Liver Disease and the Treatment of Insomnia and Other Sleep Disturbances

The average person requires between 7-8 hours of sleep per night. However, some people  require as much as10 hours of sleep per night and others require only 4 hours of sleep per night. No matter what your personal requirement is, the main objective is to feel rejuvenated upon awakening. People with liver disease often suffer from sleep disturbances. In fact, approximately 35 to 50 percent of people with cirrhosis report having sleep-related difficulties. Some people have trouble falling asleep and others have difficulty staying asleep. Many people complain of being tired all day and awake all night. Others complain of erratic sleeping habits characterized by days of excessive sleep (a condition known as hypersomnia) alternating with days of lack of sleep (a condition known as insomnia). Still others state that they experience delays of their usual bedtimes and wake-up times. For most people suffering from these sleep disorders, the sleep they do get is not refreshing. 

      Sleep disturbances may cause decreased  concentration, poor coordination, excessive fatigue, anxiety and depression.  It may affect personal relationships, work performance, and physical appearance.  These symptoms and consequences of sleep disorders are magnified in people with liver disease as they may already be suffering from one or more of the aforementioned symptoms.

The cause of sleeping disorders in people with liver disease is unclear, but most likely it relates to alterations in the body’s production of melatonin—a hormone that is produced by the pineal gland and is involved in the sleep cycle. Sometimes, sleep disturbances stem from medications used for the treatment of liver disease. For example, interferon, ribavirin, prednisone, and propanolol all may cause insomnia. Pruritus (itching) can sometimes cause a sleeping disorder. People suffering from intense itching (discussed on page xx) may find themselves awake half the night scratching. People on interferon therapy for chronic hepatitis may be drinking up to a gallon a day of water to diminish the side effect of dehydration.  Therefore, they may be awakening throughout the night to go to the bathroom.  Discontinuation of water or fluid intake 2-3 hours prior to retiring, along with urinating before bedtime, may alleviate this problem.  Caffeine, nicotine, and alcohol consumption may disturb sleep habits. Abstaining from these substances will likely assist in the quest for a good night’s sleep. Note that sleep disturbances may also be a sign of impending encephalopathy.

Treatment of sleeping disorders associated with liver disease consists of both behavioral modification and medical management.  Unwind from the day’s tensions for about an hour before lying down.  Take a warm shower or bath and consider using soothing aromatic lotions to enhance relaxation. Try drinking a tranquilizing herbal tea such as chamomile, or drink warm milk.  Milk contains the chemical tryptophan, which causes drowsiness.  Try to avoid watching late- night thrillers or scary movies as well as late night news, as these shows may cause undue stress. Soft music may enhance your ability to relax.  If you are fortunate enough to own a dog or a cat, try petting or brushing your pet prior to bedtime.  The soft purr of a cat  enhances relaxation and calms the nerves, making it easier for one to fall asleep.  Do not eat 3 hours prior to bedtime. Certain foods, as well as a heavy meal in general can cause reflux symptoms (heartburn and nausea), thereby  inhibiting a good night’s sleep.  Make sure your bed and bedroom are comfortable.  The room temperature of your bedroom, as well as the texture of your bedsheets, can affect your night’s sleep. People should use their beds only for sleeping and never for other activities, such as reading, watching television, or eating. These activities should be performed in other areas of the home. If a person is unable to fall asleep within twenty minutes of retiring, she should get out of bed and read a book or perform some other relaxing activity in another room. Lights should be kept low and the television should be kept off. Only after becoming tired should she return to bed. Also, people should make an effort arrange their schedule so that they to wake up at the same time each day—regardless of the amount time spent sleeping during the night. This type of consistency can help reduce fatigue. Although long naps of two to three hours during the day are not recommended for people with sleep disturbances, a twenty- to thirty-minute nap in the early afternoon, if it can be arranged, may have an energizing effect.

     Under no circumstances should alcohol be used as a sleeping aid.  Also, as most prescription and over-the-counter sleeping pills are broken down by the liver, they should be avoided unless their use (in low doses and for short periods) is authorized by a liver specialist. People with liver damage are at increased risk for prolonged sedative effects if these medications are used at their generally prescribed dosages.   Avoid herbal medications such as kava and valerian as  sleep aides.  These herbs can cause serious liver damage, even in people without underlying liver disease.  In people who already have liver disease, they may worsen the disease and may even lead to liver failure and death.

     Although used primarily for the treatment of depression, selective serotonin reuptake inhibitors (SSRIs)—such as Paxil, Celexa , Zoloft, Wellbutrin and Lexapro—are generally safe for most people with liver disease and may help treat insomnia. These medications, with the exception of Lexapro, must be taken on a daily basis for a period of 3-6 weeks to become effective.  Lexapro may become effective within a week of its initial daily use. SSRI’s are discussed in detail in the next section of this chapter on  psychological/psychiatric disorders on page xx .

     Extra strength Tylenol PM may be used in moderation as a sleeping aide.  This over-the-counter medication contains 500mg of acetaminophen, which functions as a pain medication and helps relieve the aches, pains and headaches (associated with interferon), as well as 25mg of diphenhydramine (Benadryl) which promotes drowsiness. Melatonin, taken in dosages of 1 to 2 milligrams taken half an hour before bedtime, may be helpful. Keep in mind that melatonin supplements are not regulated by the FDA and the amount of active ingredient contained in each pill may vary depending on the brand. Ambien (manufactured by Searle), a prescription sleeping aide, may be used on occasion. However, if Ambien is used nightly its effectiveness will typically diminish after a few weeks – a tolerance will build up.  Furthermore, if used every night for more than two weeks, a dependence upon this medication may occur.  It should be noted that Ambien has been associated with memory problems, a side effect which interferon therapy may worsen. Therefore, one should use Ambien on a limited basis only, and under the strict guidance of a doctor. Lunesta (manufactured by Sepracor), is the first and only non-narcotic sleeping aide approved for long-term use. In studies done, there was no development of tolerance and there was a low potential for abuse. Lunesta may be given at a dose of 1,2 or 3 mg prior to bedtime. In studies, people reported that they were able to fall asleep quickly, maintain quality sleep throughout the night, without waking too early, and wake-up refreshed.

All contents of this article are Copyright © Melissa Palmer, MD

Melissa Palmer, MD is the author of " Dr. Melissa Palmer's Guide of Hepatitis and Liver Disease". (Published 2004. Penguin Putnam).

The office of Melissa Palmer, M.D. is located at:

1097 Old Country Road Suite 104

Plainview, N.Y 11803

To arrange an appointment with Dr. Palmer, call

(516) 939-2626

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