68. Sleep Disorders Flashcards
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
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
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
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
Which medications help with falling asleep?
Eszopiclone
Zolpidem
Ramelteon
Zaleplon
Which medications help with staying asleep?
Eszopiclone
Zolpidem
Doxepin
Suvorexant
Which medications help with falling and staying asleep?
Eszopiclone
Zolpidem
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
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
The American Academy of Sleep Medicine (AASM) guidelines state the following treatments are NOT recommended for chronic use:
Diphenhydramine, melatonin, tiagabine, trazodone, and valerian
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)
Non-BZD hypnotics MOA (eszopiclone (Lunesta), zolpidem (Ambien, Edluar SL tabs))
act selectively at BZD receptors to increase GABA (inhibitor NT)»_space; causes CNS depression
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)
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)
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
Orexin receptor antagonists MOA
Block orexin neuropeptide signaling system, resulting in drowsiness
Examples of orexin receptor antagonists
Daridorexant (Quviviq)
Lemborexant (DayVigo)
Suvorexant (Belsomra)
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)
