Ott Sleep Disorders Flashcards by Corey Brend

Disease states, medications, and substances associated with insomnia

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

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DSM-5 definition of 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

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Medications used to help sleep onset

-Zaleplon
-Traizolam
-Eszopiclone
-Zolpidem
-Ramelteon

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Medications used to maintain sleep

-Suvorexant
-Doxepin
-Eszopiclone
-Zolpidem

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Medications used for both sleep onset and sleep maintenance

-Eszopiclone
-Zolpidem
-Temazepam

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First-line treatment for insomnia disorders

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

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Medication treatment for insomnia disorders

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

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Z-hypnotic clinical pearls

-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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Temazepam side effects

-Drowsiness
-Dizziness
-Cognitive impairment
-Increased fall risk

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Melatonin receptor agonists

-Ramelteon
-Tasimelteon

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Ramelteon clinical pearls

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

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Tasimelteon clinical pearls

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

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Orexin receptor antagonists

-Suvorexant
-Lemborexant
-Daridorexant

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Suvorexant clinical pearls

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

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Lemborexant clinical pearls

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

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Daridorexant clinical pearls

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

Doxepin clinical pearls

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

Trazodone clinical pearls

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

When to use mirtazapine

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

When to use quetiapine

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

Diphenhydramine/doxylamine clinical pearls

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

Melatonin/valerian/chamomile clinical pearls

-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

DSM-5 criteria for obstructive sleep apnea

-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

Obstructive sleep apnea symptoms

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

When to use polysomnography

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

Non-pharmacological treatment of sleep apnea

-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

The narcolepsy tetrad

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

How do you treat cataplexy?

-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

How do you treat excessive daytime sleepiness?

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

Pitolisant mechanism of action

H3 receptor antagonist/inverse agonist

Pitolisant clinical pearls

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

What should not be used with pitolisant?

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

Solriamfetol mechanism of action

Dopamine norepinephrine reuptake inhibitor

Solriamfetol indication

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

How to dose solriamfetol in patients with moderate renal impairment

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

How to dose solriamfetol in patients with severe renal impairment

Starting and max dose is 37.5 mg

Warnings for solriamfetol

-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

What to use in patients with shift work sleep disorder

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

Which drugs are used in restless leg syndrome?

-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