Hypnotics

Question 1

Which hypnotics are typically free of residual effects in the morning?

Answer 1

Zolpidem (Ambien)
Zaleplon (Sonata)
Triazolam (Halcion)

Question 2

Which hypnotics are good for sleep latency issues?

ie rapid onset of action

Answer 2

Zolpidem (Ambien)
Zaleplon (Sonata)
Triazolam (Halcion)

Question 3

Which hypnotics are good for sleep maintenance?

ie slow elimination

Answer 3

Temazepam (Restoril)
Estazolam (Prosom)
Flurazepam

Question 4

What are good hypnotics to use if a patient is struggling from depression?

Answer 4

Trazodone

Amitriptyline

Question 5

What adjustments should be made for elderly patients?

Answer 5

Use smaller doses

Question 6

What caution needs to be taken when coming off the drug?

Answer 6

Taper the drug down to avoid rebound insomnia

Question 7

Which hypnotics are most likely to cause rebound insomnia?

Answer 7

Large doses of short-acting agents

Question 8

What are the general side effects of hypnotics?

Answer 8

Risk of fall
Respiratory depression
Amnesia/Drowsiness/Confusion
Hypokinesia
Dizziness
Abnormal coordination

Question 9

What is the stongest aspect of tolerance and dependence with long-term use of these agents?

Answer 9

Psychological&raquo_space; physical

Question 10

What are the benefits of Zolpidem?

Answer 10

Rapid onset and duration (~4 hrs)

Question 11

Which type of insomnia is zolpidem and Zaleplon useful for treating?

Answer 11

Sleep-onset

Question 12

What are some specific side effects for zolpidem?

Answer 12

Disinhibition
Dissociation
Sleep-walking
Hallucination
Amnesia

Question 13

What is the benefit of Zaleplon (Sonata)?

Answer 13

Rapid onset of action and ultra-short duration (~2 hrs)

- Allows for usage of 2nd dose in the middle of the night if needed

Question 14

What drug may significantly increase the level of Zaleplon?

Answer 14

Cimetidine

Question 15

What is the main advantage of eszopiclone (Lunesta)?

Answer 15

Studies have shown long term effectiveness

Question 16

When should eszopiclone be prescribed for insomnia?

Answer 16

To decrease sleep latency and improve sleep maintenance

Question 17

What medications can increase or decrease the blood levels of eszopiclone?

Answer 17

CYP3A4 and CYP2E1 inhibitors and inducers

Question 18

What are some specific side effects of eszopiclone?

Answer 18

Dysgeusia
Headache
Coldlike symptoms
Euphoric effects (6 to 12 mg dose)

Question 19

What may happen within 48 hrs after discontinuing eszopiclone?

Answer 19

Anxiety
Abnormal dreams
Nausea
Upset stomach

Question 20

What is dysgeusia?

Answer 20

Foul, salty, rancid, or metallic taste sensation

Question 21

Which receptors are affected by rozerem (ramelteon)?

Answer 21

MT1 and MT2

Question 22

What type of food decreases the effectiveness of rozerem?

Answer 22

High fat

Question 23

What patient population should not take Rozerem?

Answer 23

Those with hepatic impairment

Question 24

What drug should not be combined with rozerem?

Answer 24

Fluvoxamine

Question 25

Which enzyme metabolizes rozerem?

Answer 25

CYP1A2

Question 26

What is a the main benefit of using rozerem over other hypnotics?

Answer 26

Less respiratory depression

Question 27

What benzos are approved for use to treat insomnia?

Answer 27

Estazolam (ProSom) Triazolam (Halcion) Flurazepam (Dalmane) Temazepam (Restoril)

Question 28

What is the benefit of estazolam (ProSom)?

Answer 28

Intermediate-acting | Slow onset and long duration

Question 29

What type of insomnia is estazolam suited for treating?

Answer 29

Sleep maintenance

Question 30

What are the disadvantages of estazolam?

Answer 30

``` More sedative then other hypnotics- Falls, impaired cognition Respiratory depression Hepatic dysfunction Low albumin Renal disease Pulmonary disease ```

Question 31

What is the benefit of using trazolam (halcion)?

Answer 31

Short acting

Question 32

What type of insomnia is triazolam suited for treating?

Answer 32

Sleep-onset

Question 33

What are some specific precautions associated with triazolam?

Answer 33

Rebound insomnia Hepatic dysfunction, low albumin, renal impairment, and pul. dis Risk of daytime sedation

Question 34

What is the benefit of flurazepam (dalmane)?

Answer 34

Long-acting metabolites

Question 35

What type of insomnia is flurazepam suited for treating?

Answer 35

Sleep maintenance

Question 36

What are some specific precautions with flurazepam?

Answer 36

Do not mix with other CNS depressants | Low albumin or hepatic impairment

Question 37

What is the benefit of temazepam (restoril)?

Answer 37

Short to intermediate action with longer latency to onset and half-life

Question 38

What type of insomnia is temazepam well suited to treat?

Answer 38

Sleep maintenance

Question 39

What are some specific precautions when using temazepam?

Answer 39

``` Drowsiness Headacahe Nervousness Dizziness Other CNS depressants low albumin or hepatic impairment ```

Question 40

What risk do elderly face when taking benadryl?

Answer 40

Delirium

Question 41

What herbal products can be used for insomnia?

Answer 41

Kava kava Valerian Melatonin

Question 42

What are some risks associated with kava kava?

Answer 42

Not useable with other sedatives | Hepatotoxic

Question 43

What type of "insomnia" can melatonin help treat?

Answer 43

Jet lag

Question 44

What is the MOA of trazodone (desyrel)?

Answer 44

5-HT2 antagonist | Inhibits 5-HT uptake

Question 45

What substances should be avoided while on trazodone?

Answer 45

Alcohol, barbituates, and CNS depressants Digoxin and phenytoin (increase serum levels) Warfarin (may decrease effectiveness of warfarin)

Question 46

Common side effects of trazodone?

Answer 46

``` Dry mouth blurred vision Constipation Urinary retention Priapism Hypotension Syncope Drowsiness or dizziness ```

Question 47

What is the MOA of nefazodone (serzone)?

Answer 47

Antagonist of 5-HT2 | Inhibits 5-HT uptake

Question 48

What medications are contraindicated in a patient taking nefazodone?

Answer 48

``` MAOIs Astemizole Carbamazepine Cisapride Terfenadine ```

Question 49

The effectiveness of which drugs are decreased by the use of nefazodone?

Answer 49

``` Anticoagulants Hypoglycemics Diuretics Clonidine Methyl dopa ```

Question 50

The effectiveness of which drugs are increased when taking nefazodone?

Answer 50

Digoxin Carbamazepine MAOIs

Question 51

What are some specific precautions when using nefazodone?

Answer 51

``` Hepatotoxic Cardiac disease Cerebrovascular disease Seizures Priapism ```

Question 52

What TCA can be used to treat insomnia

Answer 52

Amitriptyline (Elavil)- Inhibits 5-HT and NE uptake

Question 53

What drug may decrease the effectiveness of amitriptyline?

Answer 53

Phenobarbital

Question 54

What drugs might increase the levels of amitriptyline?

Answer 54

CYP2D6 inhibitors (Cimetidine, quinidine)

Question 55

What precautions should be monitored when using amitriptyline?

Answer 55

``` Anticholinergic effects - Urinary retention - Constipation - Blurred vision Cardiac conduction disturbances ```

Question 56

What are the adverse effects of mirtazapine?

Answer 56

``` Somnolence Dry mouth Increase appetite/Weight gain Dizziness Agranuocytosis ```

Question 57

What substances are contraindicated with mirtazapine?

Answer 57

MAOIs Alcohol Benzos

Question 58

What is the staple for the treatment of insomnia?

Answer 58

Sleep hygiene