Anxiolytics and Hypnotics Deck 2

Question 1

Sleep/Wake Disorders

Answer 1

Insomnia Disorders
Hypersomnolence Disorder
Narcolepsy
Breathing Related Sleep Disorders  
Circadian Rhythm Sleep Conditions  
Parasomnias
Restless Legs Syndrome
Substance/Medication Induced Sleep  Disorder

Question 2

Insomnia

Answer 2

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

Question 3

Insomnia DSM5 Criteria

Answer 3

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

Question 4

“Z drugs” for Insomnia

Answer 4

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.

Question 5

Lunesta has a half life of

Answer 5

six hours and a duration of about 6 to 8 hours

Question 6

zaleplon (sonata) half life

Answer 6

one hour and duration of four hours

Question 7

Zolipidem (ambien)

Answer 7

differen formulations/release and can be used for different sleep phases.

Question 8

Benzodiazepines for Insomnia

Answer 8

u	Clonazepam (Klonopin)
u	Lorazepam (Ativan)
u	Temazepam (Restoril)
u	Triazolam (Halcion)

TWO WEEKS ONLY.

Question 9

only FDA approved benzo for insomnia

Answer 9

restoril

Question 10

Other agents to treat insomnia

Answer 10

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

Question 11

Melatonin should take about an

Answer 11

hour before bed

Question 12

Remelteon - melatonin agonist

Answer 12

might have trouble with coverage as it’s new. Sometimes used off lable for jet lag or shift work disorders

Question 13

Suvorexant- dual orexin (OX1 and OX2) receptor antagonists (DORAs)

Answer 13

FDA approved for sleep onset and sleep maintence phases

expensive

Schedule 4

Question 14

Doxepin (Silenor)- TCA

Answer 14

Can be used in lower doses (3-6 mg) to help with sleep.

Question 15

Trazadone

Answer 15

Antidepressant and used for sleep is off lable. Lower doses can be more beneift to sleep then higher doses

Question 16

Antihistamines

Answer 16

diphenhydramien can be very helpful and are approved for insomina

Question 17

Potential side effects in hyptonics

Answer 17

Daytime grogginess or hangover effect Anterograde amnesia
CNS depression
Respiratory depression Paradoxical reactions Tolerance Discontinuation syndrome
Recreational use and abuse Complex sleep-related behaviors

Question 18

Black box warning with these medications and

Answer 18

other medications like opioids. Increasing sediation which can increase risk of respirotry depression.

Question 19

CBT for insomnia

Answer 19

Evidence based therapy
stimulus control 
sleep restriction 
relaxation training and biofeedback
cognitive control and psychotherapy
sleep hygine training
relapse prevention

Question 20

Sleep hygiene

Answer 20

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

Question 21

Restless Legs Syndrome medications

Answer 21

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

Question 22

Things to consider when assessing for restless leg syndrome

Answer 22

medications, iorn deficiency

Question 23

Wakeful Promoting Agents

Answer 23

Narcolepsy/Excessive Daytime Sleepiness/Sleep Apnea
u Stimulant medications
u Modafinil (Provigil)
u Armodafinil (Nuvigil)

Schedule 4 medications