Sleep Flashcards
Insomnia
difficulty falling asleep, staying asleep, or nonrestorative sleep
most common sleep disorder
Transient insomnia duration
several days
Short-term insomnia duration
less than 3 months
Chronic insomnia duration
at least 3 nights / week for at least 3 months
Common drugs that can cause insomnia
Alcohol, caffeine, nicotine
Anticholinergics
SSRIs/SNRIs
Alpha blockers
Beta blockers
ACE & ARBs
cholinesterase inhibitors
bronchodilators
CNS stimulants
corticosteroids
decongestants
diuretics
H2RAs
statins
opioids
Treatment of Transient Insomnia
- treatment with adequate bedtime doses of BZDRAs for 2-3 weeks
choice of agent is patient specific
Treatment of Short-Term insomnia
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
Treatment of Long-Term Insomnia
- proper diagnosis of medical/psychiatric cause
- CBT
- if rapid improvement is needed -> CBT + meds
BZDRAs (Benzos)
- 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
BZDRAs (Z drugs)
Eszopiclone (Lunesta)
Zaleplon (Sonata)
Zolpidem (Ambien)
BZDRA class effects
- caution in elderly (inc AUC)
- drowsiness, dizziness, confusion, falls
- avoid use with alcohol
- withdrawal sx upon discontinuation
Estazolam (ProSom)
Use: sleep onset + maintenance insomnia
CI: pregnancy, itraconazole, ketoconazole
ADE: hypokinesia
Eszopiclone (Lunesta)
Z drug
Use: sleep onset + maintenance insomnia (better for maintenance)
ADE: HA, dysgeusia (taste disorder), anxiety, xerostomia, infection GI upset
Food = delayed onset
Zaleplon (Sonata)
Z drug
Use: sleep onset insomnia
ADE: HA, nausea, abdominal pain
high fat meal = delayed absorption
ultra short acting, rapid onset
Zolpidem (Ambien)
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
Trazodone
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
1st Gen antihistamines
Agents: Diphenhydramine, doxylamine
OTC option for mild insomnia
ADE: anticholinergic effects, avoid in elderly, tolerance develops quickly
Suvorexant (Belsomra)
Use: sleep onset + maintenance
ADE: drowsiness, dizziness, HA, sleep paralysis, abnormal dreams, URTI
CI: narcolepsy
Onset of action : < 30 min
Lemborexant (DayVigo)
Use: sleep onset + maintenance
ADE: next day drowsiness, fall risk, HA, complex sleep behaviors, nightmares
CI: narcolepsy
Onset of action: < 30 min
Ramelteon (Rozerem)
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
Melatonin
dose of 3-5 mg in the evening over 4 weeks
Use: sleep onset, shift work, jet lag
CI: autoimmune conditions, Alzheimer’s
Doxepin
TCA
Use: sleep maintenance
BBW: suicidality
Do not take within 3 hrs of a meal (next day sleepiness)
Insomnia pharmacotherapy in the Elderly
- CBT
- Ramelteon
- Eszopiclone
- Zolpidem
- low dose doxepin
Insomnia pharmacotherapy in Pregnancy
- diphenhydramine
- doxylamine
- low dose doxepin
Central Sleep apnea
impairment of respiratory drive
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
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
Narcolepsy
impairment of both onset and offset REM and NREM
Narcolepsy Tetrad: excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis
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)
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
Armodafinil (Nuvigil)
Use: excessive daytime sleepiness (narcolepsy)
ADE: HA, insomnia, dizziness, nausea, xerostomia
Avoid in pregnancy
May decrease effectiveness of contraceptives
Caution in CVD
Solriamfetol (Sunosi)
Use: excessive daytime sleepiness in narcolepsy
ADE: HA, anxiety, insomnia, decreased appetite, nausea
CI: MAOI, unstable CVD
Pitolisant (Wakix)
Use: daytime sleepiness in narcolepsy
ADE: HA, anxiety, musculoskeletal pain, URI, QTc prolongation
CI: hepatic impairment, arrhythmias
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
Meds for Cataplexy in Narcolepsy
REM suppressants
- Fluoxetine (SSRI)
- Venlafaxine (SNRI)
- Atomoxetine (SNRI)
- Clomipramine (TCA)
- Imipramine (TCA)
- Nortriptyline (TCA)
Pitolisant
Sodium oxybate
Jet Lag
Non-pharm: napping, timed light exposure
Meds
- melatonin
- ramelteon
- short acting BZDRAs
take drug at target destination bedtimes
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
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
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
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)
Non pharm treatment of RLS
walking, biking, soaking limbs, leg massage
Treatment for RLS (pharm)
intermittent sx:
- Carbidopa - levodopa
- BZDRA (clonazepam best studied)
Chronic sx:
- pregabalin
- gabapentin
- IR pramipexole
- ropinirole
- rotigotine
