El insomnio es un trastorno que afecta a la cantidad o calidad del sueño que el paciente percibe como limitante o negativo para su actividad diurna y constituye un motivo de consulta habitual en la farmacia comunitaria. Margarita Olagorta, farmacéutica experta en fitoterapia, nos habla en este artículo de la fitoterapia frente al insomnio.
Tipos de insomnio
En función de su naturaleza, se suele clasificar en:
- De conciliación: cuando cuesta dormirse más de 30 minutos en adultos y más de 20 en jóvenes
- De mantenimiento: si el sueño se interrumpe varias veces cada noche
- Despertar precoz: éste se produce al menos 2 horas antes de lo habitual
- Sueño de mala calidad: se aplica este término cuando a pesar de dormir lo habitual no se produce sensación de haber descansado.
Medidas higiénico-dietéticas
Siempre se debe comenzar el tratamiento con ellas y en todos los casos es conveniente aplicarlas para facilitar la regulación del sueño:
- Mantener horarios regulares de acostarse y levantarse. Evitar siestas.
- Practicar regularmente ejercicio físico, pero no en las 3 horas anteriores a acostarse.
- Cenar de forma ligera.
- No consumir estimulantes 6 horas antes de ir a la cama.
- Evitar el uso de dispositivos electrónicos al menos 1 hora antes de dormir.
- Procurar que la habitación esté a unos 18ºC, sin ruido y a oscuras.
- Si después de 30 minutos se sigue despierto, levantarse y no volver a la cama hasta sentir sueño. Repetir este proceso las veces que sea necesario.
Características de la Fitoterapia frente al insomnio
Cuando esas medidas son insuficientes se puede recurrir a plantas medicinales tradicionalmente utilizadas por sus propiedades sedantes o hipnóticas. No todas están respaldadas por el mismo grado de evidencia científica; así, se puede diferenciar:
- Plantas con uso avalado científicamente: valeriana y pasiflora. Existen datos experimentales y clínicos que respaldan su eficacia.
- Plantas con uso avalado: lúpulo, espino blanco o albar y melisa. Podrían tener las mismas utilidades que las anteriores, pero es necesario realizar ensayos en humanos para confirmarlas.
- Plantas con uso no avalado científicamente: amapola de California y tila, sobre las que se ha investigado poco a pesar de su amplio uso tradicional.
- Otras: azahar o flor de naranjo amargo, sobre la que se han realizado algunos ensayos preliminares cuyos resultados parecen prometedores.
La Agencia Europea del Medicamento (EMA), basándose en su uso tradicional, acepta la indicación de las siguientes especies para aliviar los síntomas de estrés mental leve y como ayuda para conciliar el sueño, con alguna matización:
- Tila: sólo en estrés.
- Espino blanco: también en ansiedad leve, especialmente si se asocian palpitaciones o taquicardia, por su acción cardiotónica, antiarrítmica y antianginosa una vez descartada patología cardiaca.
- Valeriana: en tensión nerviosa leve y trastornos del sueño. Esa indicación se atribuye al extracto seco de valeriana (3 -7,4: 1, etanol 40-70%), que considera de uso bien establecido.
- No se dispone de monografía elaborada por la EMA sobre el azahar, por lo que su empleo se realiza exclusivamente basándose en su uso tradicional.
VENTAJAS SOBRE LOS FÁRMACOS DE SÍNTESIS
- No altera la arquitectura del sueño, con lo que no aparece somnolencia al día siguiente de su administración
- Presenta menos efectos adversos que benzodiacepinas e hipnóticos, especialmente en lo referente a dependencia y tolerancia, lo que permite realizar tratamientos prolongados.
Aspectos de interés sobre el uso terapéutico de las plantas medicinales
- Principios activos:
Son muy variados (aceites esenciales, flavonoides, alcaloides…) y no siempre están bien caracterizados ni se conocen sus mecanismos de acción. En cualquier caso, la parte de la planta utilizada debe poseer una concentración mínima de los activos de referencia para poder atribuirle propiedades terapéuticas. Este dato se recoge en las monografías de organismos como la Agencia Europea del Medicamento (EMA) y la OMS o en diferentes farmacopeas.
- Posología:
En la tabla adjunta se resumen los datos más relevantes. La dosificación completa correspondiente a cada planta medicinal con monografía se puede consultar en la página de la EMA, que es de libre acceso:
https://www.ema.europa.eu/en/committees/committee-herbal-medicinal-products-hmpc
| Planta medicinal | Posología diaria para trastornos del sueño en adultos |
| Valeriana | • Raiz en polvo: 0,3 – 2g
• Extracto seco (3 – 7,4: 1, etanol 40-70%): 400 – 600 mg Administrar una dosis por la noche. Si es necesario, añadir otra por la tarde |
| Pasiflora | Sumidad aérea en polvo: 0,5 – 2g, hasta 4 veces al día |
| Lúpulo | Flor en polvo: 0,8 – 2 g, 30 – 60 minutos antes de acostarse |
| Espino blanco | Hoja y flor en polvo: 190 – 350 mg por dosis, máximo 1750 mg/día |
| Melisa | Hoja en polvo: 0,19 – 0,55 g, 2 – 3 veces al día |
| Amapola de California | Sumidad florida en polvo: 480 – 600 mg por dosis, máximo 1500 mg/día. Una de las dosis se debe administrar 30 – 60 minutos antes de acostarse |
En el caso del azahar, se ha utilizado tradicionalmente la infusión preparada con 2 g de flores en 150ml agua, de 2- 3 veces al día.
- Consejos de administración:
Si el insomnio presenta un componente de nerviosismo o excitación, puede ser conveniente administarlas también a lo largo del día (según la especie y formulación elegida). En el caso de la valeriana, se debe tomar como mínimo 2 horas antes de acostarse porque puede desencadenar reacciones paradójicas que cursan con ansiedad e insomnio.
Aunque permiten tratamientos largos, si los síntomas persisten más de 2 semanas se debe remitir al paciente a su médico para descartar posibles patologías y evitar que el insomnio se cronifique. Por su acción suave, a veces se busca un efecto sinérgico asociando 3 o 4 especies.
- Contraindicaciones:
Es recomendable comprobar que el tratamiento no afecta durante el día, antes de conducir o realizar una actividad peligrosa. Además, en caso de cirugía es conveniente suspender la administración al menos con 2 semanas de antelación a la misma.
Por lo que respecta a cada una de las plantas descritas las contraindicaciones son las siguientes:
- Amapola de California: glaucoma
- Espino blanco: cardiopatías salvo si se usa exclusivamente bajo prescripción médica y empleando preparados estandarizados, tratamiento con digitálicos.
- Lúpulo: cáncer de mama tratado con antagonistas de receptores estrogénicos, tratamiento hormonal sustitutivo.
- Melisa: trastornos de tiroides.
- Tila: dolor abdominal de etiología desconocida, obstrucción gastrointestinal e impactación fecal.
- Interacciones:
Las interacciones descritas para estas plantas medicinales se basan en consideraciones teóricas y no se dispone de datos clínicos que permitan evaluar su trascendencia, aunque dada la gran difusión de su uso es razonable suponer que sean poco relevantes:
- Alcohol y cannabinoides:se debe evitar su consumo.
- Antihistamínicos H1: el riesgo es menor con cetirizina, levocetirizina y bilastina, que no atraviesan la barrera hematoencefálica.
- Benzodiacepinas y otros depresores del Sistema Nervioso Central: sólo se deben asociar bajo prescripción médica.
- Nitroglicerina rectal: precaución.
Recomendación en situaciones especiales
Embarazo, lactancia y niños menores de 12 años son grupos de población en los que la EMA no avala el uso de estas plantas medicinales por falta de estudios adecuados. Sin embargo, en base a su uso tradicional y evitando el empleo excesivo, se podrían recomendar:
- embarazo y lactancia: infusión de azahar o tila. Nunca se deben utilizar los aceites esenciales
- niños mayores de 4 años: tila (la EMA acepta su uso en niños de 4 a 12 años para el alivio de los síntomas del resfriado, durante una semana, utilizando la infusión preparada con 1g de droga en 150ml agua, de 2 a 4 veces al día, por lo que estas dosis pueden servir de orientación).
Criterios de derivación al médico
Debe recomendarse acudir a la consulta médica en los siguientes casos:
- Niños menores de 12 años, embarazadas o madres en período de lactancia, excepto si el insomnio se debe a causas puntuales.
- Pacientes con enfermedades que afecten directamente a la calidad del sueño como alteraciones respiratorias (apnea, asma), enfermedad de Parkinson
- Personas con trastornos psiquiátricos.
- Sujetos en tratamiento con fármacos que pueden afectar al sueño: antidepresivos, teofilina…
Además, debe remitirse al médico a quienes padezcan insomnio durante más de 3 semanas.
Selección de tratamiento
Aunque es necesario realizar estudios de eficacia en situaciones clínicas reales para comparar las distintas alternativas, en base a los datos disponibles, se podría recomendar:
- Insomnio de conciliación: valeriana, pasiflora, amapola de California
- Insomnio de mantenimiento: valeriana, pasiflora, melisa
- Despertar precoz: valeriana, pasiflora,
- Sueño de mala calidad: pasiflora, amapola de California, melisa, espino blanco
Además, si el insomnio se acompaña de:
- Nerviosismo diurno: espino blanco, melisa, tila, valeriana, pasiflora o amapola de California
- Sofocos de menopausia no tratados con terapia hormonal: lúpulo por su acción estrogénica y añadir salvia si existe sudoración intensa.
- Problemas digestivos: melisa, para la que la EMA también acepta esta indicación
Agradecimientos
A Juan del Arco Ortiz de Zárate, director técnico del Colegio Oficial de Farmacéuticos de Bizkaia, la revisión de este artículo y su asesoramiento en la elaboración de los gráficos que en él aparecen.
BIBLIOGRAFÍA
AA.VV. Insomnio. Panorama Actual del Medicamento. 2014; 38(371): 133-146. Alberdi Sudupe J, Castro Dono C, Pérez Ramírez L, Fernández Díaz A. Trastornos de insomnio. En. Guías clínicas. Fisterra; 2016. [último acceso 20/08/2019]. Disponible en: https://www.fisterra.com/guias-clinicas/trastornos-de-insomnio/ Castillo E, Martínez I (eds.). Manual de fitoterapia. 2ª ed. Barcelona: Elsevier; 2016. Consejo General de Colegios Oficiales de Farmacéuticos [Internet]. Tratamiento fitoterapéutico del insomnio [último acceso: 19/08/2019]. Disponible en: https://www.portalfarma.com/Profesionales/campanaspf/categorias/Paginas/articulo02.aspx European Medicines Agency. Herbal Medicines for human use [Último acceso 20/08/2019].Disponible en: https://www.ema.europa.eu/en/committees/committee-herbal-medicinal-products-hmpc Vanaclocha B, Cañigueral S. Vademecum de fitoterapia. [Internet]. Valencia: Cita Publicaciones y documentación; 2010. [Último acceso: 20/08/2019]. Disponible en: www. fitoterapia.net Medinteract.net. Interacciones entre principios activos, medicamentos y plantas medicinales [Internet]. Barcelona: Proyectos y Desarrollos de la Plaza S.L. [Último acceso 19/08/2019]. Disponible en: https://www.medinteract.net/interacciones.php Natural Medicines. Food, Herbs&Supplements [base de datos en línea]. Sommerville: Therapeutic Research Center; 2016. [Último acceso: julio de 2019]. Disponible en: https:// naturalmedicines.therapeuticresearch.com Navarro MC, Crespo ME, Montilla MP. Plantas medicinales para el insomnio. Madrid: Infito- Editorial Complutense; 2008 Salinas E, Díez MA, Blanco R. Curso básico sobre fitoterapia. Tema 1. Insomnio: plantas sedantes e hipnóticas. Farmacia Profesional. 2016; 30(5): 28-34. Servicio de pediatría APILAM. Lactancia materna, medicamentos, plantas, tóxicos y enfermedades. [Ultimo acceso 20/08/2019]. Disponible en: https://www.e-lactancia.org
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