Chapter 68: Sleep Disorders - Insomnia, RLS & Narcolepsy

Question 1

A diagnosis of chronic insomnia occurs when:

Answer 1

The patient has symptoms at least 3 times per week for at least 3 months

Question 2

Key drugs that can worsen insomnia

Answer 2

Acetylcholinesterase inhibitors (e.g., donepezil)
Alcohol
Antiretrovirals
Aripiprazole
Atomoxetine
Bupropion
Caffeine
Decongestants
Diuretics
Fluoxetine, if taken late in the day
Steroids
Stimulants
Varenicline

Question 3

What are some natural products used for insomnia

Answer 3

• Melatonin (note: it is a 1A2 substrate and if taken with inhibitors like cipro or fluvoxamine, can cause prolonged effects)
• Valerian
• Chamomile tea

Question 4

What is first-line treatment for insomnia

Answer 4

Non-drug treatment like CBT, keep bedroom dark, regular sleep schedule, avoid daytime naps, etc.

Question 5

What drugs can be used if a patient complains of not being able to fall asleep

Answer 5

Eszopiclone
Zolpidem
Ramelteon
Zaleplon

Question 6

What drugs can be used for a patient who needs help staying asleep

Answer 6

Eszopiclone
Zolpidem
Doxepin
Suvorexant

Question 7

What drugs can be used in a patient who needs help falling and staying asleep

Answer 7

Eszopiclone

Zolpidem

Question 8

Patients may self-treat insomnia short-term with which OTC products

Answer 8

antihistamines like Benadryl or doxylamine

Question 9

The American Academy of Sleep Medicine (AASM) guidelines state that the following treatments are not recommended for chronic use:

Answer 9

Benadryl, melatonin, tiagabine, trazadone, and valerian

Question 10

MOA of hypnotics

Answer 10

The non-BZDs act selectively at BZD receptors to increase GABA, an inhibitory NT which causes CNS depression

Question 11

Eszopiclone brand name

Answer 11

Lunesta

Question 12

Zolpidem brand name

Answer 12

Ambien, Ambien CR

Edluar, Intermezzo (SL tabs)

Question 13

What drug schedule are hypnotics

Answer 13

Schedule IV

Question 14

Dosing for Ambien, Edular, Zolpimist

Answer 14

Female/Elderly: 5 mg PO/SL/spray QHS

Male: 5-10 mg PO/SL/spray QHS

Question 15

T/F: Hypnotics do not have potential for abuse and dependance

Answer 15

False

Question 16

SE of hypnotics

Answer 16

Somnolence, dizziness, ataxia, can cause parasomnias (unusual actions while sleeping, which the pt may be unaware of)

Question 17

MOA for orexin receptor antagonists

Answer 17

Block the orextin neuropeptide signaling system, which promotes wakefulness

Question 18

Which drug is an orexin receptor antagonist

Answer 18

Suvorexant (Belsomra)

Question 19

What schedule of drugs is orexin receptor antagonists

Answer 19

C-IV

Question 20

Side effect of Suvorexant

Answer 20

Somnolence

Question 21

Which drugs are melatonin receptor agonists

Answer 21

Ramelteon and tasimelteon

has the word MEL for melatonin

Question 22

Brand name for Remelteon

Answer 22

Remeron

Question 23

Brand name for tasimelteon

Answer 23

Hetlioz

Question 24

Side effect of melatonin receptor agonists

Answer 24

somnolence

Question 25

MOA of TCAs

Answer 25

inhibit NE and 5HT reuptake. Also block ACh and histamine receptors, which contributes to side effects

Question 26

Which TCA is used for insomnia

Answer 26

Doxepin (Silenor)

Question 27

CI for doxepin

Answer 27

Requires a 2 week washout period for MAOi

Question 28

Which BZDs are FDA approved for insomnia

Answer 28

Lorazepam and oxazepam

Question 29

Doxylamine OTC brand name

Answer 29

Unisom SleepTabs

Question 30

With which disease states should Doxylamine be avoided in

Answer 30

BPH and glaucoma

Question 31

What are the primary treatments of RLS

Answer 31

Dopamine agonists (pramipexole and ropinirole) and gabapentin

Question 32

Brand name for pramipexole

Answer 32

Mirapex

Question 33

Brand name for ropinirole

Answer 33

Requip

Question 34

For RLS, the IR formulation of pramipexole and ropinirole is taken ___ hours before bedtime

Answer 34

1-3

Question 35

Which dopamine agonist comes as a patch

Answer 35

Rotigotine (Neupro)

Question 36

SE of dopamine agonists

Answer 36

orthostasis, somnolence, and nausea

Question 37

Gabapentin used for RLS should be taken at what time

Answer 37

~5 PM

Question 38

What is narcolepsy

Answer 38

excessive daytime sleepiness with cataplexy (sudden loss of muscle tone) and sleep paralysis

Question 39

How is narcolepsy treated

Answer 39

Stimulants, such as modafinil or armodafinil, or with sodium oxybate (Xyrem), or H3 receptor antagonist/inverse agonist (Pitolisant) and dopamine and NE reuptake inhibitor (Solriamfetol)

Question 40

Brand name for modafinil

Answer 40

Provigil

Question 41

Brand name of armodafinil

Answer 41

Nuvigil

Question 42

What schedule of drugs are stimulants used for wakefulness

Answer 42

C-IV

Question 43

Side effects of stimulants used for wakefulness

Answer 43

Severe rash that can be lifethreatening

Question 44

Sodium Oxybate is derived from

Answer 44

GABA

Question 45

What schedule of drug is sodium oxybate for narcolepsy

Answer 45

C-III

Question 46

sodium oxybate brand name

Answer 46

Xyrem

Question 47

Sodium oxybate is a C-I when used as an illicit drug, also known as

Answer 47

"date rape" drug

Question 48

Which drug used for narcolepsy requires a REMS program

Answer 48

sodium oxybate