61. Sleep Disorders: Insomnia, Restless Legs Syndrome (RLS) & Narcolepsy

Question 1

A patient gave the pharmacist a prescription for Lunesta 1 mg, take one tablet as-needed for sleep. Which of the following is an appropriate generic substitution for Lunesta?

A. Zolpidem
B. Zaleplon
C. Doxepin extended-release
D. Ramelteon
E. Eszopiclone

Answer 1

E. The generic name of Lunesta is eszopiclone.

Question 2

A new prescription was received at the pharmacy for Hetlioz. What is the generic name for this hypnotic?

A. Tasimelteon
B. Ramelteon
C. Suvorexant
D. Doxepin
E. Trazodone

Answer 2

A. Tasimelteon is for Non-24-Hour Sleep-Wake Disorder.

Question 3

A patient gave the pharmacist a prescription for Ambien 10 mg, take one tablet by mouth before bedtime. Which of the following is an appropriate generic substitution for Ambien?

A. Zolpidem
B. Zaleplon
C. Doxepin extended-release
D. Ramelteon
E. Eszopiclone

Answer 3

A. The generic name of Ambien is zolpidem.

Question 4

Chandra cannot get to sleep. She lies in bed unable to sleep even though her favorite rock band is playing on the radio. She just came from the gym and feels as if she should be tired since she just had a good workout. Chandra just ate a hamburger and fries and says that a heavy meal usually makes her tired. It has been recommended that she try cognitive therapy, including sleep hygiene, to help improve her sleep. What suggestions could help Chandra fall asleep and have restful sleep? (Select ALL that apply.)

A. Keep the bedroom dark, relatively quiet (perhaps peaceful music), and comfortable.
B. Exercise prior to sleep (between 1-2 hours before bedtime) to exhaust yourself.
C. Avoid eating heavy meals before bedtime; digestion takes energy and a full meal can keep a person from sleeping well.
D. If sleep does not seem possible (while lying in bed), get up and do something else for a short while.
E. Do not consume caffeine close to bedtime.

Answer 4

A, C, D, E. Sleep “hygiene” tips work for many patients-the most important for elderly is to stop daytime naps, or limit to one nap of 30 minutes or less. Other tips include following a regular sleep schedule, reserving the bedroom for sleep and sex, establishing a pre-bedtime ritual to condition your body for sleep such as pleasurable reading, or yoga, and do not take caffeine beverages after early afternoon.

Question 5

Melatonin is a hormone that regulates sleep by controlling the night-day cycle and the circadian “24-hour” rhythm cycle. Drugs that act as melatonin or melatonin agonists are used for the following purposes:

A. As a prescription agent to promote wakefulness in patients with narcolepsy.
B. As a prescription hypnotic for Non-24 hour sleep-wake disorder.
C. As a prescription hypnotic for typical insomnia cases.
D. As an over-the-counter natural product for sleep and jet lag.
E. As an over-the-counter natural product for depression.

Answer 5

B, C, D. Melatonin is available OTC. Ramelteon and tasimelteon are prescription-only melatonin receptor agonists and act similar to melatonin at the melatonin receptor in the CNS.

Question 6

A patient is beginning treatment with Silenor for difficulty with sleep latency. Which of the following statements concerningSilenor are correct? (Select ALL that apply.)

A. It is a C-IV medication.
B. If a patient is < 65 years the dose is 6 mg QHS; if the patient is 65 or older the dose is 3 mg QHS.
C. This drug requires a MedGuide (primarily due to the risk of suicidality in adolescents, but required to be dispensed with all new prescriptions and with refills).
D. The primary effect of this drug is somnolence.
E. It can be interchanged with generic doxepin.

Answer 6

B, C, D. Doxepin extended-release (Silenor) is not controlled.

Question 7

Which of the following hypnotics requires a 14-day wash out period in someone who had been using phenelzine?

A. Hetlioz
B. Rozerem
C. Silenor
D. Sonata
E. Lunesta

Answer 7

C. Silenor is extended-release doxepin, a tricyclic antidepressant.

Question 8

Sodium oxybate (Xyrem) is a REMS drug and is highly sedating, causes altered consciousness and has a risk of respiratory depression. It can easily “knock” a person out and requires careful use. Which of the following are boxed warnings for this drug? (Select ALL that apply.)

A. Hepatotoxicity
B. Respiratory depression
C. It is a salt form of GHB-a drug of abuse; do not use with other CNS depressants.
D. Restricted access through the Xyrem REMS program.
E. Addiction and physical dependence

Answer 8

B, C, D. Sodium oxybate (Xyrem) is called a “date rape drug” (called GHB) since it can sedate and confuse a person which enables another to take advantage of the person who has consumed the drug. It is tasteless and odorless and can easily be mixed into drinks when someone is not looking. Always keep your eye on what you are drinking and do not leave the drink on the table when using the restroom. Do not drink from punch bowls. Other common date rape drugs are rohypnol (“roofies”) and ketamine.

Question 9

A pharmacist is discussing the use of sleep agents on medical rounds. He is asked various questions about hypnotics by the medical and pharmacy students. Which of the following statements are correct? (Select ALL that apply.)

A. The non-benzodiazepines can increase the risk of death, even if used intermittently, due to issues such as difficulty breathing at night, increased risk of falls, infection and possibly cancer.
B. These agents have minimal risks, if taken occasionally and not abused.
C. Intermezzo SL is a form of zolpidem that is useful for patients who wake up during the night and need to sleep at least four more hours.
D. The non-benzodiazepines work by acting at the benzodiazapine receptor and acting as GABA agonists.
E. Ramelteon is a melatonin receptor antagonist.

Answer 9

A, C, D. The drugs thought of as “safe” (such as zolpidem) have come under scrutiny for various health risks. It is accurate that these drugs can increase the risk of death (due to difficulty breathing during sleep), can increase the risk of falls and may even increase infection risk and cancer risk. Ramelteon is a melatonin receptor agonist, not antagonist.

Question 10

Beth uses Lunesta 1 mg for sleep. She tells the pharmacist that the medicine puts her to sleep, but she has difficulty staying asleep. The pharmacist should instruct the patient as follows:

A. She should return to the doctor to have the medication changed because Lunesta is generally less effective than zolpidem.
B. She should stop using the medicine as she has become addicted.
C. She should stop using the medicine as she has developed pseudo-addiction.
D. She should return to the doctor to have the medication changed because Lunesta is generally less effective than ramelteon.
E. She should return to her doctor; it is likely that the dose will be increased.

Answer 10

E. Eszopiclone has unusual dosing: 1 mg if difficulty falling asleep, 2 mg if difficulty staying asleep or 3 mg if helpful for a longer duration of sleep.

Question 11

When Xyrem is used for narcolepsy with cataplexy, it has the following scheduled category:

A. C-I
B. C-II
C. C-III
D. C-IV
E. C-V

Answer 11

C. C-III for narcolepsy, but when used as a drug of abuse it is C-I.

Question 12

The primary type of patient who will receive tasimelteon (Heltioz) to help with sleep due to Non-24-Hour Sleep-Wake Disorder is a patient whose brain cannot distinguish easily between day and night. Which type of patient is this?

A. A patient with severe cognitive dysfunction.
B. A patient who has impairment due to narcolepsy.
C. A patient who is blind.
D. A patient who has failed non-benzodiazepine hypnotics.
E. A patient who has failed benzodiazepine hypnotics.

Answer 12

C. Non-24 occurs almost exclusively in persons who are completely blind. Light does not enter their eyes and they are unable to synchronize their body clock to the 24-hour light-dark cycle.

Question 13

In recent years it has been recognized that the use of the non-benzodiazepine agents such as zolpidem are not without risk. A warning has been added for this risk with the use of these agents:

A. Pancreatitis
B. Hepatic failure
C. Teratogenicity
D. Stevens-Johnson/TEN rash
E. Increased mortality

Answer 13

E. Increased mortality is present with even short-term use, which includes risk of injury, and possible risk of infection and cancer. Cognitive therapy, including “sleep hygiene” methods, are preferred over any type of drug therap

Question 14

HG is a 61 year old male patient who has come in for his routine annual physical. He reports that he has developed an urge to move his legs when he tries to sleep at night, and the only way to stop it is to get up and move. If he stops moving, the feeling comes back. HG states that this has occurred during the day a few times (when he was resting is his easy-chair) but it almost always happens when he first goes to bed. He describes it as “unpleasant, uncomfortable and creepy.” Which condition is most likely causing HG’s symptoms?

A. Non-24 Sleep-Wake Disorder
B. Insomnia
C. Cataplexy
D. Restless Legs Syndrome
E. Narcolepsy

Answer 14

D. Restless Legs Syndrome (RLS) is the common name for Willis-Ekbom Disease–although this name is rarely used.

Question 15

What is the indication for the drug Xyrem?

A. Shift-work sleep disorder
B. Narcolepsy with cataplexy
C. Insomnia with sleep latency problems
D. Non-24-hour sleep wake disorder
E. Jet lag

Answer 15

B. Sodium oxybate (Xyrem) is a REMS drug and is highly sedating. It has risk of respiratory depression. It can easiy “knock” a person out and requires careful use.

Question 16

Several benzodiazepines are considered unsafe to use in elderly patients, and in many younger patients as well. Although all benzodiazepines carry health risks, select the agents below that should be avoided in elderly patients and should not be recommended even for short-term use: (Select ALL that apply.)

A. Quazepam (Doral)
B. Flurazepam (Dalmane)
C. Lorazepam (Ativan)
D. Triazolam (Halcion)
E. Temazepam

Answer 16

A, B, D. Doral and Dalmane have a high fall (and consequently high fracture) risk, and these drugs last in the body a long time. Triazolam (Halcion) is another do-not-use benzodiazepine: this one is notable for higher rebound insomnia and daytime anxiety (psychiatric effects), it requires slow tapering upon discontinuation and is contraindicated with strong CYP 3A4 inhibitors. Elderly, if using a benzodiazepine, should use L-O-T: Lorazepam, Oxazepam and Temazepam.

Question 17

A pharmacist is discussing the use of sleep agents on medical rounds. He is asked about the usefulness of the drugRozerem. Which of the following statements are correct? (Select ALL that apply.)

A. It is not controlled.
B. It is considered safe to use long-term.
C. It can be taken with fatty food and will work within an hour when taken with a fatty meal.
D. It is more expensive than generic zolpidem, but works better.
E. The brand name is Sonata.

Answer 17

A, B. The drugs thought of as “safe” (such as zolpidem) have come under scrutiny for various health risks. It is accurate that these drugs can increase the risk of death (due to difficulty breathing during sleep), can increase the risk of falls and may even increase infection risk and cancer risk. Ramelteon is a melatonin receptor agonist, not antagonist.

Question 18

Esther is a 55 year-old female who has been prescribed Ambien for sleep. She has one glass of wine at bedtime. Esther should receive the following counseling:

A. Limit alcohol to one drink nightly.
B. Limit alcohol to two drinks nightly.
C. It is best not to use alcohol with any sleep medicine.
D. It is best to drink mixed alcoholic drinks instead of wine.
E. It is best to drink beer instead of wine.

Answer 18

C. Do not take with other medicines that can make you sleepy, unless directed by your doctor. It is best not to use alcohol with any sleep medicine.

Question 19

The zolpidem dose, along with the other non-benzodiazepines, must be lowered with concurrent use of these medications: (Select ALL that apply.)

A. Itraconazole
B. Trileptal
C. Ritonavir
D. Saquinavir
E. Erythromycin

Answer 19

A, C, D, E. The non-benzodiazepine doses should be at the lower end of the dosing range if used with any CYP 450 3A4 inhibitors; these drugs are 3A4 substrates. Oxcarbazepine is an inducer.

Question 20

Which of the following descriptions best describes some of the pharmacologic characteristics of the stimulant Nuvigil?

A. It is the active metabolite of modafinil.
B. It contains the active ingredient modafinil.
C. It is a pro-drug of modafinil.
D. Provigil contains only 50% (it’s the R-isomer) of the mix of R and S isomers found in Nuvigil.
E. Nuvigil contains only 50% (it’s the R-isomer) of the mix of R and S isomers found in Provigil.

Answer 20

E. Provigil is half of what is in Nuvigil; it contains the half with higher activity. An enantiomer contains two stereoisomers that are mirror images of each other with the opposite orientation, such as your left and right hands. One isomer is much more active than the other. This concept is important with some of other drugs; for example, warfarin is a is a racemic mixture of the R- and S-enantiomers of warfarin. The S-enantiomer exhibits 2.5 to 4 times more anticoagulant activity than the R-enantiomer.

Question 21

A patient came into the pharmacy with a prescription for Nuvigil. What is the generic name of this drug?

A. Sodium oxybate
B. Armodafinil
C. Doxylamine
D. Tasimelteon
E. Ramelteon

Answer 21

B. Modafinil is Provigil.

Question 22

A new prescription was received at the pharmacy for Belsomra. What is the generic name for this hypnotic?

A. Zolpidem
B. Eszopliclone
C. Ramelteon
D. Tasimelteon
E. Suvorexant

Answer 22

E. Suvorexant is an orexin receptor antagonist.

Question 23

Select the class of drugs used most commonly to treat Restless Legs Syndrome (RLS):

A. Beta agonists
B. Beta antagonists
C. Dopamine agonists
D. Dopamine antagonists
E. Alpha-blocking agents

Answer 23

C. Dopamine agonists are commonly used for Parkinson Disease and RLS.

Question 24

Select the correct characterization of the drugs modafinil and armodafinil:

A. These are CNS depressants.
B. These are dopamine agonists.
C. These act at the benzodiazepine receptor.
D. These are tricyclics, similar to doxepin.
E. These are stimulants.

Answer 24

E. These are stimulants used to promote wakefulness in people with narcolepsy. The advertisements for Nuvigil state that the drug provides “wakefulness when it counts.”

Question 25

Nuvigil and Provigil require a MedGuide and careful pharmacist counseling due to this risk:

A. Severe rash and serious allergic reaction.
B. Demyelinating disorder, causing nerve paralysis.
C. Progressive Multifocal Leukoencephalopathy (PML)
D. Severe abdominal pain with risk of pancreatitis
E. Neuroleptic Malignant Syndrome (NMS)

Answer 25

A. Counsel the patient that if they could develop a serious rash or serious allergic reaction that may affect parts of your body such as your liver or blood cells, and may result in hospitalization and be life-threatening. If you develop a skin rash, hives, sores in your mouth, blisters, swelling, peeling, or yellowing of the skin or eyes, trouble swallowing or breathing, dark urine, or fever, stop taking NUVIGIL and call your doctor right away or get emergency help. Tsyabri is the drug that has the risk of Progressive Multifocal Leukoencephalopathy (PML), a rare opportunistic brain infection, that usually leads to death or severe disability.

Question 26

Xyrem has a high content of which of the following:

A. Magnesium, use caution in patients with diarrhea.
B. Aluminum, use caution in patients with constipation.
C. Sodium, use caution in patients with hypertension.
D. Potassium, use caution in patients with renal impairment.
E. Calcium, use caution in patients taking vitamin D supplements or with hypercalcemia.

Answer 26

C. The sodium dose (depending on the drug dose) is 550 - 1640 mg, and would jeopardize a sodium-restricted diet.

Question 27

Xyrem is taken in 1/4 cup of water, usually in an empty pharmacy container. The patient should be instructed to do the following after consuming the drug:

A. Do some restful activity such as yoga.
B. Exercise briskly for 1/2 an hour so you can have restful sleep.
C. Run to the market and pick up milk and eggs.
D.Have an alcoholic drink (no more than 1 for women, 2 for men).
E. Immediately lie down and stay in bed.

Answer 27

E. This drug is unusual in that a second dose is taken 2.5-4 hours after the first (if the patient awakens). The patient should lie in bed and not get up after taking it; there is too high a risk for falls and injury.

Question 28

A patient at the pharmacy does not wish to purchase brand Sominex. He does not have enough money in his wallet. What can the pharmacist recommend as a less expensive alternative that contains the same active ingredient?

A. Cetirizine
B. Loratadine
C. Diphenhydramine
D. Dextromethorphan
E. Phenylephrine

Answer 28

C. Diphenhydramine brands include Benadryl, Sominex and Unisom.

Question 29

With some hypnotics, the counseling is to take right before bedtime. Why is this counseling correct? Select the most appropriate reason:

A. The drug is absorbed within a few minutes and starts to work within 5-10 minutes.
B. The patient may be at risk for falls immediately after taking the hypnotic.
C. The hypnotics cause tachycardia and should be taken lying down.
D. The patient may start to feel sleepy sooner than the drug is absorbed due to a placebo effect and in some patients it starts to have an effect within ~1/2 hour; it can be dangerous if the patient is up and about.
E. The patient may start to feel sleepy due to benzodiazepine receptors in the gut lining; it can be dangerous if the patient is up and about.

Answer 29

D. It can be quite dangerous for patients to think that they have a half hour or so before the drug starts to work and so they run out to the market, or perhaps to the local bar to have a drink. The onset can be sudden. It is best if they take the medication, and lie down. All hypnotics require oral absorption and work in the CNS; this takes time. With some the counseling is to take shortly before bed.

Question 30

Beth is a 46 year-old female who has been using Lunesta for sleep. Her other medications include lisinopril and a calcium plus vitamin D supplement. Her spouse complained that Beth had eaten his leftover birthday cake. Beth denied it. Cake crumbs were found in the bed and in Beth’s teeth. What are likely reasons for the missing birthday cake? (Select ALL that apply.)

A. Beth may have developed psychotic symptoms from an acute infection.
B. Beth may be experiencing the beginning of dementia of the Alzheimer’s type.
C. Beth is being set-up by an angry spouse.
D. Beth got up at night and ate the cake but does not remember eating it.
E. Beth has experienced a parasomnia due to the use of Lunesta.

Answer 30

D, E. The non-benzodiazepines can cause parasomnias (unusual actions while sleeping of which the patient may not be aware). Counsel patients that some people have found that they get out of bed while not being fully awake and do an activity that they do not know remember doing.

Question 31

The rationale behind avoiding benzodiazepines as sleep agents in the elderly is due to the following concerns: (Select ALLthat apply.)

A. The risk of falling and having injury.
B. The risk of tachycardia and hypertensive crisis with chronic use.
C. The risk of rebound hypertension.
D. The risk of cognitive impairment.
E. The risk of physical (physiological) dependence and having to live dose-to-dose.

Answer 31

A, D, E. The risk of physiological dependence is high, and will happen if taken continually. It is not pleasant to be living dose-to-dose. Medications that cause physiological dependence are used when the benefit outweighs the risk, but not when there are other alternatives.

Question 32

A patient arrives at the pharmacy with a prescription for new-onset Restless Legs Syndrome (RLS). Which of the following options would represent an appropriate starting treatment dose for this condition?

A. Requip 0.25 mg taken 1-3 hours before bedtime
B. Requip 1 mg taken 1-3 hours before bedtime
C. Requip XL 2-4 mg daily
D. Mirapex 0.5 mg taken 1-3 hours before bedtime
E. Mirapex XL 0.75 mg daily

Answer 32

A. Only choice A is feasible; ropinirole is available in higher doses but these are never starting doses. This class of drugs is carefully titrated up; see side effect profile and safe starting doses in the Parkinson disease chapter. Long-acting formulations of the oral dopamine agonists are not as useful than the IR taken closer to bedtime since the dose should be highest when the efficacy is required. However, some patients find that the patch, which is taken once daily, provides adequate benefit. Pramipexole is started at 0.125 mg 2-3 hours before bedtime.

Question 33

Counseling for most hypnotics and for the erectile dysfunction drugs advises the patient to avoid fatty food when taking the drug. Why is this counseling accurate? Select the appropriate answer below:

A. Fatty food will slow down the absorption and the drug may not work at the desired time.
B. Fatty food increases the drug toxicity, causing hypotension and falls.
C. Fatty food will make the patient have flatulence in bed.
D. Fatty food increases the drug toxicity, causing priapism.
E. Fatty food increases absorption, causing drug toxicity.

Answer 33

A. If fatty food is taken with the drug (for most) the onset is slowed down considerably. This is true for many other drugs and in those classes where timed onset is important (hypnotics, erectile dysfunction drugs) the counseling to avoid fatty food is important. Any food (versus plain water) will slow down absorption, but fatty food will have the largest effect with several classes of drugs.

Question 34

A pharmacist will instruct a medical resident about the medication Ambien. Which of the following statements regardingAmbien are correct? (Select ALL that apply.)

A. This medication comes as tablets (IR and CR), a spray, a sublingual tab called Edluar and a sublingual formulation that is for night-time awakening called Intermezzo.
B. The dosing for Intermezzo is 1.75 mg for males and 3.5 mg for females; take one SL tablet if you intend to sleep at least 2 more hours.
C. In addition to somnolence, this type of medication can cause dizziness, ataxia and has a risk of parasomnias. However, the long-term safety is considered fine.
D. Lifestyle changes should be attempted prior to the use of prescription hypnotics.
E. Do not mix with alcohol.

Answer 34

A, D, E. The dosing for Intermezzo is 3.5 mg for males and 1.75 mg for females; take one SL tablet if you intend to sleep at least 4 more hours. In addition to somnolence, this type of medication can cause dizziness, ataxia and has a risk of parasomnias. However, the long-term safety is now considered unsafe, due to reports of increased risk of death, infection and cancer–even with occasional use.

Question 35

Janice enters the pharmacy with a prescription for Lunesta. What is the controlled (DEA) category for Lunesta?

A. C-III
B. C-IV
C. C-V
D. C-I
E. C-II

Answer 35

B. Benzodiazepines, barbiturates and the non-benzodiazepines such as zolpidem are C-IV.

Question 36

Which of the following drugs are used in the treatment of Restless Legs Syndrome (RLS)? (Select ALL that apply.)

A. Neupro
B. Horizant
C. Reglan
D. Mirapex
E. Requip

Answer 36

A, B, D, E. Metoclopramide (Reglan) is a dopamine antagonist and could worsen RLS.

Question 37

In 2014 a new hypnotic called Belsomra was approved that is an orexin receptor antagonist. The orexin signaling system is involved in the following:

A. Promoting sleepiness/sedation
B. Promoting wakefulness
C. Decreasing restless legs symptoms
D. Decreasing non-24 sleep
E. Reducing sleep onset

Answer 37

B. The orexin signaling system promotes wakefulness. This new drug is an orexin receptor antagonist (blocker) and thus, is helpful to block wakefulness (and help with sleep).

Question 38

Janice is a 70 year-old female. She is having difficulty sleeping since her cat died. She is not clinically depressed. She states she naps little during the day. The physician wishes to prescribe a hypnotic. From the choices below select the most appropriate option:

A. Lorazepam
B. Clonazepam
C. Zolpidem
D. Alprazolam

Answer 38

C. The non-benzodiazepines are preferred over benzodiazepines for the treatment of insomnia. These agents have a decreased risk of abuse, dependence and tolerance. Although it is accurate that the non-benzodiazepines are preferred over the benzodiazepines for use in the elderly, they are not the first-line recommendation. Rather lifestyle changes (part of a cognitive therapy approach) and not drugs of any type are the preferred treatment for insomnia in all patients, including elderly.

Question 39

Why are modafinil and armodafinil rated as C-IV drugs by the Drug Enforcement Administration (DEA)?

A. They are a primary drug of abuse by street gangs.
B. They are commonly converted into methamphetamine in home laboratories.
C. They can cause severe constipation that requires prophylactic drugs, including stimulants.
D. They are euphoric.
E. They are stimulants, and have abuse and physical (physiological) dependence risk.

Answer 39

E. The reason why any drug is controlled is due to this risk, however some have lower risk than others. The lower the number the higher the risk; for example, C-II is higher risk than C-IV. C-I is the highest risk; these are drugs used for either research purposes or illicit purposes, but also includes marijuana, which is now legal or decriminalized in some jurisdictions.

Question 40

Do not use the narcolepsy stimulants modafinil and armodafinil or other stimulants in patients with this pre-existing condition:

A. Shift-work sleep disorder
B. Hearing loss
C. Cardiovascular disease
D. Vision Loss
E. Urinary tract infections

Answer 40

C. If the case warrants, an ECG or other diagnostic test should be taken prior to treatment in patients who will be using stimulants to rule-out a pre-existing condition.

Question 41

A patient has been using zolpidem 10 mg but wishes to switch to Ambien CR. What is the equivalent dose?

A. 11 mg
B. 12.5 mg
C. 15 mg
D. 20 mg
E. 25 mg

Answer 41

B. Most commonly, making a drug controlled-release adds about 2.5 mg for each 10 mg of the immediate-release. In this case, it is exactly that amount.

Question 42

Beth usually takes Lunesta prior to sleep. Last night, her husband took her out to dinner for her birthday. She brought home leftover fettuccini alfredo and birthday cake. She ate the leftovers with a glass of wine right before bed. When she took theLunesta shortly afterwards, she found that she could not get to sleep for almost two hours. What was the most likely reason that the Lunesta did not help her get to sleep quickly?

A. She drank wine before bedtime.
B. She got home later than usual.
C. She had sugary foods in her stomach when she took the sleeping medicine.
D. She had fatty food in her stomach when she took the sleeping medicine.
E. Any of the above could be possible reasons why she could not get to sleep.

Answer 42

D. Sleeping agents, including the non-benzodiazepines and ramelteon, should not be taken with fatty food; this will delay the onset.

Question 43

Select common side effects of the narcolepsy stimulants modafinil and armodafinil:

A. Somnolence, risk of severe rash
B. Somnolence, espiratory depression, risk of severe rash
C. Parasomnias, restless legs, risk of severe rash
D. Headache, dizziness, anxiety, risk of severe rash
E. Photophobia, decreased night vision, blurry vision, risk of severe rash

Answer 43

D. These are stimulants and the side effects of headache, dizziness, anxiety and nausea are common with this group of agents. In children using ADHD drugs it is important to titrate up slowly due to nausea (they may vomit) and typical stimulant overdose symptoms (anxiety, tachycardia, etc.)

Question 44

A patient gave the pharmacist a prescription for Rozerem 8 mg tablets #15. Which of the following is an appropriate generic substitution for Rozerem?

A. Zolpidem
B. Zaleplon
C. Doxepin extended-release
D. Ramelteon
E. Eszopiclone

Answer 44

D. The generic name of Rozerem is ramelteon.

Question 45

Jerry is using tamsulosin, psyllium, atenolol, sertraline and latanoprost. He wishes to purchase over-the-counter diphenhydramine for sleep, as suggested by his physician. Choose the correct statements: (Select ALL that apply.)

A. This medication will cause excessive urination at night, making it more difficult to rest well.
B. This medication can cause dry mouth.
C. This medication can cause diarrhea.
D. This medication will make it more difficult to urinate; it can worsen prostate symptoms.
E. This medication might slightly worsen constipation.

Answer 45

B, D, E. Anticholinergic side effects are present with the centrally acting antihistamines, including diphenhydramine and chlorpheniramine. They cause sedation, confusion, dry mouth, urinary retention, dry/blurry vision and constipation. They will make it difficult for a patient with BPH to urinate (and they already have difficulty) and may increase IOP (slightly) in patients with glaucoma. These are not contraindications, but caution is advisable.

Question 46

A patient arrives at the pharmacy with a prescription for Horizant for restless legs syndrome (RLS). Select the correct statement regarding this drug:

A. The generic name is pregabalin.
B. It is indicated to help with fluid retention.
C. It is indicated for RLS and for painful episodes caused by a shingles outbreak.
D. It helps promote wakefulness.
E. It is a C-IV drug.

Answer 46

C. Gabapentin enacarbil (Horizant) is used for RLS and postherpetic neuralgia due to shingles (herpes zoster) infection. As an anticonvulsant, it has a warning (and required counseling) for suicidal thoughts or actions, and will contribute to CNS-depressant effects. It is not C-IV; the related compound pregabalin (Lyrica) is C-IV.