68. Sleep Disorders Flashcards by Yerin M

A dx of chronic insomnia occurs when the patient has symptoms at least ____ for at least ____ despite adequate opportunity to sleep

3x per week for at least 3 months

How well did you know this?

Not at all

Perfectly

Non-drug treatment for chronic insomnia

Cognitive behavioral therapy is preferred and includes changes to sleep hygiene that can reduce need for drugs
Important to treat any underlying medical conditions that may be contributed (e.g. pain, SOB d/t HF, bipolar disorder, depression, alcoholism) and d/c any meds that can worsen insomnia

How well did you know this?

Not at all

Perfectly

Natural products used for insomnia

Melatonin or valerian
Kava not recommended d/t hepatotoxicity
Drink chamomile tea may help pts feel calmer and help with sleep

How well did you know this?

Not at all

Perfectly

Drugs that worsen insomnia

ACEi (e.g. donepezil)
alcohol
antiretrovirals (e.g. emtricitabine, INSTIs)
Aripiprazole
Atomoxetine
Bupropion
Caffeine
Decongestants (e.g. pseudoephedrine)
Diuretics (d/t nocturia)
Fluoxetine, if taken late in the day
Steroids
Stimulants (e.g. methylphenidate, phentermine)
Varenicline

How well did you know this?

Not at all

Perfectly

Which medications help with falling asleep?

Eszopiclone
Zolpidem
Ramelteon
Zaleplon

How well did you know this?

Not at all

Perfectly

Which medications help with staying asleep?

Eszopiclone
Zolpidem
Doxepin
Suvorexant

How well did you know this?

Not at all

Perfectly

Which medications help with falling and staying asleep?

Eszopiclone
Zolpidem

How well did you know this?

Not at all

Perfectly

If pts using rx drugs long-term for insomnia, which drugs are preferred?

Non-BZDs preferred over BZDs d/t decreased risk of physical dependence and fewer daytime cognitive effects

How well did you know this?

Not at all

Perfectly

Pts may self-treat insomnia with OTC first-gen antihistamines, such as ___ or ___. While these can help short-term, should not be used long-term.

Diphenhydramine
Doxylamine

How well did you know this?

Not at all

Perfectly

The American Academy of Sleep Medicine (AASM) guidelines state the following treatments are NOT recommended for chronic use:

Diphenhydramine, melatonin, tiagabine, trazodone, and valerian

How well did you know this?

Not at all

Perfectly

What drugs used for insomnia are on Beers Criteria

BZDs, non-BZDs hypnotics (e.g. zolpidem), and first-gen antihistamines
If BZDs are used, use L-O-T drugs (lorazepam, oxazepam, temazepam)

How well did you know this?

Not at all

Perfectly

Non-BZD hypnotics MOA (eszopiclone (Lunesta), zolpidem (Ambien, Edluar SL tabs))

act selectively at BZD receptors to increase GABA (inhibitor NT)&raquo_space; causes CNS depression

How well did you know this?

Not at all

Perfectly

Non-BZD hypnotics (eszopiclone (Lunesta), zolpidem (Ambien, Edluar SL tabs) warnings

Increased risk of CNS depression and next-day impairment with <7-8 hrs of sleep (esp with higher doses or coadmin of CNS depressants or alcohol), abnormal thinking and behavioral changes (can worsen depression), respiratory depression, increased risk for hazardous sleep-related activities (e.g. sleep driving)

Potential for abuse/dependence (can cause withdrawal symptoms if used longer than 2 weeks)

How well did you know this?

Not at all

Perfectly

Side effects of Non-BZD hypnotics (eszopiclone (Lunesta), zolpidem (Ambien, Edluar SL tabs)

somnolence, dizziness, ataxia, HA, can cause parasomnias (unusual actions while sleeping. which the pt may be unaware of), lightheadedness, “pins and needles” feeling on the skin

Eszopiclone= dysgeusia (altered sense of taste)

How well did you know this?

Not at all

Perfectly

Non-BZD hypnotics (eszopiclone (Lunesta), zolpidem (Ambien, Edluar SL tabs) can cause additive effects when using with other sedating drugs including ___

most pain meds, muscle relaxants, anthistamines, mirtazapine (Remeron), trazodone, and alcohol

How well did you know this?

Not at all

Perfectly

Orexin receptor antagonists MOA

Block orexin neuropeptide signaling system, resulting in drowsiness

How well did you know this?

Not at all

Perfectly

Examples of orexin receptor antagonists

Daridorexant (Quviviq)
Lemborexant (DayVigo)
Suvorexant (Belsomra)

How well did you know this?

Not at all

Perfectly

Side effects of orexin receptor antagonists

Somnolence

Others: HA, dizziness, abdnormal dreams

How should orexin receptor antagonists be taken?

Empty stomach (food delays absorption)

Examples of melatonin receptor agonists

Ramelteon (Rozerem)
Tasimelteon (Hetlioz, Heltizoz LQ)

Side effects of melatonin receptor agonists

Somnolence, dizziness

T/F: Ramelteon (Rozerem), Tasimelteon (Hetlioz) are C-IV meds

False - not controlled substance

TCA (Doxepin (Silenor)) MOA

Inhibit NE and 5-HT reuptake, also block ACh and histamine receptors which contribute to side effects (e.g. somnolence)

Contraindications of TCA

Requires 2 week washout for MAOi

Silenor is a branded doexpin that is FDA-approved for insomnia. What other TCAs can be used off-label for sleep (but not recommended in guidelines)?

Generic doxepin, trazodone, mirtazapine

Side effects of BZDs used in insomnia

Drowsiness, dizziness/increase fall risk, cognitive impairment

Examples of antihistamines used in insomnia

Diphenhydramine (Benadryl) Doxylamine (Unisom SleepTabs)

Side effects for antihistamines used in insomnia (diphenhydramine, doxylamine)

Sedation (tolerance to sedative effects can develop after 10 days of use), confusion (can exacerbate memory/cognition difficulty) Antihistamines may cause paradoxical excitation in younger children; do NOT use doxylamine in children <12 yo Peripheral anticholinergic side effects: dry mouth, urinary retention (makes it very diff for males with BPH to urinate), dry/blurry vision, constipation

It is best to avoid antihistamines for insomnia in pts with ___ and ___

BPH (can worsen symptoms) Glaucoma (can worsen IOP)

Define restless legs syndrome

Urge to move the lower legs, which is sometimes described as "creeping" sensation" Worse at night and is relieved with movement Thought to be d/t a dysfunction of dopamine in the brain's basal ganglia circuits

Primary treatment of restless leg syndrome includes ____

dopamine agonists and anticonvulsant gabapentin

___ and ___ are dopamine agonists primarily used in longer-acting formulations for Parkinson disease. For RLS, the IR formulation is taken ____ before bedtime

Pramiprexole Ropinirole 1-3 hrs before bed time

____ is a dopamine agonist patch applied once daily (used for both Parkinson's and RLS)

Rotigotine (Neupro)

Doapmine agonist side effects

orthostasis, somnolence and nausea (dose-related) Dose should be titrated up slowly

What formulation of gabapentin is approved for postherpetic neuralgia (PHN) and RLS?

Gabapentin enacarbil (Horizant) - ER form of gabapentin Taken with food and must be swallowed whole Note: IR gabapentin is used off-label as less expensive alt

Define narcolepsy

Excessive daytime sleepiness with cataplexy (sudden loss of muscle tone) and sleep paralysis

Narcolepsy is treated with ____ such as _____ Several stimulants used for ADHD have indication for narcolepsy including ______

Stimulants such as modafinil or armodafinil or with sodium oxybate (Xyrem) or calcium, magnesium, potassium, and sodium oxybate (Xywav) - both of which are derived from inhibitor NT GABA Several stimulants used for ADHD have indication for narcolepsy including dextramphetamine (Dexedrine, ProCentra, Zenzedi), dextroamphetamine/amphetamine (Adderall), and methylphenidate (e.g. Methylin and Ritalin)

Side effects for Modafinil (Provigil), Armodafinil (Nuvigil)

Severe rash, can be life-threatening (SJS), HA, insomnia, anxiety, nausea

T/F: Modafinil (Provigil) and armodafinil (Nuvigil) are C-IV

True

Armodafinil is the __-isomer of modafinil

R-isomer

Sodium oxybate (Xyrem) and calcium, magnesium, potassium and sodium oxybates (Xywav) boxed warnings

Strong CNS depressant; respiratory depression, coma and death can result; risk increased when taken with other CNS depressants Active moiety of oxynbate salts is the sedative GHB (illicitly used to facilitate sexual assault) - REMS program required for pts with narcolepsy with cataplexy

T/F: Sodium oxybate (Xyrem) and calcium, magnesium, potassium and sodium oxybates (Xywav) are C-IV when used for narcolepsy

False - C-III (narcolepsy), C-I (illicit use)

Pitolisant (Wakix) MOA

Histamine-3 (H3) receptor antagonist/inverse agonist

Solriamfetol (Sunosi) MOA

Dopamine and NE reuptake inhibitor (DNRI)