InsomniaFC Flashcards
Drugs Likely to Contribute to Insomnia
Bupropion
Stimulants
OTC appetite supressants
Decongestants
MAO-B inhibitors
Fluoxetine
Caffeine
Steroids
Alcohol
Antihistamines or diuretics taken later in the day
Sleep Hygiene Methods to Improve Sleep
Keep the bedroom dark, comfortable, and quiet
Regular sleep schedule
Avoid daytime naps (limit to 30 mins)
Reserve bedroom for only sleep and sex
Turn the face of the clock away
Establish a pre-bedtime ritual
Avoid exercising before bed
Do not eat heavy meals before bed
Avoid Caffeine in the afternoon
Natural Products for Insomnia
St. John’s wort
Chamomile tea
Melatonin
Valerian
Non-Benzodiazepines MOA
Act selectively at the benzodiazepine receptors to increase GABA
Z drugs names
Zolpidem (Ambien, Zolpimist - oral spray, Edluar - SL tabs, Intermezzo - SL tabs for nighttime awakenings), Zaleplon (Sonata), Eszopiclone (Lunesta)
SE z drugs
-SE: increase risk of mortality, abuse, somnolence, dizziness, ataxia, parasomnias, lightheadedness, “pins and needles” feeling on skin
how to take the z drugs
Do not take with fatty food, a heavy meal, or Alcohol
why take z drus over bzds?
Preferred over benzodiazepines (due to decrease abuse, dependence, and tolerance)-
DDIs with z drugs
-Caution use with potent 3A4 inhibitors
Non-Benzodiazepines Patient Counseling : zolpimist
Zolpimist: spray directly into your mouth over your tongue (once for 5mg; twice for 10mg); prime if 1st-time use
how to take the z drugs ?food or no food?
heavy or high-fat meals may prevent medication from working
how long for wd sx to go away for z drugs
Withdrawal symptoms subside after 1-2 days
Melatonin Receptor Agonist name
Ramelteon (Rozerem)
melatonin SE
SE: somnolence, dizziness
dose of melatonin for insomnia
Dose: 8mg QHS
how to take melatonin
Do not take with fatty foods
adv of melatonin
not limited to short-term use
Tricyclic Antidepressants for insomina
Doxepin ER (Silenor), Generic Doxepin, trazodone, mirtazapine are used off-label for sleep
tcas contraindications
-CI: requires 2 week washout for MAOIs
why use TCAs for insomnia
-Used for difficulty “staying” asleep
SE of tcas
SE: somnolence, anticholinergic SEs, low incidence of nausea and upper respiratory infection
doxepin dose for insomnia
6mg qhs , 3mg if older than 65
Benzodiazepines MOA
Potentiate GABA, an inhibitory neurotransmitter, causing CNS depression
ativan
Lorazepam (Ativan)
restoril
Temazepam (Restoril)
caution for quazepam
Quazepam (Doral): Caution in elderly due to its long half-life (risk of falls and fractures)
caution with flurazepam
Flurazepam (Dalmane): Caution in elderly due to its long half-life (risk of falls and fractures)
caution and CI from triazolam
Triazolam (Halcion): associated with higher rebound insomnia and daytime anxiety; CI with efavirenz (Sustiva), delavirdine (Rescriptor), azole antifungals, PIs, and all 3A4 inhibitors
Benzodiazepines (SE & Monitoring)
Potential for abuse and dependence
SE: drowsiness, dizziness, ataxia, lightheadedness, anterograde amnesia
Withdrawal symptoms when discontinued
which bzds to use in the elderly?
-L-O-T (lorazepam, oxazepam, & temazepam) can be used in elderly
Antihistamines MOA
Block histamine H1 receptors
benadryl, sominex, unisom generic and dose for insomnia
-Diphenhydramine (Benadryl, Sominex, Unisom): 25-50mg QHS
aldex, unisom, generic and dose for insomnia
-Doxylamine (Aldex, Unisom): 25mg QHS
SE of antihitimaines
SE: sedation, confusion, dry mouth, urinary retention, blurry vision, increase IOP, constipation
which population to avoid antihistiamines
Best to Avoid use in elderly and patients with BPH or glaucoma
non benzos over benzo why chose?
non benzo preferred b/c less abuse potential.
parasomnias
common w/ non benzos.
sleepign agents and fatty foods
non benzos and remelton should not be taken w/ fatty food b/c it delays the absorption.
eszoplicone dosing
1 mg if difficulty falling asleep, 2 mg if difficulty staying asleep or 3 mg if helpful for a longer duration of sleep.
non benzos substrates of?
cyp 3A4. so w/ inhibitors need lower dose (erythromycin and itraconazole)
concerns with non benzos (z drugs)
they work the same way as the benzos and can cause increase the risk of death, even if used intermittently, due to issues such as difficulty breathing at night, increased risk of falls, infection and possibly cancer.
how to go from immediate release to control release for a drug
making a drug controlled-release adds about 2.5 mg for each 10 mg of the immediate-release. In this case, it is exactly that amount.
remelton brand and controlled status and MOA
rozerem. non controlled. melatonin receptor agonist instead of gaba.
elderly benzos:
doral and dalman have high fall risk. and triazolam ANOTHER do not use benzo (high rebound insomnia and anxiety- psychiatric effects. slow tapering upon discontinuation and CI.
which bz to use in elderly
Elderly, if using a benzodiazepine, should use L-O-T:
Lorazepam, for sleep or anxiety
Oxazepam, for anxiety
Temazepam, for sleep
diphenhydramine brand names
benadryl and sominexx. recall benadryl can it more difficult to urinate; it will worsen prostate symptoms.
Intermezzo SL what is it useflu for?
is a form of zolpidem that is useful for patients who wake up during the night and need to sleep at least four more hours.
zolpidem other forms
tablet, a spray, a sublingual tab called Edluar and a new sublingual formulation that is for night-time awakening called Intermezzo.
Ambien
Zolpidem
Zolpimist
Zolpidem spray
Edluar
Zolpidem SL tabs
Intermezzo
Zolpidem SL tabs
Sonata
Zaleplon
Lunesta
Eszoplicone
Rozerem
Ramelteon
Silenor
Doxepin ER
Remeron
Mirtazapine (off-label)
Desyrel
Trazodone (off-label)
Sinequan
Doxepin (off-label)
Ativan
Lorazepam
Restoril
Temazepam
Prosom
Estazolam
Doral
Quazepam
Dalmane
Flurazepam
Halcion
Triazolam
Benadryl
Diphenhydramine
Sominex
Diphenhydramine
Unisom
Diphenhydramine
Unisom nighttime
Doxylamine
Aldex
Doxylamine
