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
• Kava not recommended d/t hepatotoxicity

Question 4

What is first-line treatment for insomnia

Answer 4

Non-drug treatment like cognitive behavioral therapy (CBT), keep bedroom dark, regular sleep schedule, avoid daytime naps, etc. (sleep hygeine)

Question 5

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

Answer 5

Eszopiclone
Zolpidem
Ramelteon
Zaleplon

EZZR (easier) way to fall asleep

Question 6

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

Answer 6

Eszopiclone
Zolpidem
Doxepin
Suvorexant

SEDZ (sedated)

Question 7

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

Answer 7

Eszopiclone
Zolpidem

EZ tip for excellent ZZZZ (sleep) -> E and Z are in all treatment groups

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 (eszopiclone, zolpidem, zaleplon)

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 orexin neuropeptide signaling system, which normally promotes wakefulness, leading to drowsiness

Question 18

Which drug is an orexin receptor antagonist

Answer 18

lemborexant (DayVigo)
Suvorexant (Belsomra)

Question 19

What schedule of drugs is orexin receptor antagonists

Answer 19

C-IV

Question 20

Side effect of orexin antagonists (lemborexant, 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

What DEA class is ramelteon and tasimelteon?

Answer 22

not controlled

only melatonin agonist

Question 23

MOA of TCAs

Answer 23

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

Question 24

Which TCA is used for insomnia

Answer 24

Doxepin (Silenor)

Question 25

CI for doxepin

Answer 25

Requires a 2 week washout period for MAOi

Question 26

Restoril generic name

Answer 26

temazepam

Question 27

Unisom SleepTabs generic name

Answer 27

Doxylamine (OTC)

Question 28

With which disease states should Doxylamine be avoided in

Answer 28

BPH and glaucoma

Question 29

What are the primary treatments of RLS

Answer 29

Dopamine agonists (pramipexole and ropinirole) and gabapentin

Question 30

Brand name for pramipexole

Answer 30

Mirapex

Question 31

drug class used for RLS

Answer 31

dopamine agonists | and gabapentin

Question 32

Generic for Requip

Answer 32

ropinirole

Question 33

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

Answer 33

1-3

Question 34

Which dopamine agonist comes as a patch

Answer 34

Rotigotine (Neupro) | once daily

Question 35

SE of dopamine agonists

Answer 35

orthostasis, somnolence, and nausea | monitor for pyschiatric SEs

Question 36

Gabapentin (Horizant) used for RLS should be taken at what time

Answer 36

~5 PM

Question 37

What is narcolepsy

Answer 37

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

Question 38

How is narcolepsy treated

Answer 38

Stimulants, such as modafinil or armodafinil or with sodium oxybate (Xyrem), Ca Mg K and Na oxybate (Xywav), dextro/amphetamines, methylphenidate

Question 39

What schedule of drugs are stimulants used for wakefulness (modafinil, armodafinil)

Answer 39

C-IV

Question 40

Side effects of stimulants used for wakefulness

Answer 40

Severe rash that can be lifethreatening

Question 41

Sodium Oxybate is derived from

Answer 41

GABA

Question 42

What schedule of drug is sodium oxybate for narcolepsy

Answer 42

C-III

Question 43

sodium oxybate brand name

Answer 43

Xyrem

Question 44

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

Answer 44

"date rape" drug

Question 45

Which drug used for narcolepsy requires a REMS program

Answer 45

sodium oxybate (Xyrem) Ca Mg K and Na oxybate (Xywav)

Question 46

Other oral medications for narcolepsy include: 1. pitolisant 2. solriamfetol what are the drug classes?

Answer 46

1. histamine-3 receptor antagonist/inverse agonist 2. DA and NE reuptake inhibitor (DNRI)