Chapter 68 - Sleep Disorder Flashcards
What are the primary types of sleep disorders that are managed with medications:
- Chronic insomnia
- Restless legs syndrome (RLS)
- Narcolepsy
Another common sleep disorder is:
- Obstructive sleep apnea
–> primarily treated with non-drug measures,
(continuous positive airway pressure (CPAP)
Characteristics of insomnia
- diagnosis?
- Difficulty falling asleep (sleep initiation or sleep latency)
- Reduced sleep duration and/or poor sleep quality (awakenings after sleep onset)
A diagnosis of chronic insomnia occurs when the patient has (despite adequate opportunity to sleep):
- Symptoms at least 3x per week
- For at least 3 months
Non drug ttmt of insomnia
- Cognitive behavioral therapy for insomnia (CBT-I) is preferred and includes changes to sleep hygiene that can reduce the need for drugs
- Treat any underlying medical conditions that may be contributing (pain, shortness of breath due to heart failure, anxiety, bipolar disorder, depression, alcoholism)
- Discontinue medications that can worsen insomnia
Natural Products for insomnia
- Melatonin (3 - 5 mg in the evening)
. Jet lag
. + others CNS depressants –> drowsiness, daytime somnolence
. It is a substrate of CYP 450 1A2, and prolonged effects may be observed with CYP1A2 inhibitors (ciprofloxacin, fluvoxamine). - Valerian
. Few adverse risks: liver toxicity; the significance of this risk is unclear. - Drinking chamomile tea in the evening to feel calmer
Medications that can worsen insomnia
1- Acetylcholinesterase inhibitors (donepezil) (Dementia)
2- Alcohol
3- Antiretrovirals (emtricitabine, INSTls)
4- Aripiprazole (Abilify)
5- Atomoxetine (Strattera)
6- Bupropion (Antidepressant)
7- Caffeine
8- Decongestants (pseudoephedrine)
9- Diuretics (due to nocturia)
10- Fluoxetine (Prozac), if taken late in the day
11- Steroids
12- Stimulants (methylphenidate, phentermine)
13- Varenicline (for smoking cessation and ttmt of dry eyes)
thought process of insomnia management
- Non-drug ttmt: CBT-I
- Sleep problem persists?
1) Need help falling asleep?
- Eszopiclone
- Zolpidem
- Ramelteon
- Zaleplon
2) Need help staying asleep?
- Eszopiclone
- Zolpidem
- Doxepin (TCA)
- Suvorexant (Orexin Antagonist)
3) Need help falling and staying asleep?
- Eszopiclone
- Zolpidem
- What do we prefer, nonbenzo or benzo for long term? Why?
- What dose and duration of action do we want for all meds?
In patients using prescription drugs long-term, non-benzodiazepines are preferred over benzodiazepines
- Decreased risk of physical dependence
- Fewer daytime cognitive effects
The lowest effective dose should be used for all medications to minimize adverse effects
Treatment should be limited to the shortest duration possible.
- What are some OTC meds that pts could self treat with?
- For how long can they use them?
Patients may self-treat insomnia with OTC first-generation antihistamines, such as:
- Diphenhydramine (Antihistamine)
- Doxylamine (Unisom - Antihistamine)
While these can help short-term, they should not be used long-term for the treatment of insomnia.
The American Academy of Sleep Medicine (AASM) guidelines state that the following treatments are not recommended for chronic use:
- Diphenhydramine (Antihistamine)
- Melatonin
- Tiagabine (Anticonvulsant)
- Trazodone (serotonin modulator)
- Valerian
- What Benzo can be used short term?
- Beers criteria for insomnia?
- Benzo for elderly pts?
Benzodiazepines (e.g., temazepam) can be tried for short-term treatment (such as from acute trauma) if there is no substance abuse history or current use of opioids.
According to Beers Criteria, the following are considered potentially inappropriate in patients aged 65 years and older.
- benzodiazepines
- non-benzodiazepine hypnotics (e.g., zolpidem)
- first-generation antihistamines
If benzodiazepines are used, lorazepam, oxazepam and temazepam (L-0-T) are preferred in the elderly due to the lower risk of adverse reactions)
Eszopiclone
- Brand
- Dose
- Brand: Lunesta (Eyyy ya amar)
- C- IV
- Dose: 1-3 mg PO QHS
Start with 1 mg immediately before bed and increase to 2 mg or 3 mg if necessary
Zolpidem
- Brand
- Dose
- Ambien, Ambien CR: IR and ER tablets
- Zolpimist: Oral spray (5 mg/spray)
- Edluar, Intermezzo: SL tablets
C·IV
1) Ambien, Edluar, Zolpimist
- Female/Elderly: 5 mg PO/SL/spray QHS
- Male: 5-10 mg PO/SU spray QHS
2) Ambien CR:
- Female/Elderly: 6.25 mg PO QHS
- Male: 6.25-12.5 mg PO QHS
3) Intermezzo:
- Female/Elderly: 1.75 mg SL QHS
- Male: 1.75-3.5 mg SL QHS
Zaleplon
- Brand
- Dose
- Sonata
- C-IV
- Dose: 5-20 mg PO QHS
BOXED WARNINGS of hypnotics
Complex sleep behavior can lead to serious injury or death
- Sleep-walking
- Sleep-driving
- Engaging in other activities while not fully awake
WARNINGS for hypnotics
- Inc risk of CNS depression and next-day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol)
- Abnormal thinking and behavioral changes (can worsen depression)
- Respiratory depression
- Increased risk for hazardous sleep-related activities (sleep-driving)
- Potential for abuse and dependence (can cause withdrawal symptoms if used longer than 2 weeks)
CONTRAINDICATIONS of hypnotics
History of complex sleep behavior
SIDE EFFECTS of hypnotics
- Somnolence, dizziness
- Ataxia
- Headache
- Can cause parasomnias (unusual actions while sleeping, which the patient may be unaware of),
- Lightheadedness
- “Pins and needles” feeling on the skin
- Eszopiclone: dysgeusia (altered sense of taste)
- What do we worry about with hypnotics?
- Do we prefer them over benzo? Why?
- Drug food interactions?
- C-IV drugs; risk of physical (physiological) dependence, abuse (addiction) and tolerance
- Preferred over benzodiazepines for first-line treatment due to less abuse, dependence and tolerance
- Do not take with fatty food, a heavy meal or alcohol
Eszopiclone, Zaleplon and Zolpidem Drug Interactions
- Use caution in combination with potent CYP3A4 inhibitors (Protease inhibitors, ketoconazole, itraconazole, erythromycin and clarithromycin).
- Can cause additive effects when used with other sedating drugs, including most pain medications, muscle relaxants, antihistamines, mirtazapine (Remeron), trazodone and alcohol.
Orexin Receptor Antagonists moa
- The orexin neuropeptide signaling system promotes wakefulness.
- Orexin receptor antagonists block the orexin neuropeptide signaling system, resulting in drowsiness.
Lemborexant
- brand
- dose
Orexin receptor antagonist
DayVigo
C-IV
C-IV
- Dose: 5-10 mg PO QHS if at least 7 hours of sleep remaining
- Use 5 mg with weak CYP3A4 inhibitors
- Avoid use with strong or moderate CYP3A4 inhibitors
Suvorexant
brand
DDI
orexin receptor antagonist
Belsomra
C-IV
- Dose: 10-20 mg PO QHS if at least 7 hours of sleep remaining
- Use 5 mg with moderate CYP3A4 inhibitors and do not exceed 10 mg daily
- Avoid use with strong CYP3A4 inhibitors
(when pt cant stay asleep)
CONTRAINDICATIONS of Orexin Receptor Antagonists
Narcolepsy
WARNINGS of Orexin Receptor Antagonists
- Worsening depression/suicidal ideation
- Sleep paralysis
- Hallucinations
- Cataplexy-like symptoms (sudden loss of muscle tone)
- Increased risk for complex sleep behavior
- Daytime impairment (risk inc with other CNS depressants)