8 - Insomnia Flashcards
How often does insomnia need to occur for the diagnosis?
3 nights/week for 3 months
Everyone should be screened for ?
obstructive sleep apnea
Non-pharms?
sleep hygiene specific to the patient
What are the 3 categories for insomnia agents?
- Benzos
- BZD receptor agonists
- Other hypnotics
What are the 4 BZD approved by HC for insomnia?
Which ones are not recommended?
- flurazepam, nitrazepam, temazepam and triazolam
- the first 2 are not recommended, esp in elderly (long t1/2 and can accumulate)
Which benzos should you try first?
- temazepam
- triazolam
Which BZD is more suited for initial insomnia than maintenance insomnia?
triazolam - has fast onset and short DOA so more suited for initial insomnia than maintenance insomnia
Describe when patients should take oxazepam
Slow absorption
- take 60-90 mins before bed if used for initial insomnia
- take at bedtime if used for maintenance insomnia
What class is zopiclone from?
BZD receptor agonist
Zopiclone: patients should not drive until at least ___ hours after the dose
12
When is zolpidem used for?
for complex sleep disorders
Who should get a lower dose of Zolpidem?
women and elderly
Do not combine zolpidem with _____
alcohol
High doses of ______ may be useful in those who want to avoid BZD
L-tryptophan (> 1 g)
Should people try melatonin?
Yes - evidence for efficacy is controversial but bc it has low s/e everyone should try it
What is the TCA approved for sleep maintenance insomnia?
doxepin
______ can double doxepin serum concentrations
cimetidine
_____ is available in US only and has high selectivity for melatonin receptors. It is effective and well-tolerated.
Rameltron
What is Suvorexant?
- orexin 1 and 2 receptor antagonist
- not available in Canada
- next day somnolence can occur and can increase digoxin levels
What is orexin?
orexin sustains wakefulness, so blocking it’s receptors promotes sleep
What can we recommend for pregnancy after non-pharms?
- although lacking evidence, zopiclone could be used intermittently (assess risk vs benefit)
- do not use BZD - can cause orofacial malformations
What can we recommend for breastfeeding after non-pharms?
BZD, zolpidem or zopiclone
*not doxepin
