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PHRM 845 > 60 - Pharmacotherapy of sleep > Flashcards

60 - Pharmacotherapy of sleep Flashcards

1
Q

disease states, medications, substances, associated with insomnia

A
  • anxiety
  • caffeine
  • modafinil
  • amphetamines
  • beta-agonists
  • BB
  • nicotine
  • thyroid meds
  • mood disorders
  • bupropion
  • decongestants
  • methylphenidate
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2
Q

DSM-5 insomnia disorders

primary complaint of unsatisfying sleep quantity or quality

difficulties with sleep initiation ( __ ), sleep maintenance, and/or early-morning awakening

takes place at least ___ nights per week
present for at least ___ months

A

latency
3
3

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3
Q

sleep onset only (5)

A
  • zaleplon
  • triazolam
  • eszopiclone
  • zolpidem
  • ramelteon
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4
Q

sleep maintenance only (4)

A
  • suvorexant
  • doxepin
  • eszopiclone
  • zolpidem
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5
Q

sleep onset and sleep maintenance (3)

A
  • eszopiclone
  • zolpidem
  • temazepam
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6
Q

treatment of insomnia disorders

First line treatment is Non-PCOL
- sleep hygiene principles are necessary and should be counseled by the pharmacist - often need drug therapy

the z-hypnotics (3) are the most commonly used sleep meds

initial dose of zolpidem is lower in women and elderly - ___ mg

eszopiclone (Lunesta) - FDA approved for ___ term (6 months) use.
- patients complain of ___ taste

___ substrates - metabolism impacted by inhibition/induction

somnolence, dizziness, ataxia, headaches

parasomnias - unusual actions while a person is sleeping - warning on all sleep meds

controlled substances, additive effects with other CNS depressants

A
  • zolpidem, eszopiclone, zaleplon
  • 5 mg
  • long
  • metallic
  • 3A4
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7
Q

treatment of insomnia disorders

BZD
- longer acting agents more likely to cause ___
- ANY BZD can be used for insomnia
- MUST consider dose ___ to d/c (avoid life-threatening withdrawal, seizures, can take up to ___ months)
- ___ is the BZD used for sleep
- drowsiness, dizziness, cognitive impairment, increases fall risk

___ agonists: ramelteon, tasmelteon) for sleep onset

orexin antagonist for sleep onset of maintenance

doxepine (Silenor) - lower branded dose FDA approved for sleep (TCA)

all FDA approved insomnia medications have sleep ___ warning s

A
  • hangover
  • taper, 4
  • temazepam

behavior

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8
Q

melatonin receptor agonists - ramelteon

  • greater affinity for melatonin receptors than melatonin
  • attenuates the alerting signal from the suprachiasmatic nucleus to promote sleep
  • CI with ___ or angiodema with past use
  • sleep onset within ___ min ; may require up to ___ weeks of use to see effect
  • ___ upset, next day __, hyper ___
  • ___ substrates: watch for inducers/inhibitors
A
  • fluvoxamine
  • 30
  • GI, somnolence, hyperprolactinemia
  • 1A2
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9
Q

melatonin receptor agonists - tasimelteon

  • FDA approved for ___ sleep wake disorder in adults
  • similar MOA, SE, and DI as ramelteon
  • increased ALT, nightmares, unusual dreams
  • ___ substrates: watch for inducers/inhibitors
A
  • non-24
  • 1A2
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10
Q

orexin receptor antagonists (C-IV)

suvorexant
- 10 mg within 30 min of bedtime and at least ___ hours to sleep
- 10 mg - warn for impairment, 20 mg warn against daytime driving
- CI in ___ - causes ___ like SE
- ___ substrate

associated with potential for worsening depression/suicidal ideation

A
  • 7
  • narcolepsy, narcolepsy
  • 3A4
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11
Q

orexin receptor antagonists (C-IV)

lemborexant
- 5 mg within 30 min of bedtime and at least ___ hours to sleep
- onset may be delayed if taken with a meal
- decrease dose if moderate hepatic impairment
- 10 mg: avoid next day driving
- CI in ___ - causes ___ like SE
- ___ substrate

associated with potential for worsening depression/suicidal ideation

A

7
narcolepsy, narcolepsy
3A4

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12
Q

orexin receptor antagonists (C-IV)

daridorexant
- 25 mg within 30 min of bedtime and at least ___ hours to sleep
- delayed absorption with a high fat, high calorie meal
- 50 mg: avoid next day driving
- CI in ___ - causes ___ like SE
- ___ substrate

associated with potential for worsening depression/suicidal ideation

A

7
narcolepsy, narcolepsy
3A4

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13
Q

doxepin

TCA - low doses exert effect through ___ receptor antagonism
- useful for sleep onset and maintenance difficulties
- elderly = 3 mg
- duration of action about ___ hours
- ___ SEs

A

H1
- 7
- anticholinergic

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14
Q

trazodone

  • not FDA approved for ___
  • highly sedating ____
  • commonly used in low doses for sleep
  • long t1/2 - may see daytime ___
A
  • insomnia
  • antidepressant
  • hangover
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15
Q

mirtazapine

  • non-FDA approved for insomnia
  • sedation is SE of lower doses
  • clinically used as a sleep agent, especially in patients with ___ who have difficulty sleeping
  • 7-15 mg at bedtime more sedating than 30 mg
A

depression

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16
Q

quetiapine

  • atypical antipsychotic with sedation side effects
  • low dose is not recommended for use in insomnia unless there is a co-morbid ___ disorder
A

psychiatric

“glorfied antihistamine”

17
Q

OTC antihistimines and natural products

diphenhydramine/doxylamine
- not recommended by AASM
- ___ SE - avoid in elderly patients

A

anticholinergic

18
Q

OTC antihistimines and natural products

melatonin/chamomile
- melatonin can be considered for ___ and patients with low melatonin levels; ___ substrate
- german chamomile contains BZD like compoind; allergic reactions in patients with ___ or ___ allergies

A
  • jet-lag, 1A2
  • ragweed, daisy
19
Q

choosing treatment

  • Academy of Sleep Medicine has stated that CBT and behavioral therapies are first line
  • drug therapy is FDA-approved for ___ use (10 days)
A

short term

20
Q

DSM-5 criteria - obstructive sleep apnea

patient must have evidence of at least ___ obstructive apneas per hour of sleep confirmed by polysomnography
- symptoms include excessive daytime sleepiness, snoring, pauses in breathing during sleep, headache, irritability, sore throat, ED, impaired memory, GERD, mood disturbance
- clinically, there is greater recognition that many patients hae bpth apnea and ___ - both need treated with ___ treated first

A

5
insomnia, apnea

21
Q

AASM - diagnostic testing for sleep apnea

___ only if there is a significant ___ disease, potenitial repiratory muscle weakness due to neuromuscular condition, sleep related hypoventilation, chronic opioid medication use, stroke, or severe insomnia

A

polysomnography
cardiorespiratory

22
Q

treatment of sleep apnea

  • weight loss, smoking cessation, avoid alcohol and CNS ___ , sleep on side
  • if an overweight patient comines in for insomnia evaluation, consider looking ___ to medications
  • ___ - continuous positive airway pressure
  • excessive daytime sleepiness (EDS) can be treated with ___ or ___ - need to review CPCP adherence first and possibility of RLS or PLMS

when considering treating apnea and insomnia, ensure that the obstructive apnea is addressed before recommending ___ / ___ drug therapy

A
  • depressants
  • prior
  • CPAP
  • modafinil, armodafinil
  • sedative/hypnotic
23
Q

DSM-5 criteria - narcolepsy

  • recurring episodes of irresistible need to sleep

at least one of the following
- ___ episodes
- hypocretin deficiency
- ___ sleep latency

sleep paralysis may also occur

A
  • cataplexy
  • REM
24
Q

the narcolepsy tetrad

___ - occurs in 100% of patients, generally more severe in Type I narcolepsy
- narcolepsy with cataplexy or hypcretin deficiency syndrome

cataplexy - sudden loss of ___ tone triggered by ___ - 75%

hallucinations - 30-60%

sleep paralysis - 25-50%

all 4 symptoms - 10-33%

A

EDS
muscle, emotion

25
Q

treatment of narcolepsy- cataplexy

  • sodium oxybate (Xyrem) - GHB - ___ sodium content
  • Xywav - for adults and children aged ___ or older, also approved for idiopathic hypersomnia in adults - ___ sodium
  • Lumryz - for adults only - ER dosage form, once nightly dosing, ___ sodium content
A
  • 7
  • high
  • lower
  • high
26
Q

treatment of narcolepsy - excessive daytime sleepiness

  • ___ / ___: associated with possible life threatening ___
  • sodium oxybate
  • methylphenidate, dextroamphetamine
  • ___ and ___ recently FDA-approved for EDS
  • selegiline
A
  • modafinil/armodafinil, rash
  • pitolisant, solriamfetol
27
Q

___ (Wakix)
- FDA approved for excessive daytime sleepiness; efficacy in cataplexy
- ___ receptor antagonist/inverse agonist
- CI in severe ___ impairment
- prolongs ___ interval
- ___ / ___ substrate
- weak ___ inducer - may reduce effectiveness of ___
- avoid use with centrally acting ___ receptor antagonists (OTC ___)

A

pitolisant
- H3
- hepatic
- QT
- 3A4/2D6
- 3A4, OC
- H, antihistamines

28
Q

___ (Sunosi) C-IV
- ___ - ___ reuptake inhibitor (DNRI)
- indicated for improvement in ___ in adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea
- moderate ___ impairment - start ___ mg, may increase to ___ mg after at least 7 days
- severe renal impairment - starting and max dose: ___ mg

warnings
- ___ and ___ increases; avoid in unstable CV disease and arrhythmias
- use caution in patients with a history of psychosis or bipolar disorder
- decrease dose or d/c if psychiatric symptoms develop
- use with caution with ___ drugs

A

solriamfetol
- dopamine-norepinephrine
- wakefulness
- renal, 37.5, 75
- 37.5
- BP, HR
- dopaminergic

29
Q

shift work sleep disorder

___ or ___ are drugs of choice, taken 1 hour before the work period starts during “wake time”

A

modafinil, armodafinil

30
Q

restless legs syndrome

urge to move the legs in response to an uncomfortable or unpleasant sensation that begins/worsens during periods of rest

drug therapy
- ___ enacarbil - prodrug, FDA-approved for RLS, growing evidence base for effectiveness, may be considered first line
- dopamine agonists (IR formulation) - ___ or ___
- ___ supplementation may be considered
- levodopa/carbidopa may be cosidered

A
  • gabapentin
  • pramipexole, ropinirole
  • iron

PHRM 845 (62 decks)

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