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Therapeutics P3 Fall > Sleep > Flashcards

Sleep Flashcards

1
Q

Insomnia

A

difficulty falling asleep, staying asleep, or nonrestorative sleep
most common sleep disorder

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2
Q

Transient insomnia duration

A

several days

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3
Q

Short-term insomnia duration

A

less than 3 months

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4
Q

Chronic insomnia duration

A

at least 3 nights / week for at least 3 months

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5
Q

Common drugs that can cause insomnia

A

Alcohol, caffeine, nicotine
Anticholinergics
SSRIs/SNRIs
Alpha blockers
Beta blockers
ACE & ARBs
cholinesterase inhibitors
bronchodilators
CNS stimulants
corticosteroids
decongestants
diuretics
H2RAs
statins
opioids

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6
Q

Treatment of Transient Insomnia

A
  • treatment with adequate bedtime doses of BZDRAs for 2-3 weeks

choice of agent is patient specific

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7
Q

Treatment of Short-Term insomnia

A

Goal: treatment plan that will result in normal sleep with no meds

  • correct underlying sleep complaint
  • good sleep hygiene
  • sleep diary
  • treatment with adequate bedtime doses of BZDRAs for 2-3 weeks which may be followed by
    – reduction of dose for 2-3 weeks
    – QOD dosing for 2-3 weeks
    – PRN supply
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8
Q

Treatment of Long-Term Insomnia

A
  • proper diagnosis of medical/psychiatric cause
  • CBT
  • if rapid improvement is needed -> CBT + meds
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9
Q

BZDRAs (Benzos)

A
  • Estazolam (ProSom)
  • Fluazepam (Dalmane)
  • Quazepam (Doral)
  • Temazepam (Restoril)
  • Triazolam (Halcion)

BBW: concurrent opioid use -> sedation / resp depression, risk of dependence

CI: sleep apnea, substance abuse

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10
Q

BZDRAs (Z drugs)

A

Eszopiclone (Lunesta)
Zaleplon (Sonata)
Zolpidem (Ambien)

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11
Q

BZDRA class effects

A
  • caution in elderly (inc AUC)
  • drowsiness, dizziness, confusion, falls
  • avoid use with alcohol
  • withdrawal sx upon discontinuation
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12
Q

Estazolam (ProSom)

A

Use: sleep onset + maintenance insomnia

CI: pregnancy, itraconazole, ketoconazole

ADE: hypokinesia

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13
Q

Eszopiclone (Lunesta)

A

Z drug

Use: sleep onset + maintenance insomnia (better for maintenance)

ADE: HA, dysgeusia (taste disorder), anxiety, xerostomia, infection GI upset

Food = delayed onset

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14
Q

Zaleplon (Sonata)

A

Z drug

Use: sleep onset insomnia

ADE: HA, nausea, abdominal pain

high fat meal = delayed absorption

ultra short acting, rapid onset

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15
Q

Zolpidem (Ambien)

A

Z drug

Use: Sleep maintenance (ER tablet), Sleep onset (IR tab/spray, ER tablet), trouble returning to sleep (SL tablet)

CI: hepatic impairment

ADE: HA, nausea

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16
Q

Trazodone

A

Use: Off label sleep maintenance
- useful in pats with Hx of substance abuse / depression

ADE: carryover sedation, alpha adrenergic blockade, orthostasis (caution in elderly)

BBW: suicidal thoughts and actions

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17
Q

1st Gen antihistamines

A

Agents: Diphenhydramine, doxylamine
OTC option for mild insomnia
ADE: anticholinergic effects, avoid in elderly, tolerance develops quickly

18
Q

Suvorexant (Belsomra)

A

Use: sleep onset + maintenance

ADE: drowsiness, dizziness, HA, sleep paralysis, abnormal dreams, URTI

CI: narcolepsy

Onset of action : < 30 min

19
Q

Lemborexant (DayVigo)

A

Use: sleep onset + maintenance

ADE: next day drowsiness, fall risk, HA, complex sleep behaviors, nightmares

CI: narcolepsy

Onset of action: < 30 min

20
Q

Ramelteon (Rozerem)

A

Use: sleep onset

ADE: HA, dizziness somnolence

CI: fluvoxamine

Onset of action: 30 min

approved for long term use

not as effective in patients who have already trialed a BZDRA

21
Q

Melatonin

A

dose of 3-5 mg in the evening over 4 weeks

Use: sleep onset, shift work, jet lag

CI: autoimmune conditions, Alzheimer’s

22
Q

Doxepin

A

TCA
Use: sleep maintenance
BBW: suicidality
Do not take within 3 hrs of a meal (next day sleepiness)

23
Q

Insomnia pharmacotherapy in the Elderly

A
  • CBT
  • Ramelteon
  • Eszopiclone
  • Zolpidem
  • low dose doxepin
24
Q

Insomnia pharmacotherapy in Pregnancy

A
  • diphenhydramine
  • doxylamine
  • low dose doxepin
25
Central Sleep apnea
impairment of respiratory drive
26
Obstructive Sleep Apnea
upper airway collapse and obstruction multiple episodes of airway closure and cessation of breathing + awakenings per hour increases risk of comorbid conditions: CV, stroke, depression
27
Obstructive Sleep Apnea therapy
- nasal positive airway pressure during sleep (CPAP) - weight management - avoid CNS depressants and drugs that cause weight gain - meds for excessive daytime sleepiness
28
Narcolepsy
impairment of both onset and offset REM and NREM Narcolepsy Tetrad: excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis
29
Narcolepsy treatment
Non-pharm: good sleep hygiene and scheduled daytime naps Avoid drugs that cause daytime sleepiness (benzos, opiates, antipsychotics, alcohol) Treat daytime sleepiness, cataplexy, and REM abnormalities: - Modafinil or armodafinil (EDS) - TCAs, SNRIs, and SSRIs (cataplexy)
30
Modafinil (Provigil)
Use: excessive daytime sleepiness (narcolepsy) ADE: HA, nausea, anxiety, dizziness, dyspepsia, xerostomia, back pain, rhinitis Avoid in pregnancy May decrease effectiveness of contraceptives Caution in CVD
31
Armodafinil (Nuvigil)
Use: excessive daytime sleepiness (narcolepsy) ADE: HA, insomnia, dizziness, nausea, xerostomia Avoid in pregnancy May decrease effectiveness of contraceptives Caution in CVD
32
Solriamfetol (Sunosi)
Use: excessive daytime sleepiness in narcolepsy ADE: HA, anxiety, insomnia, decreased appetite, nausea CI: MAOI, unstable CVD
33
Pitolisant (Wakix)
Use: daytime sleepiness in narcolepsy ADE: HA, anxiety, musculoskeletal pain, URI, QTc prolongation CI: hepatic impairment, arrhythmias
34
Sodium oxybate (Xyrem)
Use: extreme daytime sleepiness and cataplexy in narcolepsy ADE: confusion, HA, dizziness, weight loss, decreased appetite, urinary incontinence, drowsiness, somnambulism, anxiety dosed at bedtime after patient is in bed with second dose 2.5 - 4 hrs later BBW: CNS depression, abuse, restricted access
35
Meds for Cataplexy in Narcolepsy
REM suppressants - Fluoxetine (SSRI) - Venlafaxine (SNRI) - Atomoxetine (SNRI) - Clomipramine (TCA) - Imipramine (TCA) - Nortriptyline (TCA) Pitolisant Sodium oxybate
36
Jet Lag
Non-pharm: napping, timed light exposure Meds - melatonin - ramelteon - short acting BZDRAs take drug at target destination bedtimes
37
Shift Work Disorder
Non-pharm: sleep scheduling, sleep hygiene, naps, exposure to bright lights at night and darkness during day Meds: - melatonin - ramelteon - short acting BZDRAs - Modafinil and armodafinil to improve wakefulness
38
Parasomnias
abnormal behavior during sleep: sleep walking, sleep driving, nightmares can be worsened by taking Z drugs with alcohol or antidepressants Treatment: - safety latches - Benzos, SSRIs, TCAs - reduce stress, anxiety, and sleep dep for nightmares
39
Restless Legs Syndrome (RLS)
Paresthesias felt deep in the calf muscles, thighs, and arms with an urge to keep limbs in motion. Often bilateral. - temporarily relieved by movement
40
Possible causes of RLS
- iron deficiency - Vitamin B or folate deficiency - caffeine and alcohol use - centrally acting antihistamines (meclizine, hydroxyzine, diphenhydramine, doxylamine) -- loratadine preferred - antidepressants -> use Bupropion - antipsychotics - antinausea drugs (metoclopramide, promethazine)
41
Non pharm treatment of RLS
walking, biking, soaking limbs, leg massage
42
Treatment for RLS (pharm)
intermittent sx: - Carbidopa - levodopa - BZDRA (clonazepam best studied) Chronic sx: - pregabalin - gabapentin - IR pramipexole - ropinirole - rotigotine

Therapeutics P3 Fall (21 decks)

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