Ott Sleep Disorders Flashcards
Disease states, medications, and substances associated with insomnia
-Anxiety
-Caffeine
-Modafinil
-Amphetamines
-Beta-agonists
-Bupropion
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
Medications used to help sleep onset
-Zaleplon
-Traizolam
-Eszopiclone
-Zolpidem
-Ramelteon
Medications used to maintain sleep
-Suvorexant
-Doxepin
-Eszopiclone
-Zolpidem
Medications used for both sleep onset and sleep maintenance
-Eszopiclone
-Zolpidem
-Temazepam
First-line treatment for insomnia disorders
Non-pharmacological - sleep hygiene principles are necessary and should be counseled by the pharmacist (CBT)
Medication treatment for insomnia disorders
-Z-hypnotics (most commonly used)
-Temazepam
-Melatonin receptor agonists
-Orexin receptor antagonists
-Doxepin/trazodone
-Mirtazapine/quetiapine
-OTC antihistamines
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
Temazepam side effects
-Drowsiness
-Dizziness
-Cognitive impairment
-Increased fall risk
Melatonin receptor agonists
-Ramelteon
-Tasimelteon
Ramelteon clinical pearls
-Contraindicated with fluvoxamine
-GI upset
-Next day somnolence
-Hyperprolactinemia
-Prolactinoma
-1A2 substrate
Tasimelteon clinical pearls
-FDA approved for non-24 sleep-wake disorder
-1A2 substrate
Orexin receptor antagonists
-Suvorexant
-Lemborexant
-Daridorexant
Suvorexant clinical pearls
-Allow time for 7 hours of sleep
-Contraindicated in narcolepsy - causes narcolepsy-like side effects
-3A4 substrate
Lemborexant clinical pearls
-Allow time for 7 hours of sleep
-Contraindicated in narcolepsy - causes narcolepsy-like side effects
-3A4 substrate
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
