Anxiolytics and Hypnotics Deck 2 Flashcards
Sleep/Wake Disorders
Insomnia Disorders Hypersomnolence Disorder Narcolepsy Breathing Related Sleep Disorders Circadian Rhythm Sleep Conditions Parasomnias Restless Legs Syndrome Substance/Medication Induced Sleep Disorder
Insomnia
Diagnosis of insomnia made by self-report
No overnight sleep study required to diagnose insomnia
However, sleep studies might be conducted to rule- out other sleep disorders that might cause or coexist with the insomnia
Insomnia DSM5 Criteria
The DSM-5 defines insomnia as dissatisfaction with sleep quantity or quality, associated with one (or more) of the following symptoms:
u Difficulty initiating sleep
u Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings
u Early-morning awakening with inability to return to sleep
Other criteria include the following:
u The sleep disturbance causes clinically significant distress or impairments in social, occupational, educational, academic, behavioral, or other important areas of functioning
u The sleep difficulty occurs at least 3 nights per week
u The sleep difficulty is present for at least 3 months
u The sleep difficulty occurs despite adequate opportunity for sleep
u The insomnia cannot be explained by and does not occur exclusively during the course of another sleep-wake disorder
u The insomnia is not attributable to the physiological effects of a drug of abuse or medication.
u Coexisting mental disorders and medical conditions do not adequately explain the predominant complaint of insomnia
“Z drugs” for Insomnia
Bind selectively to specific subunits of GABA receptors that induce sleep
u Eszopiclone (Lunesta) u Zaleplon (Sonata) u Zolpidem (Ambien)
different structure resutls in different anxioltic or anticonvulsant effects. If you have someone on a benzo do not used together or switch between. Start low and go slow.
all are fda approved for different types of sleep disorders and are used for different phases based on half life.
Lunesta has a half life of
six hours and a duration of about 6 to 8 hours
zaleplon (sonata) half life
one hour and duration of four hours
Zolipidem (ambien)
differen formulations/release and can be used for different sleep phases.
Benzodiazepines for Insomnia
u Clonazepam (Klonopin) u Lorazepam (Ativan) u Temazepam (Restoril) u Triazolam (Halcion)
TWO WEEKS ONLY.
only FDA approved benzo for insomnia
restoril
Other agents to treat insomnia
u Melatonin u Ramelteon- melatonin agonist u Suvorexant- dual orexin (OX1 and OX2) receptor antagonists (DORAs) u Doxepin (Silenor)- TCA u Trazodone – antidepressant u Antihistamines
Melatonin should take about an
hour before bed
Remelteon - melatonin agonist
might have trouble with coverage as it’s new. Sometimes used off lable for jet lag or shift work disorders
Suvorexant- dual orexin (OX1 and OX2) receptor antagonists (DORAs)
FDA approved for sleep onset and sleep maintence phases
expensive
Schedule 4
Doxepin (Silenor)- TCA
Can be used in lower doses (3-6 mg) to help with sleep.
Trazadone
Antidepressant and used for sleep is off lable. Lower doses can be more beneift to sleep then higher doses
Antihistamines
diphenhydramien can be very helpful and are approved for insomina
Potential side effects in hyptonics
Daytime grogginess or hangover effect Anterograde amnesia
CNS depression
Respiratory depression Paradoxical reactions Tolerance Discontinuation syndrome
Recreational use and abuse Complex sleep-related behaviors
Black box warning with these medications and
other medications like opioids. Increasing sediation which can increase risk of respirotry depression.
CBT for insomnia
Evidence based therapy stimulus control sleep restriction relaxation training and biofeedback cognitive control and psychotherapy sleep hygine training relapse prevention
Sleep hygiene
u Limit daytime naps
u Avoid stimulants
u Exercise
u Avoid certain food before bed, avoid excessive liquids, don’t go to bed hungry
u Exposure to natural light during the day
u Establish regular, relaxing bedtime routine
u Pleasant sleep environment
u Use bed only for sleep and sex
Restless Legs Syndrome medications
u Pramipexole (Mirapex)
u Ropinirole (Requip)
u Gabapentin (Neurontin)
u Levodopa plus carbidopa (Sinemet)
u Dopaminergic agonists – reduce RLS symptoms
u Dopaminergic agents – reduce RLS symptoms u Benzodiazepines – allow for a more restful sleep u Opiates – induce relaxation and diminish pain u Iron
Things to consider when assessing for restless leg syndrome
medications, iorn deficiency
Wakeful Promoting Agents
Narcolepsy/Excessive Daytime Sleepiness/Sleep Apnea
u Stimulant medications
u Modafinil (Provigil)
u Armodafinil (Nuvigil)
Schedule 4 medications
