Chapter 68: Sleep Disorders - Insomnia, RLS & Narcolepsy Flashcards
A diagnosis of chronic insomnia occurs when:
The patient has symptoms at least 3 times per week for at least 3 months
Key drugs that can worsen insomnia
Acetylcholinesterase inhibitors (e.g., donepezil) Alcohol Antiretrovirals Aripiprazole Atomoxetine Bupropion Caffeine Decongestants Diuretics Fluoxetine, if taken late in the day Steroids Stimulants Varenicline
What are some natural products used for insomnia
- Melatonin (note: it is a 1A2 substrate and if taken with inhibitors like cipro or fluvoxamine, can cause prolonged effects)
- Valerian
- Chamomile tea
- Kava not recommended d/t hepatotoxicity
What is first-line treatment for insomnia
Non-drug treatment like cognitive behavioral therapy (CBT), keep bedroom dark, regular sleep schedule, avoid daytime naps, etc. (sleep hygeine)
What drugs can be used if a patient complains of not being able to fall asleep
Eszopiclone
Zolpidem
Ramelteon
Zaleplon
EZZR (easier) way to fall asleep
What drugs can be used for a patient who needs help staying asleep
Eszopiclone
Zolpidem
Doxepin
Suvorexant
SEDZ (sedated)
What drugs can be used in a patient who needs help falling and staying asleep
Eszopiclone
Zolpidem
EZ tip for excellent ZZZZ (sleep) -> E and Z are in all treatment groups
Patients may self-treat insomnia short-term with which OTC products
antihistamines like Benadryl or doxylamine
The American Academy of Sleep Medicine (AASM) guidelines state that the following treatments are NOT recommended for chronic use:
Benadryl, melatonin, tiagabine, trazadone, and valerian
MOA of hypnotics
The non-BZDs act selectively at BZD receptors to increase GABA, an inhibitory NT which causes CNS depression
Eszopiclone brand name
Lunesta
Zolpidem brand name
Ambien, Ambien CR, Edluar
Intermezzo (SL tabs)
What drug schedule are hypnotics (eszopiclone, zolpidem, zaleplon)
Schedule IV
Dosing for Ambien, Edular, Zolpimist
Female/Elderly: 5 mg PO/SL/spray QHS
Male: 5-10 mg PO/SL/spray QHS
T/F: Hypnotics do not have potential for abuse and dependance
False
SE of hypnotics
Somnolence, dizziness, ataxia, can cause parasomnias (unusual actions while sleeping, which the pt may be unaware of)
MOA for orexin receptor antagonists
Block the orexin neuropeptide signaling system, which normally promotes wakefulness, leading to drowsiness
Which drug is an orexin receptor antagonist
lemborexant (DayVigo)
Suvorexant (Belsomra)
What schedule of drugs is orexin receptor antagonists
C-IV
Side effect of orexin antagonists (lemborexant, suvorexant)
Somnolence
Which drugs are melatonin receptor agonists
Ramelteon and tasimelteon
has the word MEL for melatonin
What DEA class is ramelteon and tasimelteon?
not controlled
only melatonin agonist
MOA of TCAs
inhibit NE and 5HT reuptake. Also block ACh and histamine receptors, which contributes to side effects
Which TCA is used for insomnia
Doxepin (Silenor)
CI for doxepin
Requires a 2 week washout period for MAOi
Restoril generic name
temazepam
Unisom SleepTabs generic name
Doxylamine (OTC)
With which disease states should Doxylamine be avoided in
BPH and glaucoma
What are the primary treatments of RLS
Dopamine agonists (pramipexole and ropinirole) and gabapentin
Brand name for pramipexole
Mirapex
drug class used for RLS
dopamine agonists
and gabapentin
Generic for Requip
ropinirole
For RLS, the IR formulation of pramipexole and ropinirole is taken ___ hours before bedtime
1-3
Which dopamine agonist comes as a patch
Rotigotine (Neupro)
once daily
SE of dopamine agonists
orthostasis, somnolence, and nausea
monitor for pyschiatric SEs
Gabapentin (Horizant) used for RLS should be taken at what time
~5 PM
What is narcolepsy
excessive daytime sleepiness with cataplexy (sudden loss of muscle tone) and sleep paralysis
How is narcolepsy treated
Stimulants, such as modafinil or armodafinil
or with sodium oxybate (Xyrem), Ca Mg K and Na oxybate (Xywav), dextro/amphetamines, methylphenidate
What schedule of drugs are stimulants used for wakefulness (modafinil, armodafinil)
C-IV
Side effects of stimulants used for wakefulness
Severe rash that can be lifethreatening
Sodium Oxybate is derived from
GABA
What schedule of drug is sodium oxybate for narcolepsy
C-III
sodium oxybate brand name
Xyrem
Sodium oxybate is a C-I when used as an illicit drug, also known as
“date rape” drug
Which drug used for narcolepsy requires a REMS program
sodium oxybate (Xyrem)
Ca Mg K and Na oxybate (Xywav)
Other oral medications for narcolepsy include:
1. pitolisant
2. solriamfetol
what are the drug classes?
- histamine-3 receptor antagonist/inverse agonist
- DA and NE reuptake inhibitor (DNRI)
