Lecture 4 - Insomnia Flashcards by Patryk Lasiuk

Risk factors for insomnia

Women
advancing age
Comorbid conditions = pulmonary, neurologic disease, HF
some meds = corticosteroids, stimulant, withdrawal
stressors

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Primary insomnia

no clear cause, abnormality of sleep-wake cycle or circadian rhythm

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Secondary insomnia

due to other factors

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secondary insomnia meds

anticonvulsants
stimulants
antidepressants
diuretics
central adrenergic blockers
corticosteroids
opioids
substance withdrawal

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Acute vs Chronic insomnia

Acute = < 3 months
Chronic = > 3 months

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initial insomnia

difficulty falling asleep
inc time ( >30min) to sleep onset

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Middle insomnia

difficulty maintaining sleep
frequent awakenings during the night

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Terminal insomnia

early morning awakening
total sleep time < 6hs
common in depression

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Excessive daytime sleepiness & non-restorative sleep

results in fatigue throughout the day

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3 components of CBT-I

Education
Cognitive therapy
Behavioral therapy

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1st line therapy for insomnia

CBT-I

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negative of sleep restriction therapy

will cause day time sleepiness for people

adjust sleep time based on amount of time it takes to fall asleep

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who shouldn’t use sleep restriction therapy?

seizure disorders

little sleep can lower seizure threshold

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Who can use Somryst

> 22 yrs old w/ chronic insomnia
have access to mobile device + app
under supervision of HCP

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Who shouldn’t use Somryst

pts w/ bipolar, schiz disorder
pts w/ untreated OSS
pts w/ epilepsy, high risk falls, pregnant, parasomnias
pts w/ stuff thats worsened by less sleep

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Sleep Hygiene

Set regular time to go to bed
avoid napping
avoid watching TV,working, eating in bed
dont exercise within 6hrs of bedtime
avoid ehavy/spicy food in evening
avoid drinking lots of fluid in evening
minimize tobacco, caffeine, alc in evening

Cognitive Therapy (CBT-I)

change dysfunctional beliefs about sleep
reduce anxiety surrounding sleep
confront fear of not sleeping

Stimulus control therapy

only go to bed when tired
only use bed for sleep and sex
avoid daytime naps
schedule “worry time” during day
avoid lighted screens before bed
hide clock
set alarm same time every morning

relaxation training (CBT-I)

deep breathing
meditation
mindfulness therapies

1st gen antihistamine for sleep

Diphenhydramine + doxylhamine

ADE: anticholinergic
DI: sedating agents, other anticholinergic, alc
Precaution: CNS depression, BPG, glaucoma
Monitor: improve sleep n ADE

Pt ed: can cause grogginess next morning

tolerance quickly, not good for chronic insomnia ( ~ 10 days)
not best in older adults or liver disease
Doxylamine safe for pregnancy

Herbal products for insomnia

Tryptophan

Valerian- 3-4wk for benefit

Melatonin info

Take 30min before bedtime
OTC not FDA approved

** most helpful pts w/ Jet lag, delayed sleep phase syndrome or low melatonin**
** may help w/ sleep onset**

safe for short-term use

Ramelteon (Rozerem)

8mg 30min before bed (not after high-fat meal)
CI strong CYP1A2 inhib (Fluvoxamine)
$$$, 3 wks for effect, helpful in elderly
melatonin receptor agonist

Benzos for Insomnia

Triazolam (Halcion) + Temazepam (Restoril)

Temazepam = longer acting, help with maintenance
Triazolam = good for onset

Benzo insomna prestations

should be used for no more than 7-10 days tolerance likely within ~4 weeks, (2wks w/ Triazolam) can have rebound insomnia once stop ** Dont use w/ sleep apnea, substance use disorder, pregnancy ** ** Inc risk of falls n hip fractures in elderly ** reduces sleep latency, inc stage 2 sleep, reduces stages 3,4, & REM sleep, inc total sleep time

which drugs work on GABA A subunit?

Z-drugs

Zaleplon (Sonata) Zolpidem (Ambien) Eszopiclone (Lunesta)

Zolpidem info

women req lower starting dose than men Highest affinity for alpha-1 subunit

Eszopiclone info

max of 2mg in hepatic impairment or use with CYP3A4 inhibitors

Z-drugs used for onset vs maintenance

onset = Zaleplon Maintenance = Zolpidem, Eszopiclone

Z-drug patient education

devote >7-8h to sleep for zolpidem ER/eszopiclone if using Zaleplon or Zolpidem SL for middle of night awakenings, ensure has >4h of sleep take on empty stomach, food delays absorption risk of complex sleep-related behaviors, tell doc if they occurs impairment maybe present even if feeling awake

Z-drug clinical considerations

possibly less tolerance and less rebound insomnia should limit to < 4 wk to dec risk of tolerance and dependence eszopiclone FDA approved for up to 6 months

Trazadone for insomnia

good for onset and maintenance can improve sleep continuity not FDA approved low dose = 25mg

Doxepin (Silenor) for insomnia

FDA approved for insomnia good for sleep maintenance 3-6mg empty stomach w/in 30min bedtime

Mirtazapine for insomnia

7.5-15mg QHS not FDA approved good option if pt has depression/anxiety

Dual Orexin Receptor Antagonist (DORA)

Suvorexant (Belsomra) Lemborexant (Dayvigo) Daridorexant (Quviviq)

DORA info

issues with liver dysfunction + CYP3A4 Precaution: pts with depression CI: pt with narcolepsy monitor insomnia six after 7-10 days avoid alc, faster onset taken w/o meal, next day somnolence