EXAM 5 Sleep disorders Dr. Thomason Flashcards
Patient with depression, taking fluoxetine, exercise to help with, uses phone before bedtime with insomnia.
What causes insomnia?
-Fluoxetine: especially when taken before bedtime, sometimes even when taken in the morning
-depression itself can cause insomnia
-should not exercise or use the phone right before bedtime
-coffee in the late afternoon
-counsel on sleep hygiene: only go to bed if sleepy, if can’t fall asleep in 20 mins get up and try again when tired, go to bed and wake up at the same time
How to handle fluoxetine-induced insomnia?
-should be taken in the morning
-may add trazodone for insomnia (CAUTION: sedation, next-day hangover - will go away, orthostasis, priapism (rare))
-change the drug -> citalopram, escitalopram
-may use rating tool to assess if fluoxetine is working, if it does stay and treat insomnia with trazodone
Patient with maintenance insomnia - wakes up and can’t sleep again. Stressful job, alcohol before bed. HTN and obesity.
Tried Melatonin, Zolpidem (currently on), Eletriptan, Ramelteon, Amitriptyline
Factors contributing to insomnia
-Stressful job -> recommend relaxation, mindfulness, meditation (app), CBTI app, therapist for cognitive therapy
-Alcohol before bed
-Ramelteon helps with sleep onset, not maintenance
-may change to Zolpidem XR which may get him through the night (but may worsen feeling tired throughout the day)
-may change to Escopline (Lunesta), approved for onset and maintenance
-may add low dose Doxepin (TCA) - but don’t use TCAs when over 65 or BPH
-may add Benzo like Temazepam, CAUTION for dependence, not the best if they drink alcohol
-Orexin receptor antagonist (suvorexant): watch out for morning hangover - educate for sleep paralysis
-follow up after 2 weeks with sleep diary
What is the recommended dose of Zolpidem for women?
5 mg
for men = 10 mg
-> side effects of post antegrade amnesia, eating while asleep - weight gain
-> may change to trazodone (may develop tolerance, hold for 1 week, and restart after 1 week, use hydroxyzine in the meantime)
-may switch to lunesta (can also cause night-eating but less common)
-switch to suvorexant (helps with night behavior)
Does Zolpidem need taper?
Yes
after D/C they may experience rebound insomnia for 2-3 nights - often with non-benzos and benzos
What is narcolepsy?
Falling asleep during the day
-irrepressible sleep attacks
-directly into the REM phase
may have it with Cataplexy:
-loss of muscle tone
-induced by emotions (crying, laughing)
-remain consciousness
What are the criteria for narcolepsy diagnosis?
daily excessive sleepiness for at least 3 months, not caused by other meds or disorders
-cataplexy (induced by emotions) may be present
-should be confirmed with PSG and MSLT (sleep lab), especially if they don’t have cataplexy symptoms
How do Neurotransmitter levels change during the REM phase in patients with Narcolepsy?
less NE, 5-HT, and DA
increase in cholinergic activity
Genetic:
-disruption of the hypocretin receptor-2 gene (Hctr2)
How fast do patients go into REM phase when having a narcoleptic episode?
within 15 minutes
SOREM: sleep-onset REM period
When is narcoplesy daignostic?
Multiple Sleep Latency Test (MSLT)
it takes the patient less than 8 minutes to fall asleep and has more than 2 SOREMs (going directly into the REM phase)
Drugs for EDS (excessive daytime sleepiness)
Stimulants:
-Modafanil (C-IV)
-armodafinil
-amphetamine
-dextroamphetamine
-methamphetamine
-methylphenidate
-also sodium oxybate !!!
Drugs for Cataplexy
-sodium oxybate!!!
-clomipramine
-imipramine
-protriptyline
-fluoxetine
Which drug can be used for patients with narcolepsy with cataplexy?
sodium oxybate
CAUTION with Modafinil in which patients?
CAUTION in patients with
-LVH (left ventricular hypertrophy)
-arrhythmias
-CYP3A4 inducer - autoinduction - makes oral contraceptives, cyclosporin, and triazolam less effective
-CYP2C19 inhibitor: increases phenytoin, diazepam, propranolol
ADE of Modafinil
!
headache, nausea
insomnia, anxiety - since it is a stimulant
How is Armodafanil (Nuvigil) different freom Modafinil?
R enantiomer
-longer half-life -> once a day dosing
Which Psychostimulants are primarily used?
Methylphenidate and dextroamphetamine (C-II)
-increases NE and DA
-may cause tolerance after some time -> increase the dose or change the drug
ADE: insomnia, HTN, palpitations, irratbiility
Use of Sodium oxybate (Xyrem)
-helps with nocturnal sleep
-reduces narcolepsy
-helps with EDS and cataplexy
-helps with hypnogogic hallucinations and sleep paralysis
ADE of Sodium oxybate (Xyrem)
-headache
-N/V
-dizziness, somnolence
How to take it Sodium oxybate
comes in powder -> dilute with 2oz of water
-don’t eat 2 hours before taking it (reduces absorption), avoid alcohol
2.5g at bedtime -> 2.5g 2-4h later (set alarm)
What is the max dose of Sodium oxybate
9g
Role of Antidepressants
-SSRIs and TCAs
-REM supressant effects
-don’t decrease sleep attacks
-somewhat helps with sleep paralysis (but not so great)
Non-pharmacologic treatment
-regular bedtimes
-two scheduled 15-minute naps
-still need to take meds
What is the most common cause of restless legs syndrome?
FYI
iron deficit anemia
Drug of choice for Restless-legs syndrome
FYI
Dopamine agonist
-Pramipexole
-ropinirole
counsel on sleep attacks, and impulsive behavior: shopping, gambling
other meds:
Clonazepam
Med-induced restless legs syndrome
FYI
high doses of SNRIs -> reduce the dose
