Sleep Flashcards
Pregnancy and hypnotics
Benzos category X slight increase risk cleft palate
CNS depression In neonate
Floppy baby syndrome
Not recommended during brewer feeding - evidence of secretion
Strong inhibitors of which enzyme affect levels of most benzos?
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
Eszopiclone interactions
Eszopiclone is a 3A4 and 2E1 substrate
Zaleplon interactions
Cimetidine increase level- initial dose should be 5mg
Non benzos sleepers and pg (z drugs)
Class c
Don’t breast feed w zaleplon
Ramelteon - category C
Ramelteon interactions
1a2 inhibitors (fluvoxamine) 3a4 inhibitors (keto , fluconazole) Donepezil doubles concn Doxepin increases by 66% Inducers of 1a2 decrease effect
Preferred pregnancy sleeper
Doxylamine
Category B
Not lactation though- no data
Dx confirmed by psg at night followed by mslt during day - what and what are these?
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
Cataplexy signs
Csf hypocretin-1 levels are less than 110 mcg/ml or
1/3 of control values
Dx of sleep apnea Hypopnea syndrome
PSG of 5 or more obstruct apneaa or Hypopnea per hour And subjective sx
Or
15 /hr
Mslt use
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
Ahi and significance
Apnea Hypopnea index
Mild 5-15
Moderate 15-30
Severe > 30
Pharmacotherapy for EDS
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
What NOT to use for OSA
SSRI Methylxanthine Estrogen Nasal decongestants Protriptyline primary therapy
PLMD
Repetitive stereotyped limb movements
Plms index > 15 jerks per minute
Rls dx
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
Coexistence of RLS and PLMD?
Yes PLMD occurs in 80-90% pts with RLS
Interactions with ropinirole
Metabolized by 1A2 Smoking induces metab Fluvoxamine and cipro inhibit Estrogens also reduce clearance Dopamine antag- antipsychotics, metoclopramide, reduce effectiveness
Interactions with pramipexole
Not as significant as ropinirole
Cimetidine inhibits
Dopamine antagonists reduce effectiveness
Tx intermittent RLS sx
Don’t treat PLMD without RLS
RLS meds can be taken as needed -DA agonists, sinemet, low dose BZD , opioids
Tx gl first line RLS
- DA agonists
- Anticonvulsants (gabapentin is the enacarbil form)
- Opioids
- Benzodiazepines
Refractory tx of RLS
- Switch DA agonists
- Change to opioid or anticonvulsant
- Add a 2nd medication
- Consider a drug holiday
- Reserve High potency opioids (methadone) for severe and resistant cases
RLS in pregnancy
Treat iron and folate levels
Opioids may be considered in severe cases. Try to delay tx till 3rd semester
Peds: non pharma
Stevens Johnson syndrome risk drug
Modafinil
Armldafinil
Mslt use
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
What enzyme inhibitor are benzos most affected by?
Strong 3a4 eg itraconazole ketoconazole
FDA approval for sodium oxybate
Treatment of EDS and cateplexy associated with narcolepsy
ADR with sodium oxybate
Dose dependent nv parenthesia sleepwalking feeling drunk Incontience - check for sz
Empty stomach
