Sleep

Question 0

Pregnancy and hypnotics

Answer 0

Benzos category X slight increase risk cleft palate
CNS depression In neonate
Floppy baby syndrome
Not recommended during brewer feeding - evidence of secretion

Question 1

Strong inhibitors of which enzyme affect levels of most benzos?

Answer 1

3A4
Eg ketoconazole itracon not with triazolam or estaxolam
Flurazepam shouldn’t be used with protease inhibitors (ritonavir) or nefazodone
Triazolam contraindicated with atazanavir keto itra nefazodone riton

Question 2

Eszopiclone interactions

Answer 2

Eszopiclone is a 3A4 and 2E1 substrate

Question 3

Zaleplon interactions

Answer 3

Cimetidine increase level- initial dose should be 5mg

Question 4

Non benzos sleepers and pg (z drugs)

Answer 4

Class c
Don’t breast feed w zaleplon
Ramelteon - category C

Question 5

Ramelteon interactions

Answer 5

1a2 inhibitors (fluvoxamine)
3a4 inhibitors (keto , fluconazole)
Donepezil doubles concn
Doxepin increases by 66%
Inducers of 1a2 decrease effect

Question 6

Preferred pregnancy sleeper

Answer 6

Doxylamine
Category B
Not lactation though- no data

Question 7

Dx confirmed by psg at night followed by mslt during day - what and what are these?

Answer 7

Narcolepsy
PSG =overnight test while subject is sleeping; records multiple measurements (heart rate RR brain and muscle electrical activity)
MSLT= objective series of daytime tests q 2 hrs following this night of recorded electrical activity
Then sleep onset - healthy Indians 10-20 min; narcoleptics=8 min or less sleep onset

Question 8

Cataplexy signs

Answer 8

Csf hypocretin-1 levels are less than 110 mcg/ml or

1/3 of control values

Question 9

Dx of sleep apnea Hypopnea syndrome

Answer 9

PSG of 5 or more obstruct apneaa or Hypopnea per hour And subjective sx
Or
15 /hr

Question 10

Mslt use

Answer 10

Usually in dx narcolepsy - usually takes 10-20 min to fall asleep, OSA pts in 5-10 min
MWT maintenance of wakefulness test - similar to mslt but goal for pt to stay wake

Question 11

Ahi and significance

Answer 11

Apnea Hypopnea index
Mild 5-15
Moderate 15-30
Severe > 30

Question 12

Pharmacotherapy for EDS

Answer 12

Secondary after CPAP and weight loss
Modafinal/armldafinil
Nasal steroids if rhinitis
Protriptyline - not much evidence. In theory suppresses REM sleep via inhibition of 5-HT and NE reuptake

Question 13

What NOT to use for OSA

Answer 13

SSRI
Methylxanthine
Estrogen
Nasal decongestants
Protriptyline primary therapy

Question 14

PLMD

Answer 14

Repetitive stereotyped limb movements

Plms index > 15 jerks per minute

Question 15

Rls dx

Answer 15

RLS which has “creepy crawly” sensations relieved by movement, in clusters of a few minutes up to hours , movements every 20-40 sec
Forceful leg jerks
Ferritin levels less than 50 ng/ml assoc with greater severity RLS

Question 16

Coexistence of RLS and PLMD?

Answer 16

Yes PLMD occurs in 80-90% pts with RLS

Question 17

Interactions with ropinirole

Answer 17

Metabolized by 1A2
Smoking induces metab
Fluvoxamine and cipro inhibit
Estrogens also reduce clearance
Dopamine antag- antipsychotics, metoclopramide, reduce effectiveness

Question 18

Interactions with pramipexole

Answer 18

Not as significant as ropinirole
Cimetidine inhibits
Dopamine antagonists reduce effectiveness

Question 19

Tx intermittent RLS sx

Answer 19

Don’t treat PLMD without RLS

RLS meds can be taken as needed -DA agonists, sinemet, low dose BZD , opioids

Question 20

Tx gl first line RLS

Answer 20

1. DA agonists
2. Anticonvulsants (gabapentin is the enacarbil form)
3. Opioids
4. Benzodiazepines

Question 21

Refractory tx of RLS

Answer 21

1. Switch DA agonists
2. Change to opioid or anticonvulsant
3. Add a 2nd medication
4. Consider a drug holiday
5. Reserve High potency opioids (methadone) for severe and resistant cases

Question 22

RLS in pregnancy

Answer 22

Treat iron and folate levels
Opioids may be considered in severe cases. Try to delay tx till 3rd semester

Peds: non pharma

Question 23

Stevens Johnson syndrome risk drug

Answer 23

Modafinil

Armldafinil

Question 24

Mslt use

Answer 24

Usually in dx narcolepsy - usually takes 10-20 min to fall asleep, OSA pts in 5-10 min
MWT maintenance of wakefulness test - similar to mslt but goal for pt to stay wake

Question 25

What enzyme inhibitor are benzos most affected by?

Answer 25

Strong 3a4 eg itraconazole ketoconazole

Question 26

FDA approval for sodium oxybate

Answer 26

Treatment of EDS and cateplexy associated with narcolepsy

Question 27

ADR with sodium oxybate

Answer 27

Dose dependent nv parenthesia sleepwalking feeling drunk Incontience - check for sz
Empty stomach