Exam 4 - Lec 62 Sleep Disorders Ott

Question 1

Look at slide 3 for disease states, meds, and substances assoc with insomnia

Answer 1

Ok sure thing

Question 2

select the FALSE statement about DSM-5 criteria for insomnia:

a. insomnia is considered difficulties with sleep initiation (latency), sleep maintenance, and/or early‐morning awakening
b. takes place at least 3 nights per week
c. present for at least 6 months

Answer 2

c. present for at least 6 months (3 months)

Question 3

first line tx for insomnia disorders

Answer 3

non-pharm (AASM recommends CBT and behavioral therapies first line)

Question 4

which med class are the most commonly used sleep medications?

Answer 4

Z-hypnotics (zolpidem, zaleplon, eszopiclone)

Question 5

T or F: the initial dose of zolpidem is higher in women and elderly - 10 mg

Answer 5

F (lower; 5 mg)

Question 6

which Z-hypnotic causes a metallic taste?

a. zolpidem
b. eszopiclone
c. zaleplon

Answer 6

b. eszopiclone

Question 7

Z-hypnotics can cause _________, which are unusual actions while a person is sleeping

Answer 7

parasomnias

(this is a warning for all sleep meds)

Question 8

benzodiazepine used for sleep

Answer 8

temazepam

Question 9

two melatonin receptor agonists drugs

Answer 9

ramelteon
tasimelteon

Question 10

ramelteon is CI with which med?

Answer 10

fluvoxamine (1A2 inhibitor)

Question 11

drug that is FDA‐approved for non‐24 sleep‐
wake disorder in adults

a. ramelteon
b. tasimelteon

Answer 11

b. tasimelteon (used in blind ppl)

Question 12

SE for ramelteon (4 of them; slide 9)

Answer 12

GI upset, next day somnolence, hyperprolactinemia, prolactinoma

Question 13

melatonin receptor agonists are substrates of which CYP?

Answer 13

1A2 (watch for 1A2 inducers and inhibitors)

Question 14

3 orexin receptor antagonist drugs (same ending)

Answer 14

suvorexant
lemborexant
daridorexant

Question 15

the orexin receptor antagonists (-orexants) are substrates of which CYP?

Answer 15

3A4

Question 16

how many hours of sleep do you need when taking orexin receptor antagonists?

Answer 16

at least 7 hours

Question 17

CI for the orexin receptor antagonists

Answer 17

CI in narcolepsy, causes narcolepsy-like SE

Question 18

how does doxepin work for sleep?

Answer 18

TCA, low doses exert effect through H1 receptor antagonism

Question 19

SE of doxepin

Answer 19

anticholinergic SE

Question 20

T or F: trazodone is FDA-approved for sleep

Answer 20

F (not FDA-approved, but is used)

Question 21

which drug has a long half-life and can cause daytime hangover?

a. doxepin
b. trazodone
c. mirtazapine
d. quetiapine

Answer 21

b. trazodone

Question 22

Clinically used as a sleep agent, especially in
patients with depression who have difficulty
sleeping

a. doxepin
b. trazodone
c. mirtazapine
d. quetiapine

Answer 22

c. mirtazapine

Question 23

Low dose __________ is not recommended for
use in insomnia unless there is a co‐morbid
psychiatric disorder

a. doxepin
b. trazodone
c. mirtazapine
d. quetiapine

Answer 23

d. quetiapine

Question 24

T or F: diphenhydramine/doxylamine is not recommended by the AASM for insomnia

Answer 24

T

Question 25

__________ can be considered in jet lag and patients with low __________ levels; 1A2 substrate (same drug in each blank)

Answer 25

melatonin

Question 26

melatonin/valerian/chamomile can cause an allergic rxn in which pts?

Answer 26

pts with daisy or ragweed allergies

Question 27

DSM-5 criteria for obstructive sleep apnea: pt must have evidence of at least ___ obstructive apneas per hour of sleep confirmed by polysomnography

Answer 27

5

Question 28

which is treated first in a pt that has both sleep apnea and insomnia?

Answer 28

sleep apnea

Question 29

diagnostic test for obstructive sleep apnea

Answer 29

polysomnography (there is more in bold on slide 16)

Question 30

some non-pharm interventions for tx of sleep apnea

Answer 30

Weight loss (adjunctive rather than curative), smoking cessation, avoid alcohol and CNS depressants, sleep on side rather than back

Question 31

what machine is used for tx of sleep apnea?

Answer 31

CPAP machine

Question 32

Excessive daytime sleepiness (EDS) due to sleep apnea can be treated with what two drugs?

Answer 32

modafinil or armodafinil - need to review CPAP adherence first and possibility of RLS or PLMS

Question 33

T or F: When considering treating apnea and insomnia, ensure that the obstructive apnea is addressed before recommending sedative/hypnotic drug therapy

Answer 33

T

Question 34

narcolepsy tetrad

Answer 34

-EDS -cataplexy -hallucinations -sleep paralysis

Question 35

T or F: excessive daytime sleepiness (EDS) occurs in 50% of narcolepsy pts, generally more severe in Type I narcolepsy (narcolepsy w/ cataplexy or hypocretin deficiency syndrome)

Answer 35

F (EDS occurs in 100% of pts)

Question 36

what is cataplexy?

Answer 36

sudden loss of muscle tone triggered by emotion

Question 37

3 drugs for tx of cataplexy in narcolepsy

Answer 37

-sodium oxybate (Xyrem) -Xywav -Lumryz

Question 38

which is for adults and children aged 7 or older, and is also approved for idiopathic hypersomnia in adults? a. sodium oxybate (Xyrem) b. Xywav c. Lumryz

Answer 38

b. Xywav

Question 39

which drug is for adults only, ER dosage form, has once nightly dosing, and high sodium content? a. sodium oxybate (Xyrem) b. Xywav c. Lumryz

Answer 39

c. Lumryz

Question 40

which has the lowest sodium content? a. sodium oxybate (Xyrem) b. Xywav c. Lumryz

Answer 40

b. Xywav

Question 41

drugs for excessive daytime sleepiness (slide 20)

Answer 41

modafinil/armodafinil sodium oxybate pitolisant and solriamfetol

Question 42

CI for pitolisant (Wakix) a. severe hepatic impairment b. severe renal impairment c. thyroid C-cell tumors d. Huntington's Chorea

Answer 42

a. severe hepatic impairment

Question 43

pitolisant (Wakix) MOA

Answer 43

H3 receptor antag/inverse agonist

Question 44

pitolisant (Wakix) is a weak _____ inducer, may reduce effectiveness of oral contraceptives

Answer 44

3A4

Question 45

which of the following is FALSE about pitolisant (Wakix)? a. CI in severe hepatic impairment b. prolongs QT interval c. H3 antagonist/inverse agonist d. 1A2/3A4 substrate e. avoid use with centrally-acting H1 receptor antagonists

Answer 45

d. 1A2/3A4 substrate (it is a 2D6/3A4 substrate)

Question 46

which is TRUE about Solriamfetol (Sunosi)? a. it is an SNRI b. indicated for insomnia c. increases BP and HR; avoid in unstable CV disease and arrhythmias d. no dose adjustment needed in renal impairment

Answer 46

c. increases BP and HR; avoid in unstable CV disease and arrhythmias (a. it is a DNRI; b. indicated for EDS due to narcolepsy or OSA; d. does need to be dose adjusted in moderate-severe impairment)

Question 47

how should Solriamfetol be dosed in moderate or severe renal impairment?

Answer 47

moderate: start 37.5 mg, may inc to 75 mg after at least 7 days severe: starting and max dose is 37.5 mg

Question 48

T or F: Solriamfetol should be used with caution in pts with history of psychosis or bipolar disorder

Answer 48

T (dec dose or d/c if psychiatric sx develop)

Question 49

T or F: Solriamfetol should be used with caution with dopaminergic drugs

Answer 49

T

Question 50

what are the drugs of choice for shift work sleep disorder? (2 of them)

Answer 50

modafinil and armodafinil (take 1 hour before the work period starts during "wake time")

Question 51

drugs for restless legs syndrome (3 of them; slide 24)

Answer 51

-gabapentin enacarbil -pramipexole -ropinirole

Question 52

what is the gabapentin prodrug that is FDA-approved for RLS?

Answer 52

gabapentin enacarbil

Question 53

_____ supplementation may be considered with restless legs syndrome

Answer 53

iron