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Therapeutics III > Ott Sleep Disorders > Flashcards

Ott Sleep Disorders Flashcards

1
Q

Disease states, medications, and substances associated with insomnia

A

-Anxiety
-Caffeine
-Modafinil
-Amphetamines
-Beta-agonists
-Bupropion

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2
Q

DSM-5 definition of insomnia disorders

A

-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

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3
Q

Medications used to help sleep onset

A

-Zaleplon
-Traizolam
-Eszopiclone
-Zolpidem
-Ramelteon

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4
Q

Medications used to maintain sleep

A

-Suvorexant
-Doxepin
-Eszopiclone
-Zolpidem

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5
Q

Medications used for both sleep onset and sleep maintenance

A

-Eszopiclone
-Zolpidem
-Temazepam

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6
Q

First-line treatment for insomnia disorders

A

Non-pharmacological - sleep hygiene principles are necessary and should be counseled by the pharmacist (CBT)

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7
Q

Medication treatment for insomnia disorders

A

-Z-hypnotics (most commonly used)
-Temazepam
-Melatonin receptor agonists
-Orexin receptor antagonists
-Doxepin/trazodone
-Mirtazapine/quetiapine
-OTC antihistamines

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8
Q

Z-hypnotic clinical pearls

A

-Initial dose of zolpidem is lower in women and elderly
-Eszopiclone may cause metallic taste
-3A4 substrates
-Somnolence, dizziness, ataxia, headaches
-Can cause parasomnias - unusual actions while a person is sleeping
-Controlled substances - potential for misuse
-Additive effects with other CNS depressants

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9
Q

Temazepam side effects

A

-Drowsiness
-Dizziness
-Cognitive impairment
-Increased fall risk

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10
Q

Melatonin receptor agonists

A

-Ramelteon
-Tasimelteon

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11
Q

Ramelteon clinical pearls

A

-Contraindicated with fluvoxamine
-GI upset
-Next day somnolence
-Hyperprolactinemia
-Prolactinoma
-1A2 substrate

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12
Q

Tasimelteon clinical pearls

A

-FDA approved for non-24 sleep-wake disorder
-1A2 substrate

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13
Q

Orexin receptor antagonists

A

-Suvorexant
-Lemborexant
-Daridorexant

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14
Q

Suvorexant clinical pearls

A

-Allow time for 7 hours of sleep
-Contraindicated in narcolepsy - causes narcolepsy-like side effects
-3A4 substrate

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15
Q

Lemborexant clinical pearls

A

-Allow time for 7 hours of sleep
-Contraindicated in narcolepsy - causes narcolepsy-like side effects
-3A4 substrate

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16
Q

Daridorexant clinical pearls

A

-Allow time for 7 hours of sleep
-Contraindicated in narcolepsy - causes narcolepsy-like side effects
-3A4 substrate

17
Q

Doxepin clinical pearls

A

-TCA - low doses exert effects through H1 receptor antagonism
-Anticholinergic side effects

18
Q

Trazodone clinical pearls

A

-Not FDA-approved for insomnia
-Long half-life - may see daytime hangover

19
Q

When to use mirtazapine

A

Clinically used as a sleep agent, especially in patients with depression who have difficulty sleeping

20
Q

When to use quetiapine

A

Low dose quetiapine is not recommended for use in insomnia unless there is a co-morbid psychiatric disorder

21
Q

Diphenhydramine/doxylamine clinical pearls

A

-Not recommended by AASM
-Anticholinergic side effects - avoid in elderly patients

22
Q

Melatonin/valerian/chamomile clinical pearls

A

-Melatonin can be considered in jet lag and patients with low melatonin levels; 1A2 substrate
-German chamomile can cause allergic reactions in patients with daisy or ragweed allergies

23
Q

DSM-5 criteria for obstructive sleep apnea

A

-Patients must have evidence of at least 5 obstructive apnea per hour of sleep confirmed by polysomnography
-Clinically, there is greater recognition that many patients have both apnea and insomnia - both need to be treated with apnea treated first

24
Q

Obstructive sleep apnea symptoms

A

-Excessive daytime sleepiness
-Snoring
-Pauses in breathing during sleep
-Headache
-Irritability
-sore throat
-Erectile dysfunction
-Impaired memory
-GERD
-Mood disturbances

25
Q

When to use polysomnography

A

Only if there is a significant cardiorespiratory disease, potential respiratory muscle weakness due to a neuro-muscular condition, sleep-related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia

26
Q

Non-pharmacological treatment of sleep apnea

A

-Weight loss, smoking cessation, avoid alcohol and CNS depressants, sleep on side rather than back
-If a patient is overweight/obese and comes for evaluation for insomnia, consider assessment for sleep apnea before initiating medication
-CPAP - continuous positive airway pressure
-Excessive daytime sleepiness can be treated with modafinil or armodafinil - need to review CPAP adherence first and possibility of RLS or PLMS
-When considering treating apnea and insomnia, ensure that the obstructive apnea is addressed before recommending sedative/hypnotic drug therapy

27
Q

The narcolepsy tetrad

A

-EDS
-Cataplexy (sudden loss of muscle tone triggered by emotion)
-Hallucinations
-Sleep paralysis

28
Q

How do you treat cataplexy?

A

-Sodium oxybate (Xyrem) - GHB - high sodium content
-Xywav - for adults and children 7 or older, also approved for idiopathic hypersomnia in adults - lower sodium content
-Lumryz - for adults only - ER dosage form, once nightly dosing, high sodium content

29
Q

How do you treat excessive daytime sleepiness?

A

-Modafinil/armodafinil: associated with possible life-threatening rash
-Sodium oxybate
-Pitolisant and solriamfetol

30
Q

Pitolisant mechanism of action

A

H3 receptor antagonist/inverse agonist

31
Q

Pitolisant clinical pearls

A

-Contraindicated in severe hepatic impairmentand OTC antihistamines
-Prolongs QT interval
-2D6/3A4 substrate
-Weak 3A4 inducer - may reduce effectiveness of oral contraceptives

32
Q

What should not be used with pitolisant?

A

Avoid use with centrally-acting H1 receptor antagonists (OTC antihistamines)

33
Q

Solriamfetol mechanism of action

A

Dopamine norepinephrine reuptake inhibitor

34
Q

Solriamfetol indication

A

Indicated for improvement in wakefulness in adults with excessive daytime sleepiness due to narcolepsy or obsutructive sleep apnea

35
Q

How to dose solriamfetol in patients with moderate renal impairment

A

-Start 37.5 mg
-May increase to 75 mg after at least 7 days

36
Q

How to dose solriamfetol in patients with severe renal impairment

A

Starting and max dose is 37.5 mg

37
Q

Warnings for solriamfetol

A

-Blood pressure and heart rate increases - avoid in unstable cardiovascular disease and arrhythmias
-Use caution in patients with a history of psychosis or bipolar disorder - decrease dose or discontinue if psychiatric symptoms develop
-Use with caution with dopaminergic agents

38
Q

What to use in patients with shift work sleep disorder

A

Modafinil and armodafinil are the drugs of choice, taken 1 hour before the work period starts during “wake time”

39
Q

Which drugs are used in restless leg syndrome?

A

-Gabapentin enacarbil - prodrug of gabapentin, FDA approved for RLS, growing evidence base for effectiveness, may consider first-line
-Dopamine agonists (IR formulation) -pramipexole or ropinirole
-Iron supplementation may be considered

Therapeutics III (42 decks)

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