Lecture 61 - Pharmacotherapy of Sleep Disorders Flashcards
DISEASE STATES, MEDICATIONS, SUBSTANCES ASSOCIATED WITH INSOMNIA
anxiety, caffeine, modafinil, amphetamines, beta-agonists, beta blockers, nicotine, thyroid meds, mood disorders, bupropion, decongestants, methylphenidate
DSM‐5 – INSOMNIA DISORDERS
Difficulties with sleep initiation (latency), sleep maintenance, and/or early‐morning awakening
Takes place at least 3 nights per week
Present for at least 3 months
MEDICATION CHOICES BASED ON SLEEP COMPLAINTS
sleep onset only
sleep maintenance only
sleeo onset and sleep maintenance
Sleep onset only
zaleplon, triazolam, eszopiclone, zolpidem, ramelteon
Sleep maintenance only
suvorexant, doxepin, eszopiclone, zolpidem
Sleep onset and sleep maintenance
eszopiclone, zolpidem, temazepam
TREATMENT OF INSOMNIA DISORDERS
1st line treatment is non-pharmacological: Sleep hygiene principles are necessary and should be counseled by the pharmacist
The z‐hypnotics (zolpidem, eszopiclone, zaleplon) are the most commonly used sleep medications: * Initial dose of zolpidem is lower in women and elderly – 5 mg
* Eszopiclone (Lunesta®) is FDA‐approved for long‐term (6 months) use – patients
complain of metallic taste
* 3A4 substrates – metabolism is impacted by 3A4 inhibition and induction
* Somnolence, dizziness, ataxia, headaches
* Can cause parasomnias – unusual actions while a person is sleeping – is a warning on all medications used for sleep
* Controlled substances – potential for misuse
* Additive effects with other CNS depressants
Benzodiazepines can be used for insomnia
*Temazepam is the benzodiazepine used for sleep
*Drowsiness, dizziness, cognitive impairment, increased fall risk
All medications FDA‐approved for insomnia have sleep behaviors warning
Melatonin Receptor Agonists
Ramelteon: Contraindicated with
fluvoxamine; GI upset, next day somnolence, hyperprolactinemia, prolactinoma
Tasimelteon: FDA‐approved for non‐24 sleep‐ wake disorder in adults
1A2 substrates: watch for 1A2 inducers and inhibitors
OREXIN RECEPTOR ANTAGONISTS (C‐IV)
suvorexant
lemborexant
daridorexant
Suvorexant
- 10 mg within 30 minutes of bedtime and at least 7 hours to sleep
- Contraindicated in narcolepsy – causes
narcolepsy‐like side effects - 3A4 substrate
Lemborexant
- 5 mg at bedtime with at least 7 hours to sleep
- Contraindicated in narcolepsy - causes narcolepsy like side effects
- 3A4 substrate
Daridorexant
- 25 mg at bedtime with at least 7 hours to sleep
- Contraindicated in narcolepsy – causes narcolepsy‐like side effects
- 3A4 substrate
Doxepin
- TCA - low doses exert effect through H1 receptor antagonism
- Anticholinergic side effects
Trazodone
- Not FDA approved for insomnia
- Long half-life may see daytime hangover