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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
Q

Central Sleep apnea

A

impairment of respiratory drive

26
Q

Obstructive Sleep Apnea

A

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
Q

Obstructive Sleep Apnea therapy

A
  • nasal positive airway pressure during sleep (CPAP)
  • weight management
  • avoid CNS depressants and drugs that cause weight gain
  • meds for excessive daytime sleepiness
28
Q

Narcolepsy

A

impairment of both onset and offset REM and NREM

Narcolepsy Tetrad: excessive daytime sleepiness, cataplexy, hallucinations, sleep paralysis

29
Q

Narcolepsy treatment

A

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
Q

Modafinil (Provigil)

A

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
Q

Armodafinil (Nuvigil)

A

Use: excessive daytime sleepiness (narcolepsy)

ADE: HA, insomnia, dizziness, nausea, xerostomia

Avoid in pregnancy

May decrease effectiveness of contraceptives

Caution in CVD

32
Q

Solriamfetol (Sunosi)

A

Use: excessive daytime sleepiness in narcolepsy

ADE: HA, anxiety, insomnia, decreased appetite, nausea

CI: MAOI, unstable CVD

33
Q

Pitolisant (Wakix)

A

Use: daytime sleepiness in narcolepsy

ADE: HA, anxiety, musculoskeletal pain, URI, QTc prolongation

CI: hepatic impairment, arrhythmias

34
Q

Sodium oxybate (Xyrem)

A

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
Q

Meds for Cataplexy in Narcolepsy

A

REM suppressants
- Fluoxetine (SSRI)
- Venlafaxine (SNRI)
- Atomoxetine (SNRI)
- Clomipramine (TCA)
- Imipramine (TCA)
- Nortriptyline (TCA)

Pitolisant

Sodium oxybate

36
Q

Jet Lag

A

Non-pharm: napping, timed light exposure

Meds
- melatonin
- ramelteon
- short acting BZDRAs

take drug at target destination bedtimes

37
Q

Shift Work Disorder

A

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
Q

Parasomnias

A

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
Q

Restless Legs Syndrome (RLS)

A

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
Q

Possible causes of RLS

A
  • 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
Q

Non pharm treatment of RLS

A

walking, biking, soaking limbs, leg massage

42
Q

Treatment for RLS (pharm)

A

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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