Meds for insomnia and sleep disorders

Question 1

OTC products

Answer 1

• Diphenhydramine HCL
• Doxylamine Succinate
• Melatonin
• Herbals -> valerian root, chamomile tea, and hemp gummies

Question 2

Benzodiazepines (BZN)

Answer 2

Longer acting - Positive GABA-A allosteric modulators
- Estazolam (Prosom)
- Quazepam (Doral)
- Temazepam (Restoril)
- Flurazepam (Dalmane)

Question 3

Z drugs

Answer 3

Shorter acting - Alpha 1 subunit of GABA-A agonist
- Eszopiclone (Lunesta)
- Zaleplon (Sonata)
- Zolpidem (Ambien)

Question 4

Risk/Benefits of BNZ and Z drugs

Answer 4

Benefits:
- Fast onset to decrease sleep latency
- Long acting to decrease nocturnal awakenings
Risks:
- Rebound insomnia after discont.
- Anterograde Amnesia
- Physical/psychological dependency
- Residual daytime sedation
- Dose related SE greater for females

Question 5

TCAs

Answer 5

• Doxepin (Silenor)
• Used to reduce frequency of nocturnal awakenings
• MOA: HIstamine1 antagonist
• ADRs: Daytime sedation, anticholinergic SE
• CI: Do not use Monoamine Oxidase Inhibitors depressants within 14 days

Question 6

DORA

Answer 6

• Datidorexant (Quviviq)
  Onset 35-40 min; T1/2 = 8 hours
• Duvorexant (Belsomra)
  Onset 30 min; T1/2 = 12 hours
• Lemborexant (DayVigo)
  Onset 15-20 min; T1/2 = 17-19 hours

Question 7

Melatonin MT1/MT2 agonist

Answer 7

Ramelteon (Rozerem) - short term option

Question 8

Meds for shift work sleep disorder (SWSD)

Answer 8

• Modafinil (Provigil)
  
  • Decreases GABA activity
• Armodafinil (Nuvigil)

Question 9

Meds for narcolepsy (excessive daytime sleepiness)

Answer 9

Psychostimulants
- Methylphenidate (Ritalin)
- Amphetamine mixed salts (adderall)
- Modafinil (Provigil)
- Armodafinil (Nuvigil)
- Solriamfetol (Sunosi) -> dopamine/NE reuptake inhibitor
- Pitolisant (Wakix) -> Histamine-3 antagonist/inverse agonist

Question 10

Narcolepsy with Cataplexy

Answer 10

• Gamma hydroxybutyrate (GHB)
  
  • Sodium Oxybate (Xyrem)
  • Ca, mg, K, and sodium oxbates
    (xywav)
  • Sodium Oxybate ER susp
    (lumryz)
• Pitolisant (Wakix)

Question 11

Treatment for sleep apnea

Answer 11

• CPAP -> 1st line
• Solriamfetol (Sunosi)

Question 12

Treatment for RLS and PLM (periodic limb movements)

Answer 12

• Consider starting with gabapentin
• Ropinirole (Requip)
• Pramipexole (Mirapex)
• Rotigotine (Neupro) - Dopamine agonist