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701 > Sleep > Flashcards

Sleep Flashcards

1
Q

What part of the brain controls the biological clock?

A

Suprachiasmatic nucleus

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2
Q

What are sleep cycles?

A
  • 4-6 each night
  • Back and forth between NREM and REM sleep
  • Last about 70-120 minutes
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3
Q

What are the 4 stages of sleep

A
  1. NREM stage 1: 5-10 minutes of falling asleep
  2. NREM stage 2: HR, temp drops, sleep spindles produced
  3. NREM stage 3: muscles relax, BP + RR drop (deepest sleep)
  4. REM sleep: brain active, dreaming, eye movement, muscles paralyzed
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4
Q

Sleep spindles

A

Allow us to sleep through loud noises and disturbances (stage 2)

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5
Q

K-complexes

A

Allow for sleep-based memory consolidation (stage 2)

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6
Q

Delta waves

A

Slow wave sleep, difficult to awaken from (stage 3 deep sleep)

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7
Q

What chemicals modulate wakefulness?

A
  • NE
  • ACh
  • Histamine
  • Serotonin
  • Dopamine
  • Orexin/hypocretin
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8
Q

What chemicals modulate sleepiness?

A
  • Adenosine
  • GABA
  • Melatonin
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9
Q

What chemicals modulate NREM sleep?

A
  • GABA
  • Adenosine
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10
Q

What chemical modulates REM sleep?

A

ACh

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11
Q

S/S of sleep disorders

A
  • EDS
  • Impaired daytime functioning
  • Irregular breathing
  • Increased movement during sleep
  • Irregular sleep/wake cycle
  • Difficulty falling asleep
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12
Q

Insomnia

A

Persistent sleep difficulty, adequate sleep opportunity, and associated daytime function
- Most common
- Difficulty falling asleep, staying asleep, or feeling restored from sleep
- Women 2x likely than men

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13
Q

Insomnia categories

A

Several days: transient insomnia
<3 months: short-term insomnia
At least 3 nights per week for >3 months: chronic insomnia

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14
Q

Common insomnia-worsening drugs

A
  • Alcohol, caffeine, nicotine
  • Anticholinergics
  • SSRIs/SNRIs*** (could be short term)
  • BBs, alpha blockers
  • ACEi/ARBs
  • Cholinesterase inhibitors
  • Bronchodilators
  • CNS stimulants
  • Steroids
  • Decongestants
  • Diuretics
  • H2RAs
  • Statins
  • Opioids***
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15
Q

Treatment for transient/short term insomnia?

A

Correct underlying problem, avoid medication ADEs
- Sleep diary?
- Good sleep hygiene
- Avoid napping, regular schedule
- Short term use of medication

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16
Q

First line therapy for long-term insomnia?

A

Cognitive behavioral therapy (+/- medications)
- Initial CBT-I + medication taper if quick improvement is necessary

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17
Q

What are reasons to avoid first-line BZRAs?

A
  • Older age
  • Cognitive dysfunction
  • Opioid use
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18
Q

BZRAs

A
  • Most common insomnia treatment
  • Agonist of GABA
  • Always take before bedtime
  • Caution in the elderly (drowsiness, confusion, risk of falls)
  • Avoid with alcohol, opioids
  • Withdrawal upon discontinuation (tremors, muscle cramps, seizures)
  • All Z drugs are FDA approved for sleep, but not all benzos
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19
Q

Benzodiazepines

A
  • Reduce sleep latency
  • Increase stage 2, decrease delta
  • Dose-dependent side effects
  • Caution in sleep-apnea/substance abuse
  • Anxiolytic
  • Beer’s list strong recommendation
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20
Q

Nonbenzodiazepine GABA agonists (Z drugs)

A
  • More selective
  • Increase total sleep time
  • Less disruptive of sleep stages
  • Less withdrawal/tolerance/rebound
  • Parasomnic episodes with amnesia (sleep walking, driving, etc)***
  • Beer’s list strong recommendation
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21
Q

Benzo BBWs

A
  • Use with opioids
  • Abuse potential
  • Physical dependence
22
Q

Z-drugs BBW

A

Sleep behaviors (parasomnic episodes) -> DISCONTINUE IMMEDIATELY

23
Q

Which BZRAs have quick onset?

A
  • Flurazepam
  • Zolpidem
  • Zaleplon
  • Eszopiclone
24
Q

Which BZRAs have long half lives?

A
  • Quazepam
  • Temazepam
  • Estazolam
25
Q

Eszopiclone

A
  • CIV
  • Rapid absorption -> approved for sleep-onset (delayed with food)
  • Good for sleep maintenance or early morning awakenings (approved for maintenance)
  • Duration 6-9 hours
  • Major CYP3A4
26
Q

Zaleplon

A
  • CIV
  • Ultra-short acting rapid onset (delayed with high fat meal)
  • Approved for short-term insomnia (max 30 days)
  • Duration 3-4 hours
  • Major CYP3A4
27
Q

Zolpidem

A
  • CIV
  • Rapid onset, short half-life
  • Many formulations with different dosing/indications
  • take immediately HS and plan 7-8 sleep except for intermezzo SL tablet
28
Q

Zolpidem formulations

A
  • Intermezzo SL tab: middle-of-night awakening
  • Ambien CR (ER) tab: sleep onset or maintenance
  • Edluar SL tab: sleep onset (off label sleep maintenance)
  • Ambien (IR) tab: sleep onset (off label sleep maintenance)
  • Generic IR cap: sleep onset (off label sleep maintenance) -> use 7.5mg if 5mg of another product is ineffective
29
Q

DORAs

A
  • CIV
  • suvorexant, lemborexant, daridorexant
  • turns off wake signaling, approved sleep onset or maintenance
  • Take HS plan 7h
  • CYP3A4
  • CI in narcolepsy
30
Q

Suvorexant (Belsomra)

A
  • Onset <30 min
  • Long half life 12h
  • CYP3A4
  • ADE sleep paralysis, abnormal dreams***
31
Q

Lemborexant (DayVigo)

A
  • Onset <30 min
  • Long half life 17-19 hours
  • CYP3A4
  • Next day drowsiness, increased falling risk (effects persist)
  • ADE complex sleep behaviors, abnormal dreams
32
Q

Daridorexant (Quviviq)

A
  • Onset 30 min
  • Fair half life 8h
  • CYP3A4
  • Onset delayed with food
  • ADE complex sleep behaviors, hallucinations, sleep paralysis
33
Q

Ramelteon (Rozeram)

A

Melatonin receptor agonist
- M1 induces sleep, M2 regulates circadian rhythm
- Onset 30 min
- Short half life 1-2.6h
- Approved for sleep onset + long term use
- Not as effective for patients who took BZRAs
- Noncontrol!
- Ci with fluvoxamine (CYP1A2)
- Less rebound and abuse potential

34
Q

Doxepin

A
  • TCA
  • Low dose for sleep maintenance
  • Do not take within 3 hours of a meal
  • BBW for suicidality but it’s a low dose
35
Q

Melatonin

A
  • Beneficial effects on sleep-onset latency, shift workers, jet lag
  • Avoid in autoimmune conditions
  • Not recommended in Alzheimer’s
36
Q

First-generation antihistamines

A
  • Diphenhydramine, doxylamine
  • OTC
  • Avoid in older adults (Beer’s list)
  • Quick tolerance to sedation
  • Anticholinergic ADEs
37
Q

Trazodone

A
  • OFF LABEL for sleep continuity
  • May be useful in patients with substance abuse hx or depression (non-control)
  • ADE of carryover sedation and alpha adrenergic blockade (orthostasis for elderly)
  • Taper off 2-4 weeks when discontinuing
38
Q

Best meds for elderly insomnia

A
  • Ramelteon* (sleep onset)
  • Low-dose doxepin* (sleep maintenance)
39
Q

Pregnancy

A
  • Diphenhydramine
  • Doxylamine
  • Low-dose doxepin
40
Q

Sleep apnea treatment

A
  • Behavior modification (weight loss, alter position, avoid alcohol/sedatives)
  • Positive airway pressure (PAP) is standard of care*
  • Medication for EDS
41
Q

Modafinil and armodafinil

A
  • CIV
  • Approved for EDS in OSA and narcolepsy
  • Administer in morning
  • Avoid in pregnancy
  • CYP3A4 (reduce contraceptives)
  • Caution in CV disease
  • ADE headache, SJS, TEN, CV events, mania, psychosis
42
Q

Solriamfetol (Sunosi)

A
  • CIV
  • Approved for EDS in OSA and narcolepsy
  • Dopamine and NE reuptake inhibitor
  • Administer QM, avoid <9h before bedtime
  • CI with MAOi
  • Avoid in unstable CV disease
43
Q

Pitolisant (Wakix)

A
  • Noncontrol
  • OFF LABEL for EDS in OSA but approved in narcolepsy
  • Antagonist/inverse agonist at H3 receptors
  • May prolong QT (avoid in arrhythmia)
  • ADE headaches
44
Q

Narcolepsy treatment

A
  • Good sleep hygiene, daytime naps***
  • Avoid sedatives
  • Treat symptoms (EDS, cataplexy, REM abnormalities)
    No disease-modifying therapies
45
Q

EDS medications in narcolepsy

A
  • Modafinil, armodafinil
  • Solriamfetol
  • Pitolisant
  • Amphetamines
  • Methylphenidate
  • Sodium oxybate
  • Oxybate salts
46
Q

Sodium oxybate (Xyrem)

A
  • CIII
  • REMS program***
  • Approved for cataplexy or EDS in adult narcolepsy
  • BBWs: CNS depression, abuse, restricted access
  • Take on empty stomach
  • Administer in bed, then lie down
  • 2nd dose after 2.5-4 hours
  • Can’t do anything for 6 hours after taking
    MOA: CNS depression via GABA
47
Q

Lumyrz

A

ER sodium oxybate
- Given same as Xyrem but 1 DOSE

48
Q

Oxybate salts

A

Xywav
- Contains more than sodium (Ca, Mg, K)
- Otherwise similar to Xyrem

49
Q

Cataplexy medications in narcolepsy (CAN ALSO TREAT EDS)

A

REM suppressing drugs: Venlafaxine, Fluoxetine, Duloxetine, Clomipramine
- Pitolisant
- Sodium oxybate

CAN ALSO TREAT EDS

50
Q

Restless leg syndrome

A
  • Fix nutrition first (iron, vitamin B, or folate deficiency)
  • Reduce caffeine/alcohol
  • Weight loss
51
Q

Medication withdrawal causing RLS

A
  • Central antihistamines
  • Antidepressants
  • Antipsychotics
  • Anti-nausea drugs that block dopamine
52
Q

RLS treatment

A
  • Carbidopa/levodopa
  • BZDRA (clonazepam*)
  • Pregablin, gabapentin
  • Dopamine agonists (ropinerole, rotigotine)

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