Sleep

Question 1

Common Drugs That Can Cause or Worsen Insomnia

Answer 1

• Alcohol, caffeine, nicotine
• Anticholinergics
• SSRIs/SNRIs
• Alpha blockers
• Beta blockers
• ACE-I and ARBs
• Cholinesterase inhibitors
• Bronchodilators
• CNS stimulants
• Corticosteroids
• Decongestants
• Diuretics
• H2RAs
• Statins
• Opioids

Question 2

Treatment of Long-Term Insomnia

Answer 2

• Cognitive behavioral therapy for insomnia (CBT-I)
• Preferred first-line therapy for chronic insomnia in most patients
• CBT-I +/- medications > medications alone
• If rapid improvement of insomnia is necessary, can use CBT-I +
medications initially with plan to taper medication over time

Question 3

Which Benzodiazepine Receptor Agonist (BZDRA) has the longest half life?

Answer 3

Quazepam (Doral) - 39 hours

2nd is Estazolam (ProSom) at 10-24 hours

Question 4

Which Benzodiazepine Receptor Agonist (BZDRA) has the shortest Tmax?

Answer 4

Flurazepam (Dalmane) at 0.5-1 hour

2nd is probably Zolpidem (depends on formulation) at 0.6-4 hours

Question 5

Which Benzodiazepine Receptor Agonists (BZDRAs) have clinically active metabolites?

Answer 5

Flurazepam (Dalmane) N-desalkylflurazepam Single dose: 74 – 90c Multiple doses: 111 – 113c

Quazepam (Doral) 2-oxoquazepam 39h N-desalkyl-2-oxoquazepam 73h

Question 6

Which medications treat BOTH cataplexy and EDS (used in narcolepsy)

Answer 6

Pitolisant (Wakix)
Sodium oxybate

WILL be on exam

Question 7

Medications for Cataplexy in Narcolepsy

Answer 7

• REM-suppressing drugs
• Venlafaxine (SNRI)
• Fluoxetine (SSRI)
• Duloxetine (SNRI)
• Clomipramine (TCA)
status cataplecticus (severe, nearly continuous rebound cataplexy that can last several hours) can happen with abrupt withdrawal of the above agents

• Pitolisant (also EDS)
• Sodium oxybate (also EDS)

Question 8

Which antidepressant is NOT associated with Restless Leg Syndrome (RLS)?

Answer 8

Bupropion

Question 9

Restless Leg Syndrome (RLS) Possible Causes to Rule Out

Answer 9

Nutrition
• Iron deficiency
• Iron supplementation in those with fasting
serum ferritin < 75 ng/mL
• Vitamin B or folate deficiency
• Reduce caffeine and alcohol use
• Weight loss

Withdrawal of medications which may cause RLS:
• Centrally-acting antihistamines (meclizine, hydroxyzine, diphenhydramine, doxylamine)
• Prefer second-generation antihistamines (loratadine)
• Antidepressants (TCAs, SSRIs, SNRIs)
• Bupropion not associated with RLS
• Antipsychotics
• Anti-nausea drugs that block dopamine (metoclopramide, promethazine)

Question 10

Pharmacotherapy for RLS

Answer 10

Intermittent symptoms:
• Carbidopa-levodopa
• BZDRA
• Clonazepam is the most well-studied

Chronic and persistent symptoms:
• Alpha-2-delta calcium channel ligands:
• Pregabalin
• Gabapentin

• Dopamine agonists:
• Immediate-release pramipexole
• Ropinirole
• Rotigotine

Dopamine agonists
• Use lower doses compared to Parkinson’s Disease treatment

BZDRAs
• Caution: carryover sedation

Alpha-2-delta calcium channel ligands (GABA analogs)
• Good choice for painful RLS
• Gabapentin enacarbil (Horizant) is FDA-approved for RLS