Exam 4 - Lec 62 Sleep Disorders Ott Flashcards
Look at slide 3 for disease states, meds, and substances assoc with insomnia
Ok sure thing
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
c. present for at least 6 months (3 months)
first line tx for insomnia disorders
non-pharm (AASM recommends CBT and behavioral therapies first line)
which med class are the most commonly used sleep medications?
Z-hypnotics (zolpidem, zaleplon, eszopiclone)
T or F: the initial dose of zolpidem is higher in women and elderly - 10 mg
F (lower; 5 mg)
which Z-hypnotic causes a metallic taste?
a. zolpidem
b. eszopiclone
c. zaleplon
b. eszopiclone
Z-hypnotics can cause _________, which are unusual actions while a person is sleeping
parasomnias
(this is a warning for all sleep meds)
benzodiazepine used for sleep
temazepam
two melatonin receptor agonists drugs
ramelteon
tasimelteon
ramelteon is CI with which med?
fluvoxamine (1A2 inhibitor)
drug that is FDA‐approved for non‐24 sleep‐
wake disorder in adults
a. ramelteon
b. tasimelteon
b. tasimelteon (used in blind ppl)
SE for ramelteon (4 of them; slide 9)
GI upset, next day somnolence, hyperprolactinemia, prolactinoma
melatonin receptor agonists are substrates of which CYP?
1A2 (watch for 1A2 inducers and inhibitors)
3 orexin receptor antagonist drugs (same ending)
suvorexant
lemborexant
daridorexant
the orexin receptor antagonists (-orexants) are substrates of which CYP?
3A4
how many hours of sleep do you need when taking orexin receptor antagonists?
at least 7 hours
CI for the orexin receptor antagonists
CI in narcolepsy, causes narcolepsy-like SE
how does doxepin work for sleep?
TCA, low doses exert effect through H1 receptor antagonism
SE of doxepin
anticholinergic SE
T or F: trazodone is FDA-approved for sleep
F (not FDA-approved, but is used)
which drug has a long half-life and can cause daytime hangover?
a. doxepin
b. trazodone
c. mirtazapine
d. quetiapine
b. trazodone
Clinically used as a sleep agent, especially in
patients with depression who have difficulty
sleeping
a. doxepin
b. trazodone
c. mirtazapine
d. quetiapine
c. mirtazapine
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
d. quetiapine
T or F: diphenhydramine/doxylamine is not recommended by the AASM for insomnia
T
__________ can be considered in jet lag
and patients with low __________
levels; 1A2 substrate
(same drug in each blank)
melatonin
melatonin/valerian/chamomile can cause an allergic rxn in which pts?
pts with daisy or ragweed allergies
DSM-5 criteria for obstructive sleep apnea: pt must have evidence of at least ___ obstructive apneas per hour of sleep confirmed by polysomnography
5
which is treated first in a pt that has both sleep apnea and insomnia?
sleep apnea
diagnostic test for obstructive sleep apnea
polysomnography (there is more in bold on slide 16)
some non-pharm interventions for tx of sleep apnea
Weight loss (adjunctive rather than curative), smoking cessation, avoid alcohol and CNS depressants, sleep on side rather than back
what machine is used for tx of sleep apnea?
CPAP machine
Excessive daytime sleepiness (EDS) due to sleep apnea can be treated with what two drugs?
modafinil or armodafinil - need to review CPAP adherence first and possibility of RLS or PLMS
T or F: When considering treating apnea and insomnia, ensure that the obstructive apnea is addressed before recommending sedative/hypnotic drug therapy
T
narcolepsy tetrad
-EDS
-cataplexy
-hallucinations
-sleep paralysis
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)
F (EDS occurs in 100% of pts)
what is cataplexy?
sudden loss of muscle tone triggered by emotion
3 drugs for tx of cataplexy in narcolepsy
-sodium oxybate (Xyrem)
-Xywav
-Lumryz
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
b. Xywav
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
c. Lumryz
which has the lowest sodium content?
a. sodium oxybate (Xyrem)
b. Xywav
c. Lumryz
b. Xywav
drugs for excessive daytime sleepiness (slide 20)
modafinil/armodafinil
sodium oxybate
pitolisant and solriamfetol
CI for pitolisant (Wakix)
a. severe hepatic impairment
b. severe renal impairment
c. thyroid C-cell tumors
d. Huntington’s Chorea
a. severe hepatic impairment
pitolisant (Wakix) MOA
H3 receptor antag/inverse agonist
pitolisant (Wakix) is a weak _____ inducer, may reduce effectiveness of oral contraceptives
3A4
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
d. 1A2/3A4 substrate
(it is a 2D6/3A4 substrate)
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
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)
how should Solriamfetol be dosed in moderate or severe renal impairment?
moderate: start 37.5 mg, may inc to 75 mg after at least 7 days
severe: starting and max dose is 37.5 mg
T or F: Solriamfetol should be used with caution in pts with history of psychosis or bipolar disorder
T (dec dose or d/c if psychiatric sx develop)
T or F: Solriamfetol should be used with caution with dopaminergic drugs
T
what are the drugs of choice for shift work sleep disorder? (2 of them)
modafinil and armodafinil (take 1 hour before the work period starts during “wake time”)
drugs for restless legs syndrome (3 of them; slide 24)
-gabapentin enacarbil
-pramipexole
-ropinirole
what is the gabapentin prodrug that is FDA-approved for RLS?
gabapentin enacarbil
_____ supplementation may be considered with restless legs syndrome
iron
