Sleep Disorders Flashcards
1
Q
Pharmacologic treatment of sleep disorders
Benzodiazepine sedative- hypnotics
A
- shown to both induce and maintain sleep
- differences in drugs based on onset and duration of actions
- benzodiazepine hypnotics includ flurazepam, triazolam, temazepam, estazolam, and quazipam
- tolerance can develop to use
- rebound insomnia has been reported with abrupt discontinuation
- ensure the patient is not also taking a benzodiazepine for anxiety
- adverse effects are similar to benzodiazepines used for anxiety
- are generally CYP3A4 substrates, drug interactions possible with strong 3A4 inhibitors
- avoid use in the elderly
- avoid use with other CNS depressants
2
Q
Pharmacologic treatment of sleep disorders
Benzodiazepine-1 receptor agonists
(Z-hypnotics)
A
- zolpidem, saleplon, eszopiclone
- bind selectively to the GABA-A receptor
- thought to be less disruptive to normal sleep parameters than the benzodiazepine hypnotics
- Zolpidem CR does not improve onset of sleep but may lengthen duration of sleep (not significant)
- Zaleplon has a more rapid onset of action and shorter duration, may be repeated if >4hr sleep remaining
- decreased risk of hangover vs benzos
- eszopiclone longer acting but may not improve early morning awakening over the others
- adverse effects - amnesia, dizziness, headache and GI effects
- eszopiclone can cause metalic taste
- Sleep-eating and sleep-driving have been reported
- Z-hypnotics are CYP3A4 substrates, except zaleplon
- eszopiclone is less selective at the benzo receptor and may have anticonvulsant and skeletal muscle relaxant properties
- rebound insomnia and tolerance are less likely with zaleplon
- schedule IV controlled substances
- avoid with other CNS depressants
- Zolpidem sublingual available as 1.75 mg (women and elderly) and 3.5 (men). Indicated for insomnaa with middle of the night awakening an diffiulty returning to sleep (<at least 4hr of sleep left)
3
Q
Pharmacologic treatment of sleep disorders
Ramelteon
A
- melatonin agonist
- no abuse potential, not a controlled substance
- improve sleep latency - time to fall asleep, may not improve duration of sleep
- dose: 8mg orally 30 minutes before bedtime.
- adverse effects include daytome sleepines, heperprolactemia, dizziness and stomach upset
- CYP1A2 supstrate: 1A2 inhibitors (eg fluvoxamine) may increase ramelteon serum levels
- patients also taking anticoagulants may be at an increased risk of bleeding
- currently available as brand name only (Rozerem) so more expensive
- may be considered in patients with a substance-abuse history
- onset of effect may take up to 3 weeks
4
Q
Pharmacologic treatment of sleep disorders
Trazodone
A
- serotonergic antidepressant commonly used for sleep inductino
- usual doses are much lower than for depression
- starting doe 50mg at bedtime
- onset of action generally slower than other agents used for insomnia
- duration of action is longer’ may result in more significant daytime hangover
- priapism is possible with higher doses (>200mg) (incidence <1%)
5
Q
Pharmacologic treatment of sleep disorders
Doxepin
A
- tricyclic antidepressant
- recently approved by FDA for insomnia and sleep maintenance (Silenor)
- dosage range 3-6mg orally 30 minutes before sleep on an empty stomach, usual adult dose is 6mg
- warning:
- suicidal thinking (for all antidepressants)
- sleep driving (for all sedative-hypnotics)
6
Q
Pharmacologic treatment of sleep disorders
Antihistamines
A
- diphenhydramine and others found in over the counter sleep agents
- tachyphylaxis to sedative effects is common
- drug is usually effective for a few weeks then wears off
- requires a drug holiday
- anticholinergic adverse effects limit its usefulness
7
Q
Alternative therapies for sleep disorders
Melatonin
A
- almost 5% of american adults have used
- useful for jet lag and in the elderly
- an increase in endogenous melatonin may be responsible for increased sleepiness
- may increase risk of bleeding
- suggested to reduce glucose tolerance and insulin sensitivity
8
Q
Alternative therapies for sleep disorders
Chamomile
A
- theorized to affect the benzodiazepine receptor
- found in many teas and extracts
- caution use in ragweed allergy
- may increase risk of bleeding, especially in patients taking anticoagulants
9
Q
Alternative therapies for sleep disorders
Valerian
A
- thought to inhibit breakdown of GABA or increase GABA release
- no benefit shown in clinical trails but seems to be safe
- there have been reports of valerian causing hepatic toxicity, including life-threatening liver damage
10
Q
Sleep disorders
Therapy summary and patient counselling
A
- thoroughly assess the reasons for insomnia before initiating treatment
- evaluate for underlying cause of insomnia and address this in treatment
- sedative-hypnotic therapy recommended for short-term use only, zolpidem CR and exzopiclone approved for treatment up to 6 months
- rebound insomnia is possible with abrupt discontinuation of drug therapy
- a taper to discontinuation after long-term use is necessary
- recommend non-drug strategies to improve sleep
- monitoring of hypnotic therapy should include improvement of sleep, adherence to prescribed dosing, daytime hangover, changes in mood, and adverse effects
11
Q
Sleep Apnea
Risk factors
A
- increased age
- male sex
- obesity
- craniofacial abnormalities
12
Q
Sleep Apnea
Treatment
A
1) Weight loss - may significantly improve sx
2) Changing positions while sleeping
3) Surgical correction of obstruction
4) CPAP - continuous positive airway pressure
- very effective but adherence limited due to noisiness
5) Modafinil and Amodafinil for daytime sleepiness
6) use sedative-hypnotic agents with caution
