POC 101

Improving Outcomes in Non–24-Hour Sleep-Wake Disorder

Identifying Patients and Tailoring Therapy


International Classification of Sleep Disorders – Third Edition (ICSD-3).

The ICSD-3 is the authoritative clinical text for the diagnosis of sleep disorders. Updated in 2014, the third revision to the ICSD features significant changes, including new nomenclature, classifications, and diagnoses. The book also includes current and accurate diagnostic and treatment reimbursement codes (eg, ICD-10). Disorders are grouped into 6 major categories, one of which is circadian rhythm sleep-wake disorders.

American Academy of Sleep Medicine. 2014; Westchester, IL.

Clinical practice guideline for the treatment of intrinsic circadian rhythm sleep-wake disorders: advanced sleep-wake phase disorder (ASWPD), delayed sleep-wake phase disorder (DSWPD), non-24-hour sleep-wake rhythm disorder (N24SWD), and irregular sleep-wake rhythm disorder (ISWRD). An update for 2015. 

The American Academy of Sleep Medicine has recently updated clinical guidelines for the treatment of intrinsic circadian rhythm sleep-wake disorders. These guidelines were created using a systematic literature review, assessment of evidence using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, and meta-analyses.

Auger RR, et al. J Clin Sleep Med. 2015;11(10):1199-1236.

Patient and Caregiver Resources

2009 Sleep in America Poll: Summary of Findings.

The National Sleep Foundation’s 2009 Sleep in America™ poll of 1000 respondents highlights behaviors that adversely impact sleep and the consequences of insufficient sleep.

Information on Non–24-Hour Sleep-Wake Disorder From the National Sleep Foundation.

The National Sleep Foundation website offers patient-centered information regarding symptoms, diagnosis, pharmacologic therapies, other management modalities, and associations between non–24-hour sleep-wake disorder and other medical/psychiatric conditions.

Circadian Sleep Disorders Network: Advocating for People With Misalligned Body Clocks.

The Circadian Sleep Disorders Network is a volunteer-driven nonprofit organization that is dedicated to increasing awareness of chronic circadian rhythm disorders, advocating for accommodations, and providing support for those living with these conditions.

Clinical Tools

Epworth Sleepiness Scale. 

The Epworth Sleepiness Scale (ESS) is a self-administered questionnaire that quantifies an individual’s general level of sleepiness. The total ESS score can range between 0 and 24. A score >12 indicates a significant amount of sleepiness.

Johns MW. Sleep. 1991;14(6):540-545.

National Sleep Foundation Sleep Diary.

The National Sleep Foundation’s sleep diary can help patients and clinicians track and evaluate sleep habits and problems over time, thereby standardizing an essential step in the diagnosis and management of circadian rhythm sleep-wake disorders.

The Insomnia Severity Index.

The Insomnia Severity Index is a validated instrument used to assess the degree of insomnia and treatment responses. A score of 8 to 14 indicates subthreshold insomnia, whereas a score of ≥15 indicates clinical insomnia.

Morin CM, et al. Sleep. 2011;34(5):601-608.

Suggested Readings

Non-24-hour disorder in blind individuals revisited: variability and the influence of environmental time cues.

Emens JS, et al. Sleep. 2013;36(7):1091-1100

Non-24-hour sleep-wake disorder revisited: a case study.

Garbazza C, et al. Front Neurol. 2016:7:17.

Safety profile of tasimelteon, a melatonin MT1 and MT2 receptor agonist: pooled safety analyses from six clinical studies

Leger D, et al. Expert Opin Drug Saf. 2015;14(11):1673-1685.

Alertness, mood, and performance rhythm disturbances associated with circadian sleep disorders in the blind.

Lockley SW, et al. J. Sleep. Res. 2008;17(2):207-216. 

Tasimelteon for non-24-hour sleep-wake disorder in totally blind people (SET and RESET): two multicentre, randomised, double-masked, placebo-controlled phase 3 trials.

Lockley SW, et al. Lancet. 2015;386(10005):1754-1764.

Sleep: a health imperative.

Luyster FS, et al. Sleep. 2012;35(6):727-734.

Personality differences in delayed sleep-wake phase disorder and non-24-hour sleep-wake rhythm disorder patients relative to healthy sleepers.

Micic G, et al. Sleep Med. 2016 Jun 16. [Epub ahead of print].

Excessive sleepiness: Under-recognized and essential marker for sleep/wake disorder management.

Roth T, et al. Curr Med Res Opin. 2010;26(suppl 2):S3-S24.

Adverse metabolic and cardiovascular consequences of circadian misalignment.

Scheer FA, et al. Proc Natl Acad Sci U S A. 2009;106(11):4453-4458.

Caffeine does not entrain the circadian clock but improves daytime alertness in blind patients with non-24-hour rhythms.

St Hilaire MA, Lockley SW. Sleep Med. 2015;16(6):800-804

Circadian rhythm abnormalities

Zee PC, et al. Continuum (Minneap Minn). 2013;19(1 Sleep Disorders):132-147.

Interactive Presentation

Improving Outcomes in Non–24-Hour Sleep-Wake Disorder

Karl Doghramji, MD; Paul P. Doghramji, MD, FAAFP

Improving Outcomes in Non–24-Hour Sleep-Wake Disorder

Identifying Patients and Tailoring Therapy

Non-24–Hour Sleep-Wake Disorder

A Case-Based Discussion on Diagnosis and Treatment

Relevant Resources

Improving the Management of Shift Work Disorder

Practical Diagnostic and Tailored Treatment Strategies

Acute Management of Migraine Attacks

Overcoming Pain and Gastrointestinal Distress to Improve Patient Outcomes

Clinical Updates on the Management of Gout

Evidence-Based Strategies for Improved Patient Outcomes

Opioid-Induced Constipation

Proactive Diagnosis and Targeted Management

Chronic Obstructive Pulmonary Disease, Asthma, or Both

Differential Diagnosis and Comprehensive Management Strategies

Improving Outcomes in Chronic Obstructive Pulmonary Disease

Optimizing Maintenance Therapy Across Healthcare Settings

Managing Gout in Primary Care

Evolving Strategies for Diagnosis and Long-Term Management

Clinical Issues in Chronic Pain

Consensus and Controversies for Responsible Opioid Prescribing

Noninsulin Approaches to Managing Type 2 Diabetes

Best Practices in Combination Therapy

Hitting the Target in Type 2 Diabetes

Evolving Approaches to Insulin Based Therapy

Clearing the Air

Improving Outcomes for Patients with COPD

Clinical Updates in Type 2 Diabetes

New Strategies for Insulin Replacement Therapy

How Low Do You Go?

Clinical Updates in LDL-C Management

Incretin-Based Therapies For Type 2 Diabetes

Improving Comprehensive Patient Care

Comprehensive Management of Chronic Obstructive Pulmonary Disease

Collaborative Approaches to Guideline-Concordant Patient Care

Clinical Updates in the Management of Severe Asthma

New Strategies for Individualizing Long-term Care

Comprehensive Chronic Pain Management

A Focus on Patients With Opioid-Induced Constipation

Clinical Issues in Bipolar Depression

Consensus and Controversies Across the Spectrum of Patient Presentations

Clinical Updates in Rheumatoid Arthritis

Evolving Treatment Algorithms and Expert Perspectives on Biosimilars

Caring for Patients with Severe Asthma

Evolving Best Practices to Optimize Outcomes

Can You Spot Axial Spondyloarthritis?

The PCP’s Role in Timely Recognition and Referral

Advancing the Care of Severe Asthma

Differential Diagnosis, Multidisciplinary Management, and Patient Engagement

Updates in HCV Screening and Treatment

Key Issues Impacting OB/GYN Practice

Evolving Models of HIV Care

Volume II: Expanding Evidence for the Role of Rapid ART Initiation in HIV Practice

Clearing the Air in Severe Asthma Management

Improving Patient Outcomes Through Shared Clinical Decision Making

GLP-1 Receptors Agonists in Type 2 Diabetes

Mechanistic Insights and Evolving Treatment Options

Airing It Out

A Case-Based Conversation on Managing Asthma and Chronic Rhinosinusitis With Nasal Polyposis

COPD in Managed Care

The Clinical and Utilization Benefits of Exacerbation Prevention

Assimilating the Evidence in T2DM

Cardiovascular and Renal Outcomes With SGLT2 Inhibitors

Demystifying New Evidence for COPD Management

Best Practices for Primary Care

Finding Relief in Osteoarthritis

New Paths to Chronic Pain Management

The Changing Landscape of HIV Prevention

What the Pharmacist Needs to Know about PrEP

What’s New in Systemic Lupus Erythematosus?

Unlocking Novel Paths to Patient Care

Expert Views on the Changing Landscape in RA

The Increasing Role of JAK Inhibitors

COPD Cases & Conversations

Preventing COPD Exacerbations to Improve Outcomes

Comprehensive Management in COPD

A Whole Patient Case Series

Maybe It’s NOT Mechanical Back Pain

Getting on the Fast Track to Identify AxSpA

Treating Hepatitis C in the Primary Care Setting

Establishing Clinical Readiness Through Mentored Learning

Finding the Path in Eosinophilic Esophagitis

Interdisciplinary Strategies for Adult and Pediatric Patients

Answering the Call

Interdisciplinary Management of Eosinophilic Esophagitis and Hereditary Angioedema

Getting Low in Familial Hypercholesterolemia

Reducing LDL-C and a Lifetime of Cardiovascular Risk

Expert Consult Series in Multiple Sclerosis

Updates, Clinical Scenarios, and Future Directions

Putting a Spotlight on Systemic Mastocytosis

A Multidisciplinary Look at Early Diagnosis and Management

Is It Systemic Mastocytosis?

Best Practices for Diagnosis and Management

Monoclonal Antibodies for COVID-19

An Update on Best Practices

Monoclonal Antibodies for COVID-19

New Avenues to Pre-Exposure Prophylaxis

Early Cancer Detection in Primary Care:

Are You Aware of New Blood-Based Multi-Cancer Screening Tools

Buffing Up on New and Emerging ART

A Look at the Changing HIV Playing Field

Pharmacy PrEP Education

A “How To” Series Spanning Policy to Practice


Building Bridges to Reach People who Inject Drugs with the Goal of Employing PrEP for HIV Prevention

Flexing Your Early Cancer Detection Muscles

Strengthening Your Knowledge of Blood-Based Screening Tools

Long-Acting Injectable PrEP:

Bringing HIV Prevention to a New Level

PrEParing to End the Epidemic

Optimizing HIV Prevention in Primary Care

Multi-Cancer Early Detection in Primary Care

What You Need to Know About New Blood-Based Screening Tools

A Call to Action

Monoclonal Antibodies for the Prevention and Treatment of COVID-19

What’s Next

Exploring New Treatment Avenues in Nonadvanced Systemic Mastocytosis

Best Practices in COPD

Practical Updates on the 2023 GOLD Guidelines

Answers to Everyday Practice Challenges in HIV Medicine

A Phone-a-Friend CME Series – Volume 2

What’s New in the Management of COVID-19

Incorporating New Data and Updated Guidelines Into Daily Practice

Lifting the Bar in Relapsed or Refractory Multiple Myeloma

Capitalizing on BCMA-Directed Therapies