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701 > Exam 2: Sleep disorder > Flashcards

Exam 2: Sleep disorder Flashcards

1
Q

Types of sleep disorders

A

Insomnia
sleep apnea
narcolepsy
circadian rhythm disorders
parasomnia
restless legs syndrome

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2
Q

Signs and symptoms of sleep disorders

A

Excessive daytime sleepiness (EDS)
Impaired daytime functioning
Irregular breathing
increased movement during sleep
Irregular sleep and wake cycle
Difficulty falling asleep

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3
Q

Cause of insomnia (drugs) MUST KNOW

A

Alcohol, caffeine, nicotine

alpha blockers
ACEi/ARBs
Diuretics

Statins

cholinesterase inhibitors
Anticholinergics
H2RAs

SSRIs/SNRIs
CNS stimulants
Opioids

bronchodilators
Corticosteroids
Decongestants

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4
Q

Risk for chronic insomnia

A

Psych conditions
- depression,anxiety,SUD,ptsd

Medical conditions
-COPD,rheum, CV,hyperthyroid, nocturia, GERD, DM,Cancer, preg, menopause

Neurological conditions
- neurodegenerative, neuromuscular, brain tumor, headache syndromes

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5
Q

Insomnia definition

A

persistent sleep difficulty w/ adequate sleep opportunity + associated daytime dysfunction

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6
Q

Transient insomnia

A

several days

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7
Q

Short term insomnia

A

<3 months

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8
Q

Chronic insomnia

A

at least 3 nights/week for 3 months +

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9
Q

Women are twice as likely to be affected by insomnia T/F

A

true

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10
Q

Treatment for transient/short term insomnia

A

Correct underlying sleep complaint
avoid ADR of medication (short term)
- identify stressor/resolve
- keep sleep diary

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11
Q

Sleep hygiene principles

A

maintain a regular sleep schedule
avoid napping
establish a calm bedroom setting
do not spend time in bed if awake
limit intake of nicotine, caffeine, alcohol
exercise regularly but not close to bedtime
avoid large meal close to bedtime
avoid watching the clock

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12
Q

considerations for selection of specific sleep medication:

A
  • desirability for daytime anxiolytic effect
  • need for next day early morning cognitive sharpness
  • interactions with other medications
  • patient’s specific insomnia complaints
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13
Q

Treatment of long-term insomnia

A

First line: cognitive behavioral therapy (CBT-I)
CBT-I +/- medications&raquo_space; only meds
If rapid improvement is necessary: use CBT-I + medications (taper)

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14
Q

Sleep ONSET insomnia tx

A

Older age/cognitive dysfunction/opioid use:
- DORA (daridorexant, lemoborexant, suvorexant)
- Ramelteon
>avoid next morning residual sedation
- Ramelteon

No reason to avoid first line BZRA:
- DORA
- Z drugs (eszopiclone, zaleplon, zolpidem)
- ramelteon
>want to avoid next morning residual sedation
- Zolpidem IR, zaleplon IR
- ramelteon

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15
Q

Sleep maintenance/mixed insomnia tx

A

Older age/cognitive dysfunction/opioid use:
- DORA (daridorexant, lemoborexant, suvorexant)
- DOXEPIN (low dose)

No reason to avoid first line BZRA:
- DORA
- Z drugs (eszopiclone/zolpidem)
- DOXEPIN (low dose)

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16
Q

Of benzos approved for insomnia, which has the most favorable safety profile?

A

Temazepam

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17
Q

Meds with dual indication for sleep onset + maintenance that have higher risk of next morning residual sedation include

A

DORAs
Zolpidem ER
eszopiclone
Zopiclone

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18
Q

First-line agent with less next morning residual sedation

A

Doxepin
Ramelteon

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19
Q

BZDRA

A

most commonly used to treat insomnia
Many are FDA approved but not all
includes newer non benzo gaba agonists and traditional benzos

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20
Q

BZDRA label caution for

A

COMPLEX SLEEP BEHAVIORS (think ambien, sleep walk)
anaphylaxis
facial angioedema

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21
Q

BZDRA MOA

A

agonist effect on GABA receptor

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22
Q

Benzo characteristics

A

Reduce sleep latency
Increase stage 2 and delta sleep
Anxiolytic
side effects are dose dependent

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23
Q

Caution use of benzos in:

A

sleep apnea
substance abuse
alcohol use
CNS depressant use
withdrawal (if high dose/long time)

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24
Q

Z drug characteristics

A

more selective
increase total sleep time
less disruptive of sleep stages
Generally less withdrawal, tolerance, and rebound insomnia

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25
Q

Z drug caution

A

associated with parasomnic episodes with amnesia (sleep walk/drive/eat)

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26
Q

How do you individualize BZDRA?

A

based on its PK profile and patient presentation

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27
Q

Benzo boxed warnings (3)

A
  1. use with opioids = profound sedation, resp depression, coma, death
  2. can lead to abuse = addiction = overdose/death
  3. can lead to physical dependence (withdrawal reactions, reduce risk by taper)
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28
Q

Z drugs boxed warning (1)

A

complex sleep behaviors
can result in serious injuries including death
D/C immediately if experience

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29
Q

Use of benzos in older adults

A

AVOID
- increase sensitivity = dependence, risk of fall, mv crash

OK if:
- seizure disorder
- rapid eye movement sleep behavior disorder
- benzo withdrawal
- ethanol withdrawal
- severe gen anxiety
- periprocedural anesthesia

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30
Q

Faster onset BZDRAs (tmax)

A

Flurazepam (0.5-1)
Zaleplon (1)
Temazepam (1.2-1.6)
Zolpidem (0.6-4)

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31
Q

Longer duration BZDRAs (Thalf)

A

Quazepam (39 hrs)
Estazolam (10-24)
Eszopiclone (6hr)
Temazepam (3.5-18.4hr)

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32
Q

BZD with lower daily dose

A

Triazolam 0.125-0.5 mg
Estazolam 1-2mg

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33
Q

Z drug with lower daily dose

A

Eszopiclone 1-3 mg
Zolpidem 1.75-12.5

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34
Q

BZD with higher daily dose

A

Flurazepam 15-30 mg
Temazepam 7.5-30mg
Quazepam 7.5-15mg

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35
Q

Z drug with higher daily dose

A

Zaleplon 5-20mg
Zolpidem 1.75-12.5

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36
Q

How does food alter BZDRAs onset of effect?

A

delays onset

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37
Q

T half of __________ is increased in the elderly

A

eszopiclone

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38
Q

t half of __________ is increased in the elderly

A

n-desalkylflurazepam (flurazepam metabolite)

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39
Q

T max of _______ differs based on fasting vs fed and also formulation (IR vs ER)

A

Zolpidem

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40
Q

Dosing of _____ differs based on formulation, gender, indication

A

zolpidem

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41
Q

Eszopiclone (lunesta) use

A

sleep maintenance + sleep onset
early morning awakening

Can be used longer than other agents ~6 months
delayed by food

Duration: 6-9 hrs of effect

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42
Q

major CYP3A4 substrates (4) used for sleep disorder tx

A

Eszopiclone (lunesta)
- monitor use w/ strong INHIBITOR (reduce dose to 1 mg (max 2mg)

Zaleplon (sonata)
- interaction with INDUCERS (cimetidine, rifampin)

DORAs (-rexant)
- dose reduce in weak INHIBITORS
- not recommend w/ moderate-strong inhibitors

Modafinil and armodafinil (inducers)
- may decrease the effectiveness of contraceptives

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43
Q

Eszopiclone (lunesta) ADR

A

headache
dysgeusia (metal taste)
nervousness/anxiety
xerostomia
infection
stomach upset

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44
Q

Zaleplon (sonata) use

A

Sleep onset
short term insomnia (30 days max)
Ultra short-acting, rapid onset
- less next morning residual sedation
AVOID HIGH FAT MEAL - delay

DOES NOT reduce night time awakening

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45
Q

Zaleplon (sonata) ADR

A

headache
nausea
abdominal pain

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46
Q

Zolpidem use

A

depends on formulation
AVOID in severe hepatic impairment d/t risk of encephalopathy

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47
Q

Intermezzo

A

zolpidem SL
middle of night awakening
take if more than 4hrs until wake up
F: 1.75 mg
M: 3.5 mg

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48
Q

Edular

A

Zolpidem SL
sleep ONSET (off label maintenance)
5mg, 10mg

take immediately before bedtime (w/ ≥7-8 hrs planned sleep before wake)

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49
Q

Ambien CR

A

zolpidem ER TAB
onset or maintenance
F: 6.25mg
M: 6.25-12.5mg
b4 bed w/ ≥7-8hr b4 wake

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50
Q

Ambien

A

zolpidem IR tab
onset (off label maintenance)
F: 5mg
M: 5-10mg

b4 bed w/ ≥7-8hr b4 wake

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51
Q

Generic zolpidem IR capsule

A

Sleep onset (off label maintenance)
M and F: 7.5 mg
if 5mg of another zolpidem IR product not effective, may increase to 7.5

b4 bed w/ ≥7-8hr b4 wake

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52
Q

DORAs

A

Dual orexin A and B receptor antagonists
- suvorexant
- Lemborexant
- daridorexant

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53
Q

DORA moa

A

turns off wake signaling
assists in onset/maintenance
INTERACTS CYP3A4

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54
Q

DORA contraindication

A

narcolepsey
(dora makes u sleepy)

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55
Q

DORA use

A

AT bedtime w/ ≥7 hr b4 wake

56
Q

DORA drug onset

A

Lemborexant (dayvigo) <30 min
Suvorexant (belsomra) <30 min
Daridorexant (daridorexant) 30 min

57
Q

Dora drug thalf

A

Daridorexant (Quviviq) 8 hr
Suvorexant (belsomra) 12hr
Lemborexant (dayvigo) 17-19 hr

58
Q

Suvorexant (belsomra) ADR

A

sleep paralysis
abnormal dreams
URTI
drowsiness/dizziness/headache

59
Q

Lemborexant (dayvigo) ADR

A

Complex sleep behaviors
abnormal dreams

60
Q

Which DORA has warning for next day drowsiness and increased fall risk?

A

Lemborexant (dayvigo)
NEXT DAY DROWSINESS = risk of fall
- CNS depression may persist for SEVERAL days after d/c

61
Q

Which DORA has drug onset delayed by food?

A

Daridorexant (quiviviq)

62
Q

Daridorexant (quiviviq) ADR

A

Complex sleep behaviors
HALLUCINATIONS
Sleep paralysis

63
Q

Ramelteon (Rozerem)

A

Melatonin receptor agonist
- MT1 = induce sleepiness
- MT2 = regulate circadian
1>2
T half 1-2.6 hrs

64
Q

Ramelteon use

A

Long term use, sleep ONSET insomnia
Less rebound / abuse potential

65
Q

Avoid ramelteon if

A

severe liver disease
patient already treated with BZDRA (not as effective)
ALSO TAKING FLUVOXAMINE (contraindication)

66
Q

Why is Fluvoxamine contraindicated with Ramelteon?

A

Strong CYP1A2 inhibition

67
Q

Ramelteon ADR

A

headache
dizziness
somnolence

68
Q

Doxepin

A

Tricyclic antidepressant (TCA)

69
Q

Doxepin use

A

Sleep MAINTENANCE insomnia

70
Q

Doxepin dose

A

3mg - 6mg a day
(lower than dosing for depression)
Do not take within 3 hrs of a meal

71
Q

Sleep Drugs with food effect

A

Doxepin (3 hrs!!)
Daridorexant (quiviviq)
BZDRAs

72
Q

Doxepin BBW

A

suicidality

73
Q

Melatonin

A

not approved by FDA
3mg - 5 mg QHS over 4 weeks

74
Q

Melatonin use

A

sleep onset
shift workers
jet lag

75
Q

When to avoid melatonin use

A

Alzheimers
- 2018 NICE guildlines; HA/dizziness not suitable
autoimmune conditions (immune modulator)
- can alleviate or exacerbate conditions

76
Q

first gen antihistamines

A

Diphenhydramine
Doxylamine
AVOID IN OLDER ADULTS
Tolerance to sedative effect develops quickly
Anticholinergic ADR

77
Q

Trazodone dosing

A

12.5 mg to 100mg QHS

78
Q

Trazodone use

A

For pt w/ hx substance abuse +/- depression

Off label: may improve sleep continuity (maintenance)
Not recommended for chronic insomnia by VA or AASM

79
Q

Trazodone BBW

A

suicidal ideation

80
Q

Trazodone ADR

A

carryover sedation
alpha-adrenergic block
- orthostasis, careful fall risk
TAPER

RARE: priapism (erection)

81
Q

Other off label insomnia therapies

A

TCA: amitriptyline
A2 agonist: Mirtazapine
Gabapentin

82
Q

Elderly - insomnia rx

A

ramelteon
low dose doxepin
eszopiclone
zolpidem

83
Q

Pregnancy - insomnia rx

A

diphenhydramine
doxylamine
low dose doxepin

84
Q

Sleep apnea definition

A

stop breathing during sleep followed by o2 desat –> arousal from sleep to restart breathing
more common in men, AA, hispanic

85
Q

Types of sleep apnea

A

Central (CSA)
- impair respiratory drive
Obstructive (OSA)
- upper airway collapse
Mixed

86
Q

Obstructive sleep apnea etiology

A

linked to cardio/cerebrovascular morbitity/mortality/ indepednent of other risk factors (HTN risk, drug-resistant)

Associated w/ motor vehicle accident, depression, increased cancer risk, stroke, CV disease

87
Q

Obstructive sleep apnea treatment

A
  • behavior (weight loss, alter sleep position, avoid Etoh/sedatives)
  • CPAP machine (standard of treatment)
  • use daytime sleepiness meds
    AVOID
  • cns depressant
  • weight gain drugs (ex: TCAs)
    Can improve BP and slow systemic disease onset
88
Q

OSA: excessive daytime sleepiness meds

A
  • modafinil
  • armodafinil
  • solriamfetol (sunosi)
  • pitolisant (WAKIX)
89
Q

OSA: alcohol

A

alcohol
- avoid or reduce within 2-4 hrs prior to sleep
- can exacerbate OSA, worsen daytime sleepiness, promote weight gain

90
Q

OSA: cns depressants

A

benzos
z drugs
barbituates
gabapentin
sedating antidepressants
antihistamines
opioids, etc
- may exacerbate OSA + worsen daytime sleepiness
- use EXTREME caution with opioid medications

91
Q

Modafinil and armodafinil schedule/approval

A

CIV
FDA approved for EDS in OSA and narcolepsy

92
Q

Modafinil and armodafinil use

A

Administer in the morning
promotes awakeness
avoid use in pregnancy
use in CAUTION: cardiovascular disease
DO NOT USE if left ventricular hypertrophy

93
Q

Modafinil and armodafinil DDI

A

May decrease the effectiveness of contraceptives by inducing CYP3A4

94
Q

Modafinil and armodafinil ADR

A

headache!!!!
dizziness, nausea, xerostomia
anxiety, nervousness, dyspepsia
back pain, rhinitis
SJS/TEN/DRESS reported

95
Q

Modafinil and armodafinil warnings

A

mania, exacerbation of psychotic symtpoms
CV events, chest pain, HTN, tachycardia
skin: SJS/TEN/DRESS reported

96
Q

Modafinil/armodafinil MOA

A

increase alpha, decrease delta/theta
effects on dopamine, GABA, 5HT

Armo = R enantiomer

97
Q

Solriamfetol (Sunosi) schedule/approval

A

CIV
FDA-approved EDS: OSA and narcolepsy

98
Q

Solriamfetol (Sunosi) moa

A

dopamine and NE reuptake inhibitor

99
Q

Solriamfetol (Sunosi) use

A

QAM
avoid use within 9 hrs planned bedtime (interfere w/ sleep)
AVOID use in unstable CV disease, arrhythmias (can cause tachy/htn)

100
Q

Solriamfetol (Sunosi) contraindication

A

MAOI - avoid use with or within 14 days

101
Q

Solriamfetol (Sunosi) ADR

A

headache, anxiety, insomnia, decreased appetite, nausea

102
Q

Pitolisant (WAKIX) schedule/approval

A

Not controlled
FDA for narcolepsy
Off label EDS in OSA

103
Q

Pitolisant (WAKIX) moa

A

antagonist/inverse agonist at histamine 3 receptors

104
Q

Pitolisant (WAKIX) use

A

QAM
if pt is a CYP2D6 poor metabolizer = lower the dose
Major substrate CYP2D6 and CYP3A4 (dose adjust)
dose adjust renal impairment

105
Q

Pitolisant (WAKIX) contraindication

A

severe hepatic impairment

106
Q

Pitolisant (WAKIX) warning

A

may prolong QT in patients with KNOWN arrhythmias

107
Q

Pitolisant (WAKIX) ADR

A

HEADACHE!!!!!
anxiety, musculoskeletal pain, URI

108
Q

drugs that cause URI

A

Suvorexant (belsomra) ADR
Pitolisant (WAKIX)

109
Q

Headache ADR (bolded)

A

Pitolisant (WAKIX)
Modafinil/armodafinil

110
Q

Narcolepsy definition

A

impairment of both onset and offset of REM and NREM

111
Q

Narcolepsy tetrad

A
  1. excessive/irresistible daytime sleepiness
  2. cataplexy
  3. hypnagogic hallucinations
  4. sleep paralysis
112
Q

Narcolepsy patho

A

loss of normal function of hypocretin-orexin neurotransmitter system
commonly slips into sleep phases throughout the day

113
Q

2 types of narcolepsy

A

type 1: with cataplexy (25-50/100k requires medical treatment)
type 2: without cataplexy (20-34/100k)

114
Q

Narcolepsy treatment

A

good sleep hygiene
scheduled daytime naps
Avoid drugs that worsen daytime sleepiness
No disease modifying treatment yet

115
Q

Drugs that worsen daytime sleepiness

A

benzodiazepines
opiates
antipsychotics
antiepileptics
alcohol

116
Q

Narcolepsy treatment goal

A

achieve normal alertness during conventional waking hours
Treat symptoms:
- cataplexy
- excessive daytime sleepiness (EDS)
- REM sleep abnormalities

117
Q

Narcolepsy EDS treatment

A

Modafinil
Armodafinil
Solriamfetol (sunosi)
Pitolisant
^ also for OSA
AMPHETAMINES
METHYLPHENIDATE
SODIUM OXYBATE (xyrem, lumryz)
OXYBATE SALTS (Xywav)

118
Q

Sodium oxybate schedule/approval

A

CIII Xyrem
Approved for cataplexy or EDS in adults with narcolepsy

119
Q

Sodium oxybate BBW (3)

A
  1. CNS depression
  2. Abuse/misuse
  3. Restricted access
120
Q

Sodium oxybate use

A

give on EMPTY stomach
≥ 2 hrs after eating
Give while patient in bed
LIE DOWN IMMEDIATELY AFTER DOSE AND REMAIN IN BED
1st dose: in bed
2nd dose: 2.5 - 4 hours later

121
Q

Sodium Oxybate MOA

A

CNS depressant, knocks you out, very strong
active moiety = GHB (gaba metabolite)

122
Q

Sodium oxybate ADR

A

confusion
headache, dizziness
weight loss/decreased appetite
urinary incontinence
drowsiness
depression
Somnambulism
anxiety

123
Q

Sodium oxybate COUNSELING

A

REMS:
INSTRUCT not to engage in hazardous activities req. mental alertness or motor coordination (at least 5 hrs after taking sodium oxybate)

124
Q

ER sodium oxybate oral suspension (LUMRYZ) use

A

QHS
give on an empty stomach ≥2 hrs
administer while the patient is in med - lay down immediately after and remain.
MIX: 80ml water + dose
Give within 30 min of mixing

125
Q

Oxybate salts (Xywav)

A

not just sodium –
contains calcium, magnesium, potassium, sodium
otherwise similar to Xyrem

126
Q

REM supressing drugs for cataplexy in narcolepsy

A
  • VENLAFAXINE (SNRI)
  • duloxetine (SNRI)
  • fluoxetine (SSRI)
  • clomipramine (TCA)

+Pitolisant
+sodium oxybate

Abrupt withdrawal = status cataplecticus (severe nearly rebound cataplexy that can last several hours!!)

127
Q

Circadian rhythm disorder

A

abnormalities in sleep wake pattern
- may present as insomnia +/ EDS

128
Q

Different types of circadian rhythm disorders (6)

A

Delayed sleep-wake phase disorder
advanced sleep wake phase disorder
non-24hr sleep wake rhythm disorder
irregular sleep-wake rhythm disorder
Jet lag disorder
shift-work disorder

129
Q

Jet lag disorder treatment

A

napping
timed light exposure

melatonin
ramelteon
Z drugs, benzos (risk of next day drowsiness)

130
Q

Shift work disorder

A

Sleep hygiene, napping, exposure to bright lights at night, darkness during day, CBT-I
melatonin, ramelteon, suvorexant
Z drugs, benzos
Modafinil, armodafinil

131
Q

Restless legs syndrome definition

A

paresthesias felt deep in calf muscles/thighs/ARMS
urge to keep limbs in motion
OFTEN BILATERAL
elderly,women, 10% adults, onset ≥40

132
Q

Restless Legs Syndrome is associated with

A

CKD
iron deficiency
Vitamin B or folate deficiency
pregnancy
peripheral neuropathies

133
Q

RLS: rule out other conditions

A

Nutrition
- iron deficiency (ferritin ≤75ng/mL)
- Vitamin B/folate deficiency
- Reduce caffeine and alcohol use
- weight loss

Smoking cessation
Regular moderate exercise
Sleep
Withdrawal of medications

134
Q

Withdrawal of medications that may cause RLS

A

Central antihistamines
- meclizine
- hydroxyzine
- benadryl
- doxylamine

Antidepressants
- TCA, SSRI, SNRI (not bupropion)
Antipsychotics
Anti-nausea drugs that block dopamine (metoclopramide, promethazine)

135
Q

Nonpharm treatment RLS

A

Sx relief: walking, biking, soaking limbs, leg massage
Activity to improve mental alertness
Yoga? acupuncture?

136
Q

Rx for RLS - intermittent sx

A

carbidopa-levodopa
BZDRA (clonazepam most well studied)

137
Q

Rx for RLS - chronic persistent sx

A

for painful RLS
A2 delta Calcium channel ligands
- pregabalin
- gabapentin (FDA approved)

Dopamine agonists (lower dose than PD)
- IR pramipexole
- ropinirole
- rotigotine
//increase dose – increase RLS severity – MONITOR

BZDRA: carryover sedation

701 (16 decks)

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