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PHM 701 > Sleep Disorders > Flashcards

Sleep Disorders Flashcards

1
Q

Where in the brain is the circadian clock/rhythm handled?

A

Suprachiasmatic Nucleus

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2
Q

Explain the human sleep cycle

A

4 - 6 cycles of REM and NREM sleep each one lasting about 70 - 120 minutes

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3
Q

What are the 4 stages of sleep?

A

1 - NREM Stage 1
2 - NREM Stage 2
3 - NREM Stage 3
4 - REM Stage

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4
Q

What stage of sleep is the deepest sleep?

A

NREM Stage 3

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5
Q

What stage of sleep does breathing and heart rate go down?

A

NREM Stage 2

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6
Q

Describe REM sleep

A

Paradoxical
Muscles are paralyzed
Brain is activated
Controlled by cholinergic cells
in the mesencephalic,
medullary and pontine
gigantocellular areas

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7
Q

Describe NREM sleep

A

Muscles are not paralyzed
Controlled by the basal
forebrain, lower brain stem
to the thalamus and
hypothalamus

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8
Q

What is used to monitor and measure sleep?

A

Polysomnography
Hooked up to EEG, EOG (each eye), ECG, EMG, O2 Sat

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9
Q

What are the signs/symptoms of sleep disorder?

A

Excessive Daytime Sleepiness
Impaired Daytime Functioning
Irregular breathing
Increased movement during sleep
Irregular sleep and wake cycle
Difficulty falling asleep

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10
Q

Common Types of Sleep Disorders

A

Insomnia
Sleep Apnea
Narcolepsy
Circadian rhythm disorder
Parasomnia
Restless Leg Syndrom

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11
Q

What is the most commonly reported sleep disorder?

A

Insomnia

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12
Q

How do you diagnose Insomnia?

A

Requires persistent sleep difficulty, adequate sleep opportunity and associated daytime dysfunction

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13
Q

What do you refer to several days insomnia

A

Transient insomnia

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14
Q

What do you refer to insomnia less than 3 months?

A

Short term insomnia

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15
Q

What do you refer to insomnia 3 nights/week for 3 months

A

chronic insomnia

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16
Q

What is the treatment goal of transient and short term insomnia?

A

Treat the underlying sleep complaint and avoid adverse effects of medication

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17
Q

What are common drugs that cause or worsen insomnia?

A

Alcohol/nicotine
Anticholinergics
SNRI/SSRIs
Alpha Blockers
Beta Blockers
ACEi and ARBs
CNS Stimulants
Bronchodilators
Cholinesterase inhibitors
Corticosteroids
Decongestants
Diuretics
H2RAs
Statins
Opioids

***Apple And Samsung Are Bad And Chidima Bought Croissants Cause Donuts Don’t Hit So Often

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18
Q

What are some sleep hygiene principles?

A
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19
Q

What is the treatment of long term insomnia?

A

1st line is - CBT
2nd line - CBT +/- medications (also if needed rapidly)

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20
Q

What can you give a patient for sleep onset that is older, is a substance abuser, is cognitively impaired and does not want morning residual sedation?

A

Ramelteon

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21
Q

What can you give a patient for sleep onset that is older, is a substance abuser, is cognitively impaired and wants morning residual sedation?

A

Ramelteon
DORA (rexant)

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22
Q

What can you give a patient for sleep onset that is young, is not a substance abuser, is not cognitively impaired and does not want morning residual sedation?

A

Ramelteon
Non Benzo BZDRA - zaleplon, zolpidem IR

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23
Q

What can you give a patient for sleep onset that is young, is not a substance abuser, is not cognitively impaired and wants morning residual sedation?

A

Ramelteon
Non Benzo BZDRA - zaleplon, zolpidem IR, eszoplicone
DORA (rexant)

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24
Q

What can you give a patient for sleep maintenance that is older, is a substance abuser, and is cognitively impaired ?

A

Low-dose doxepin
DORA

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25
Q

What can you give a patient for sleep maintenance that is young, is not a substance abuser, and is not cognitively impaired ?

A

Low dose doxepin
DORA
Non-Benzo BZDRA - eszoplicone or zolpidem

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26
Q

What are the most commonly used medication treatments for insomnia?

A

Benzodiazepine Receptor Agonists (BZDRAs)

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27
Q

What is a caution when using BZDRAs?

A

There is caution with use in the elderly and a possibility of complex sleep behaviors

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28
Q

How do BZDRAs work?

A

They have an agonist effect on GABA receptors

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29
Q

How should you take BZDRAs?

A

Always take before bedtime

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30
Q

What are the side effects of BZDRAs?

A

Drowsiness, Dizziness, Confusion, Risk of Falls

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31
Q

What should you avoid taking with BZDRAs?

A

You should avoid taking alcohol and opioids as it can cause CNS depression

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32
Q

Which BZDRA increases stage 2 sleep and decreases delta sleep?

A

Benzodiazepines

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33
Q

What BZDRA increases total sleep time?

A

Nonbenzo GABA Agonists

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34
Q

What BZDRA reduces sleep latency?

A

Benzodiazepines

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35
Q

What BZDRA reduces anxiety?

A

Benzodiazepines

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36
Q

What BZDRA is less disruptive of sleep stages?

A

NonBenzo GABA Agonists

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37
Q

What BZDRA has dose dependent side effects?

A

Benzodizepines

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38
Q

What BZDRA is more selective?

A

NonBenzo GABA Agonists

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39
Q

What BZDRA is associated with parasomnic episodes like amnesia?

A

NonBenzo GABA Agonists

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40
Q

What is the choice of a particular BZDRA based on?

A

It’s based on the PK profile and the patients’ preference

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41
Q

What is the Black Box Warning associated with Benzodiazepines?

A

Use of benzos and opioids can cause death
Physical dependence
Risk of abuse, overdose and death

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42
Q

What is Black Box Warning associated with Z-Drugs?

A

Complex sleep behaviors like sleep walking and sleep driving that can result in injury
**D/C if this happens

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43
Q

What list are BZDRAs on?

A

They are on the beer’s criteria for avoidance in the elderly due to increased sensitivity and decreased metabolism

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44
Q

What is the PK/PD profile of Eszoplicone?

A

Rapid absorption but delayed with food
Duration: 6 - 9 hours

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45
Q

What is eszoplicone indicated for?

A

Sleep onset and sleep maintenance

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46
Q

What is eszoplicone’s DDI?

A

Interactions with CYP3A4 inhibitors like ketoconazole and intracazole

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47
Q

What is the PK/PD profile of zaleplon?

A

Ultra short acting; rapid onset
Duration: 3 - 4 hours

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48
Q

What is zaleplon indicated for?

A

Sleep onset; short term insomnia

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49
Q

What is zaleplon’s DDI?

A

Interactions with CYP3A4 inducers like cimetidine and rifampin

50
Q

What is the PK/PD profile of Zolpidem?

A

Short acting and a short half life

51
Q

What are the different formulations of Zolpidem?

A

Intermezzo (SL tab)
Edluar (SL tab)
Ambien CR
Ambien IR
Generic IR capsule

52
Q

What is Intermezzo for and how should you take it?

A

Zolpidem formulation indicated for middle of the night awakening and should be taken if there are more than 4 hours left to sleep and you can’t go back to sleep
**Diff dose for men and women

53
Q

What is Edluar for and how should you take it?

A

Zolpidem formulation indicated for sleep onset and off label sleep maintenance and should be take immediately before bed with 7+ hours of sleep
**Diff dose for men and women

54
Q

What is Ambien for and how should you use it?

A

Zolpidem formulation for sleep onset (CR and IR) and sleep maintenance (CR only) taken immediately before bed with 7+ hours of sleep
**Diff dose for men and female

55
Q

What is Generic Zolpidem and how should you take it?

A

Zolpidem formulation for sleep onset. If 5 mg of another zolpidem formulation is not effective, you can use 7.5 mg of this generic formaultion
**Same dose for men and women

56
Q

What are DORAs?

A

Dual Orexin A and B Receptor Antagonists used for bot sleep onset and maintenance
It turns off awake signaling

57
Q

What are your DORA drugs?

A

Suborexant
Lemborexant
Dandorexant

58
Q

What are DORA’s DDIs?

A

Interactions with CYP3A4 inducer and inhibitors

59
Q

What is DORA’s contraindications?

A

It is contraindicated in narcolepsy

60
Q

How should you take DORAs?

A

Take at bedtime with at least 7 hours of planned sleep

61
Q

What is the PKPD profile of Suvorexant?

A

Onset: 30 minutes
Half life: 12 hours

62
Q

What is the side effect of Suvorexant?

A

Sleep paralysis
Abnormal dreams

63
Q

What is the PKPD profile of Lemborexant?

A

Onset: 30 minutes
Half life: 17 - 19 hours

64
Q

What is the side effect profile of Lemborexant?

A

Complex sleep behaviors
abnormal dreams

65
Q

What is the PKPD profile of Dandorexant?

A

Onset: 30 mins
Half life: 8 hours

66
Q

What is the side effect profile of Dandorexant?

A

Complex sleep behaviors
Hallucinations
Sleep paralysis

67
Q

What is Ramelteon?

A

It is a melatonin receptor agonist and is MT1 and MT2 selective
**MT1 = induces sleepiness
**MT2 = regulates circadian rhythm

68
Q

What is Ramelteon indicated for?

A

Sleep onset and long term use

69
Q

What is the PK profile of Ramelteon?

A

Onset: 30 mins
Half life: 1 - 2.6 hours

70
Q

What is Ramelteon contraindicated in?

A

Fluvoxamine

71
Q

Is Ramelteon effective in all patients?

A

It is not effective in patients that have previously use BZDRAs

72
Q

What is Doxepin?

A

TCA used for sleep maintenance

73
Q

What is the dosage of doxepin?

A

3 -6 mg/day
**Lower dose than depression

74
Q

What should you do when taking Doxepin?

A

Do not take within 3 hours of eating
**can cause next day somnolence

75
Q

What is Melatonin indicated for?

A

beneficial effects:
sleep onset latency
shift workers
jet lag

76
Q

In who should melatonin be avoided in?

A

Patients with autoimmune conditions
Patients with Alzheimers

77
Q

What 1st gen antihistamines are used in Insomnia?

A

Diphenhydramine
Doxylamine

78
Q

What patients shouldn’t use 1st gen antihistamines?

A

Avoid in older adults (beer’s list)

79
Q

What are the side effects of 1st gen antihistamines?

A

Anticholinergic side effects
- Mad (alt mental status)
- Blind (mydriasis)
- Hot (fever)
- Dry (dry mucous membrane)
- Red (flushing)
- Full (urine retention)

80
Q

What is the effect of use of 1st gen antihistamines?

A

Tolerance to sedative develops rapidly

81
Q

What is Trazodone used for in Sleep Disorders?

A

Improve sleep contiuity

82
Q

In what patients can Trazodone be useful in?

A

Patients with substance abuse
Patients with depression

83
Q

What is the side effect of Trazodone?

A

Carryover sedation
Alpha adrenergic blockade

84
Q

How should you discontinue Trazodone?

A

Gradually taper over 2 - 4 weeks

85
Q

What are other off label drugs used for Insomnia?

A

Amitriptylline
Mirtazepine
Gabapentin

86
Q

What drugs can you use in the elderly for Insomnia?

A

Low dose doxepin
Ramelteon
Zolpidem and Eszoplicone - risky

87
Q

What drugs can you use in pregnancy for Insomnia?

A

Diphenhydramine
Doxylamine
Low dose doxepin

88
Q

What is sleep apnea?

A

repeated episodes of breathing cessation during sleep. This can lead to blood oxygen desaturation and arousal to restart breathing

89
Q

What are the types of sleep apnea?

A

Central (impaired respiratory drive)
Obstructive (airway collapse/obstruction)
Mixed (CSA and OSA)

90
Q

How can you diagnose sleep apnea?

A

Polysomnography

91
Q

What is the treatment for obstructive sleep apnea?

A

The standard is Positive Airway Pressure during sleep
Behavior modify (weight loss, no alcohol/sedatives, alter sleep position)
Avoid CNS depressants & drugs that cause weight gain
Use drugs for EDS

92
Q

What are the for EDS?

A

Modafanil
Armodafinil
Solriamfetol
Pitolisant

93
Q

When should you administer modafanil/armofadinil?

A

In the morning

94
Q

Who should avoid Modafinil/Armodafinil?

A

it should be avoided in pregnant people

95
Q

What is the DDI in Modafinil/Armodafinil?

A

CYP3A4 inducer
Can reduce effectiveness of contraceptives

96
Q

What are the side effects of Modafanil/Armodafinil?

A

Headache
SJS/TEN
DRESS

97
Q

What are the warnings/precaution with Modafinil/Armodafinil?

A

It can cause mania or exacerbation of psychosis
precaution in patients with cardio events: HTN, CP, Tachycardia

98
Q

What is the MOA of Solriamfetol?

A

Dopa and NorEpi reuptake inhibitor

99
Q

How do you take (dose) Solriamfetol?

A

Take once daily upon awakening not within 9 hours of sleeping

100
Q

What is contraindicated with Solriamfetol?

A

use of MAOi (w/in 14 days)
Avoid in cardio disease and arrythmia

101
Q

What is Pitolisant?

A

Med for EDS good for substance patients

102
Q

What is the MOA of Pitolisant?

A

Inverse agonist/antagonist at histamine 3 receptors

103
Q

What is a side effect of Pitolisant?

A

May prolong QT (avoid in known arrhythmia)
Headache

104
Q

What is Narcolepsy?

A

Impairment of REM and NREM sleep onset and offset

105
Q

What is the narcolepsy tetrad?

A

Excessive & irresistible daytime sleepiness
cataplexy
hypnagogic hallucinations
sleep paralysis

106
Q

What is the pathophysiology of Narcolepsy?

A

loss of normal function of hypocretin/orexin in neurotransmitter system

107
Q

What is the non-pharm treatment of Narcolepsy?

A

good sleep hygiene and daytime naps
Avoid drugs that cause daytime sleepiness (benzos, opiates, AEDs, antipsychos, EtOH)

108
Q

What is the pharmacotherapy of Narcolepsy?

A

Goal: achieve normal and max alertness during awake hours
No disease modifying therapies
Treat symptoms: EDS, cataplexy, REM abnormalities

109
Q

What are the medications for EDS in Narcolepsy?

A

Modafinil
Armodafinil
Solriamfetol
Pitolisant
Amphetamine
Methylphenidate
Sodium oxybate
Oxybate salts

110
Q

What is Sodium oxybate indicated for?

A

Xyrem is a CIII used in cataplexy and EDS in narcolepsy

111
Q

What is the Black Box Warning with Sodium oxybate?

A

CNS depression
Abuse/misuse
Restricted access

112
Q

How should you take/admin sodium oxybate

A

Take on an empty stomach while in bed and remain in bed. Take 2nd dose 2.5 - 4 hours later.

113
Q

What is the precaution with Sodium oxybate?

A

It is part of the REMS program and is a CNS depressant. You should engagae in activities or operate heavy machinery for 6 hours

114
Q

What is Lumryz?

A

Sodium oxybate ER suspension.

115
Q

How to take Lumryz?

A

Suspend in 1/3 cup water Take lying down and remain in bed; only one dose at bedtime

116
Q

Oxybate salts

A

Na
Ca
Mg
K

117
Q

What meds are used for cataplexy in narcolepsy?

A

REM suppressing drugs
Pitolisant
Sodium oxybate

118
Q

What are the meds for EDS in narcolepsy

A

Oxybate salts

119
Q

What are your REM suppressing drugs

A

Venlafaxine (SNRI)
Duloxetine (SNRI)
Fluoxetine (SSRI)
Clomipramine (TCA)

120
Q

What can happen is you abruptly stop a REM suppressing drug?

A

Status Cataplecticus

PHM 701 (8 decks)

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