A 43-year-old executive comes to the office for a follow-up appointment. He has been traveling between the United States and Switzerland for business every 2 months. Each time he flies to Switzerland, he has difficulty adjusting to the time difference for 4-5 days afterward and is unable to sleep well at night. The patient gets irritable during work hours due to lack of sleep at night and inability to control his sleepiness during the day. He is worried that his colleagues in Switzerland have noticed his fatigue and that his work performance has suffered. He has no other medical conditions and takes no daily medications.
Vitals signs are normal. Examination shows no abnormalities.
Apart from advising exercise and exposure to bright light during the day, which of the following is the best recommendation for improving this patient's jet lag?

Question

A 43-year-old executive comes to the office for a follow-up appointment.  He has been traveling between the United States and Switzerland for business every 2 months.  Each time he flies to Switzerland, he has difficulty adjusting to the time difference for 4-5 days afterward and is unable to sleep well at night.  The patient gets irritable during work hours due to lack of sleep at night and inability to control his sleepiness during the day.  He is worried that his colleagues in Switzerland have noticed his fatigue and that his work performance has suffered.  He has no other medical conditions and takes no daily medications.
Vitals signs are normal.  Examination shows no abnormalities.
Apart from advising exercise and exposure to bright light during the day, which of the following is the best recommendation for improving this patient's jet lag?

Quizplus · Accepted Answer

11ec193a_98a8_0b21_853d_a1aeb4a7bd04_MD0002_00 This patient's presentation is consistent with jet lag, which is usually caused by rapid and long-haul flights across several time zones. The body clock controls pineal gland melatonin secretion, which regulates sleep (circadian rhythm) and is inhibited by light. Westward travel causes less disruption than eastward travel as it is easier to lengthen the natural sleep/wake cycle than to shorten it. Symptoms of jet lag include sleep disturbance, daytime fatigue, reduced performance, malaise, and gastrointestinal symptoms (eg, constipation). Exogenous melatonin can improve jet lag, especially when crossing more than 4 time zones, with few proven adverse effects. Doses of 3 mg are effective in most patients when taken at local bedtime for up to 5 nights after arrival. Other treatments include timed light exposure, exercise during the day, and short strategic naps. Small amounts of caffeine can help with wakefulness but should not be used in excessive amounts or during normal sleep periods to avoid further sleep disruption. (Choices A and E) Benzodiazepines, such as lorazepam, and non-benzodiazepine receptor agonists, such as zolpidem, may improve insomnia due to jet lag but do not promote adjustment of the endogenous circadian timing system. They have greater potential to cause unwanted side effects (eg, poor coordination and driving ability, confusion, memory deficits) when compared with melatonin and should not be suggested as first-line treatment. (Choice C) Modafinil is a wake-promoting agent that has been approved for treatment of shift work sleep disorder but not jet lag. Although its isomer, armodafinil, has been studied for jet lag, it is not recommended as first-line treatment due to its side effect profile (headache, nausea, and palpitations) and high cost. (Choice D) This patient's jet leg is causing significant symptoms and occupational impairment. Exogenous melatonin can accelerate his adjustment to the new time zone and improve his functioning with minimal side effects. Educational objective: Jet lag usually occurs after crossing several time zones with sleep disturbances, daytime fatigue, reduced performance, malaise, and gastrointestinal symptoms (eg, constipation). Behavioral modifications and melatonin are effective initial treatments with few side effects. __________ References: Treatment of shift work disorder and jet lag (http://www.ncbi.nlm.nih.gov/pubmed/20842597) Is melatonin useful for jet lag? (http://www.ncbi.nlm.nih.gov/pubmed/26731279)

A 43-Year-Old Executive Comes to the Office for a Follow-Up