxepin does carry a blood sugar warning in its extensive list of side effects, although it’s less helpful than you’d think. We’re cautioned that doxepin can raise or lower blood glucose levels. Huh? Meanwhile, our parent site notes that should you take it with tolazamide (a 1950’s era first-generation diabetes med of the sulfonylurea family that’s uncommon, but still apparently available) “dangerously low blood sugar levels” can result. To me, this suggests a risk with current generation sulfonylureas as well. 

Doxepin can also cause weight gain, so I’d expect long term glucose control issues associated with trazadone use, as increases in weight cause increases in insulin resistance, requiring more glucose-lowering meds to keep the sugar in control.

As a side note, in ladies, doxepin can cause an enlargement of the breasts, if that’s something that interests you. The bummer is that it also comes with galactorrhea: basically, leaky nipple syndrome, so it’s not exactly a free-ride boob job. Oh, and guys? You’re not off the hook here. Doxepin can give you gynecomastia, a.k.a. man boobs.

That seems to me a high price to pay for a good night’s sleep. Anyway, sorry about the boob detour. Now back to blood sugar.

In theory, as doxepin can raise or lower blood sugar, and you found that your blood sugar improved on it, it’s possible that your diabetes meds were inadequate for your needs, and that you were lucky enough to have a glucose-lowering side effect with the doxepin, so it all worked out hunky dory. In this case, the trazadone didn’t raise your blood sugar. It was high from inadequately medicated diabetes, and in switching sleep aids you got lucky in the side effects sweepstakes.

Maybe.

But I think there’s another answer.

I think the reason your blood sugar has gotten better is not due to one sleep aid or the other making your sugar higher or lower, but the simple fact that you’ve found a drug that works for you. That helps you sleep better.

And that—a good night’s sleep—everyone agrees is the best medicine for good blood sugar.

 

This is not a medical advice column. We are PWDs freely and openly sharing the wisdom of our collected experiences — our been-there-done-that knowledge from the trenches. But we are not MDs, RNs, NPs, PAs, CDEs, or partridges in pear trees. Bottom line: we are only a small part of your total prescription. You still need the professional advice, treatment, and care of a licensed medical professional.