Sleep Disorders Flashcards
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Insomnia is the most common sleep condition and is characterized by difficulty falling asleep (sleep initiation or sleep latency), reduced sleep duration and/or poor sleep quality.
A diagnosis of chronic insomnia occurs when the patient has symptoms at least ________ for at least _____________, despite adequate opportunity to sleep.
3 times per week
3 months
________________ for insomnia is preferred and includes changes to sleep hygiene that can reduce the need for drugs.
(CBT) cognitive behavioral therapy
It is important to treat any underlying medical condition that may be contributing and discontinue medications that can worsen insomnia.
Natural products used for sleep:
melatonin
valerian
Kava - Not recommended due to risk of hepatotoxicity.
chamomile tea - drinking in the evening can help to feel calmer.
The American Academy of Sleep Medicine (AASM) guidelines state that the following treatments are NOT recommended for chronic use:
diphenhydramine
melatonin
tiagabine
trazodone
valerian
Key Drugs that can worsen insomnia:
- acetylcholinesterase inhibitors
- alcohol
- antiretrovirals
- aripiprazole
- atomoxetine (stimulant)
- bupropion (activating)
- caffeine
- decongestants
- diuretics (due to nocturia)
-fluoxetine (activating) - steroids
- stimulants
- varenicline
Insomnia
- difficulty with sleep
Sleep initiation/latency: falling asleep
Sleep duration: staying asleep
Sleep quality: awakening after sleep onset
Non-drug treatments first:
CBT
Treat other conditions
Stop medications worsening insomnia
Try natural products
- keep the bedroom dark, comfortable, and quiet
- keep to a regular sleep schedule
- avoid daytime naps, even after a poor night of sleep, or limit to 30 mins
- reserve the bedroom for sleep and other appropriate activities (no TV)
- turn the face of the clock aside to minimize anxiety about falling asleep
- Do not eat heavy meals right before bedtime
- do not take caffeine in the afternoon
Need Help Falling asleep (Initiation):
Z-drugs or ramelteon
eszopiclone
zolpidem
zaleplon
Need help staying asleep (Duration):
eszopiclone
zolpidem
suvorexant
doxepin
EZ TIP for excellent Zzzzzzzzz (sleep): For help falling asleep (Initiation) and staying asleep (Duration):
E
Z
Eszopiclone
Zolpidem
Non-benzodiazepines preferred.
Can consider benzodiazepines for short term treatment.
OTC drugs sometimes used.
Beers Criteria, benzodiazepines, non-benzodiazepine hypnotics and first-generation antihistamines are considered potentially inappropriate in patients aged 65 years old and older. If benzodiazepines are used (LOT) drugs are preferred in elderly due to the lower risk of adverse reactions.
Lorazepam
Oxazepam
Temazepam
Lunesta
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eszopiclone C-IV
Class: Hypnotics
Indications: insomnia
MOA: increase GABA (inhibitory neurotransmitter) at the benzodiazepine receptor. This causes CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
History of complex sleep behavior
Warnings:
Increase risk of CNS depression and next day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol).
Potential for abuse and dependance (can cause withdrawal symptoms if used longer than 2 weeks)
Side Effects:
Somnolence, dizziness, ataxia, headache,
Parasomnias (unusual actions while you are sleeping, which the patient may be unaware of).
Monitoring:
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C-IV
Preferred over benzodiazepines for first line treatment due to decrease abuse, dependence and tolerance.
Do not take with fatty food, a heavy meal or alcohol.
Drug-Drug/Food interactions:
Ambien
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zolpidem
Class: Hypnotics
Indications: insomnia
MOA: increase GABA (inhibitory neurotransmitter) at the benzodiazepine receptor. This causes CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
History of complex sleep behavior
Warnings:
Increase risk of CNS depression and next day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol).
Potential for abuse and dependance (can cause withdrawal symptoms if used longer than 2 weeks)
Side Effects:
Somnolence, dizziness, ataxia, headache,
Parasomnias (unusual actions while you are sleeping, which the patient may be unaware of).
Monitoring:
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C-IV
Preferred over benzodiazepines for first line treatment due to decrease abuse, dependence and tolerance.
Do not take with fatty food, a heavy meal or alcohol.
Drug-Drug/Food interactions:
Edluar
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zolpidem
Class: Hypnotics
Indications: insomnia
MOA: increase GABA (inhibitory neurotransmitter) at the benzodiazepine receptor. This causes CNS depression.
Dosage forms: Sublingual tablet
Dosing:
Max dose:
Contraindications:
History of complex sleep behavior
Warnings:
Increase risk of CNS depression and next day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol).
Potential for abuse and dependance (can cause withdrawal symptoms if used longer than 2 weeks)
Side Effects:
Somnolence, dizziness, ataxia, headache,
Parasomnias (unusual actions while you are sleeping, which the patient may be unaware of).
Monitoring:
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C-IV
Preferred over benzodiazepines for first line treatment due to decrease abuse, dependence and tolerance.
Do not take with fatty food, a heavy meal or alcohol.
Drug-Drug/Food interactions:
Zolpimist
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zolpidem
Class: Hypnotics
Indications: insomnia
MOA: increase GABA (inhibitory neurotransmitter) at the benzodiazepine receptor. This causes CNS depression.
Dosage forms: oral spray
Dosing:
Max dose:
Contraindications:
History of complex sleep behavior
Warnings:
Increase risk of CNS depression and next day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol).
Potential for abuse and dependance (can cause withdrawal symptoms if used longer than 2 weeks)
Side Effects:
Somnolence, dizziness, ataxia, headache,
Parasomnias (unusual actions while you are sleeping, which the patient may be unaware of).
Monitoring:
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C-IV
Preferred over benzodiazepines for first line treatment due to decrease abuse, dependence and tolerance.
Do not take with fatty food, a heavy meal or alcohol.
Drug-Drug/Food interactions:
Sonata
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zaleplon
Class: Hypnotics
Indications: insomnia
MOA: increase GABA (inhibitory neurotransmitter) at the benzodiazepine receptor. This causes CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
History of complex sleep behavior
Warnings:
Increase risk of CNS depression and next day impairment with < 7-8 hours of sleep (especially with higher doses or coadministration of CNS depressants or alcohol).
Potential for abuse and dependance (can cause withdrawal symptoms if used longer than 2 weeks)
Side Effects:
Somnolence, dizziness, ataxia, headache,
Parasomnias (unusual actions while you are sleeping, which the patient may be unaware of).
Monitoring:
Pearls/Notes:
C-IV
Preferred over benzodiazepines for first line treatment due to decrease abuse, dependence and tolerance.
Do not take with fatty food, a heavy meal or alcohol.
Drug-Drug/Food interactions:
Use caution in combination with potent CYP3A4 inhibitors.
DayVigo
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lemborexant
Class: orexin receptor antagonist
Indications:
MOA: The orexin neuropeptide signaling system promotes wakefulness. Orexin receptor antagonists block the orexin neuropeptide signaling system, resulting in drowsiness.
Dosage forms:
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Contraindications:
Narcolepsy
Warnings:
Worsening depression/suicidal ideation, sleep paralysis, hallucinations, cataplexy-like symptoms (sudden loss of muscle tone), increased risk for complex sleep behavior, daytime impairment (risk increased with other CNS depressants).
Side Effects:
somnolence, headache, dizziness, abnormal dreams
Monitoring:
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Should be taken on an empty stomach (food delays absorption)
Not recommended in patients with severe hepatic impairment.
Drug-Drug/Food interactions:
Belsomra
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suvorexant
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Rozerem
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ramelteon
Class: melatonin receptor agonists
Indications:
MOA: drug acts at the melatonin receptors, MT1 and MT2. This promotes sleepiness and regulates the circadian rhythm to coordinate the sleep-wake cycle.
Dosage forms:
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contraindicated with fluvoxamine (increases serum concentrations of ramelteon)
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somnolence, dizziness
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Not limited to short use
Not controlled
Good for helping fall asleep.
Drug-Drug/Food interactions:
Hetliaz
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tasimelteon
Class: melatonin receptor agonists
Indications:
MOA: drug acts at the melatonin receptors, MT1 and MT2. This promotes sleepiness and regulates the circadian rhythm to coordinate the sleep-wake cycle.
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Not limited to short use
Not controlled
tasimelteon - for non-24-hour sleep wake disorder
Drug-Drug/Food interactions:
Silenor
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doxepin
Class: tricyclic antidepressant
Indications: insomnia
MOA: inhibits NE and 5-HT reuptake. They also block acetylcholine and histamine receptors which contribute to side effects (somnolence).
Dosage forms:
Dosing: 3-6mg PO QDHS
3mg if > or = to 65 years old.
Max dose:
Boxed Warnings:
increase in suicidal thoughts or actions in some children, teenagers or young adults within the first few months of treatment or when the dose is changed.
Contraindications:
Requires a w-week washout period for MAO inhibitors.
Warnings:
Side Effects:
somnolence, possibility of anticholinergic side effects.
Monitoring:
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Doxepin ER (Silenor) the brand name is FDA-approved for sleep.
Good for staying asleep
Drug-Drug/Food interactions:
Restoril
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temazepam
Class: benzodiazepine
Indications:
MOA: drug enhances GABA, an inhibitory neurotransmitter, causing CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
pregnancy due to observed teratogenicity*
Warnings:
complex sleep behaviors (e.g. sleep-driving) have been noted.
-drowsiness, dizziness, ataxia, lightheadedness
-anterograde amnesia (some of the events that occur after taking BZD cannot be stored as memories - forgetting what happens)
Side Effects:
Drowsiness, dizziness/ increased fall risk, cognitive impairment
Monitoring:
Pearls/Notes:
C-IV drugs; there is a risk of physical (physiological) dependence, abuse (addiction) and tolerance.
- Increased risk of falls, use with caution in those at high risk
- cross the placenta
- For Short Term use only, 1-2 weeks.
- Slow taper required if used long term.
Drug-Drug/Food interactions:
estazolam
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Class: benzodiazepine
Indications:
MOA: drug enhances GABA, an inhibitory neurotransmitter, causing CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
pregnancy due to observed teratogenicity*
Warnings:
complex sleep behaviors (e.g. sleep-driving) have been noted.
-drowsiness, dizziness, ataxia, lightheadedness
-anterograde amnesia (some of the events that occur after taking BZD cannot be stored as memories - forgetting what happens)
Side Effects:
Drowsiness, dizziness/ increased fall risk, cognitive impairment
Monitoring:
Pearls/Notes:
C-IV drugs; there is a risk of physical (physiological) dependence, abuse (addiction) and tolerance.
- Increased risk of falls, use with caution in those at high risk
- cross the placenta
- For Short Term use only, 1-2 weeks.
- Slow taper required if used long term.
- *Estazolam do not use with potent CYP3A4 inhibitors (e.g ketoconazole, itraconazole)
Drug-Drug/Food interactions:
Doral
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quazepam
Class: benzodiazepine
Indications:
MOA: drug enhances GABA, an inhibitory neurotransmitter, causing CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
pregnancy due to observed teratogenicity*
Warnings:
complex sleep behaviors (e.g. sleep-driving) have been noted.
-drowsiness, dizziness, ataxia, lightheadedness
-anterograde amnesia (some of the events that occur after taking BZD cannot be stored as memories - forgetting what happens)
Side Effects:
Drowsiness, dizziness/ increased fall risk, cognitive impairment
Monitoring:
Pearls/Notes:
C-IV drugs; there is a risk of physical (physiological) dependence, abuse (addiction) and tolerance.
- Increased risk of falls, use with caution in those at high risk
- cross the placenta
- For Short Term use only, 1-2 weeks.
- Slow taper required if used long term.
Drug-Drug/Food interactions:
flurazepam
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Class: benzodiazepine
Indications:
MOA: drug enhances GABA, an inhibitory neurotransmitter, causing CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
pregnancy due to observed teratogenicity*
Warnings:
complex sleep behaviors (e.g. sleep-driving) have been noted.
-drowsiness, dizziness, ataxia, lightheadedness
-anterograde amnesia (some of the events that occur after taking BZD cannot be stored as memories - forgetting what happens)
Side Effects:
Drowsiness, dizziness/ increased fall risk, cognitive impairment
Monitoring:
Pearls/Notes:
C-IV drugs; there is a risk of physical (physiological) dependence, abuse (addiction) and tolerance.
- Increased risk of falls, use with caution in those at high risk
- cross the placenta
- For Short Term use only, 1-2 weeks.
- Slow taper required if used long term.
Drug-Drug/Food interactions:
Halcion
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triazolam
Class: benzodiazepine
Indications:
MOA: drug enhances GABA, an inhibitory neurotransmitter, causing CNS depression.
Dosage forms:
Dosing:
Max dose:
Contraindications:
pregnancy due to observed teratogenicity*
Warnings:
complex sleep behaviors (e.g. sleep-driving) have been noted.
-drowsiness, dizziness, ataxia, lightheadedness
-anterograde amnesia (some of the events that occur after taking BZD cannot be stored as memories - forgetting what happens)
Side Effects:
Drowsiness, dizziness/ increased fall risk, cognitive impairment
Monitoring:
Pearls/Notes:
C-IV drugs; there is a risk of physical (physiological) dependence, abuse (addiction) and tolerance.
- Increased risk of falls, use with caution in those at high risk
- cross the placenta
-** triazolam: associated with higher rebound insomnia and daytime anxiety; contraindicated with azole antifungals, protease inhibitors and other CYP3A4 inhibitors
- For Short Term use only, 1-2 weeks.
- Slow taper required if used long term.
Drug-Drug/Food interactions:
L-O-T:
Lorazepam
Oxazepam
Temazepam
- these benzo’s are thought to be safer in liver disease
- considered safer for patient’s 65 years and older since these medications do not have active metabolites.
Bendryl
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diphenhydramine
Class: antihistamine
Indications:
MOA: drug competes with and blocks histamine H1 receptors
Dosage forms:
Dosing: 50mg PO QDHS
Max dose:
Contraindications:
Warnings:
Side Effects: sedation (tolerance to sedative effects can develop after 10 days of use), confusion (can exacerbate memory/cognition difficulty)
Antihistamines may cause paradoxical excitation in young children; DO NOT USE doxylamine in children < 12 years old.
Peripheral anticholinergic side effects: dry mouth, urinary retention (makes it very difficult for males with BPH to urinate), dry/blurry vision, constipation
Best to avoid in BPH (can worsen symptoms) and glaucoma (can elevate IOP)
Monitoring:
Pearls/Notes:
BEERS Criteria - (Anticholinergic Effects)
Drug-Drug/Food interactions:
Unisom
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doxylamine
Class: antihistamine
Indications:
MOA: drug competes with and blocks histamine H1 receptors
Dosage forms:
Dosing: 25mg PO QDHS
Max dose:
Contraindications:
Warnings:
Side Effects: sedation (tolerance to sedative effects can develop after 10 days of use), confusion (can exacerbate memory/cognition difficulty)
Antihistamines may cause paradoxical excitation in young children; DO NOT USE doxylamine in children < 12 years old.
Peripheral anticholinergic side effects: dry mouth, urinary retention (makes it very difficult for males with BPH to urinate), dry/blurry vision, constipation
Best to avoid in BPH (can worsen symptoms) and glaucoma (can elevate IOP)
Monitoring:
Pearls/Notes:
BEERS Criteria - (Anticholinergic Effects)
Drug-Drug/Food interactions:
(RLS) Restless Leg Syndrome:
Urge to move lower legs.
- worse at night
- relieved with movement
Drug treatment for RLS: increase (DA) dopamine
“usually used in PD for movement disorder”
dopamine agonists
- (Mirapex) pramipexole
- (Requip) ropinirole
- (Neupro) rotigotine - patch
- (Horizant) gabapentin enacarbil - approved for RLS and postherpetic neuralgia. (Take with food, swallow whole)
For RLS, the immediate release (IR) formulation is taken 1-3 hours before bedtime.**
(Neupro) rotigotine is a dopamine agonist that comes in a patch formulation (used for both PD and RLS). The patch is applied once daily, and patients must be counseled on appropriate use. (e.g. do not apply a heat source over the patch, remove the patch before an MRI procedure, rotate sites to avoid skin irritation.
Dopamine agonists cause:
orthostasis, somnolence and nausea that is dose related.
Narcolepsy:
is excessive daytime sleepiness with cataplexy (sudden loss of muscle tone) and sleep paralysis.
- sudden and uncontrollable sleep attacks with cataplexy (sudden loss of muscle tone)
- poor control of normal sleep-wake cycle
- excessive sleepiness
Drug Treatment for Narcolepsy:
Stimulants
- modafinil (Provigil)
- armodafinil (Nuvigil)
Sodium oxybate (Xyrem)
calcium, magnesium, potassium and sodium oxybate (Xywav)
Several of the ADHD stimulants also have an indication for Narcolepsy:
- dextroamphetamine
- dextroamphetamine/amphetamine
- methylphenidate
Provigil
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modafinil
Class: stimulant for wakefulness
Indications: narcolepsy, obstructive sleep apnea (to help with daytime sleepiness) and shift work disorder.
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Avoid with pre-existing cardiac conditions, caution with hepatic or renal dysfunction, psychiatric disorders and Tourette’s syndrome.
Side Effects:
*Severe rash, can be life threatening (SJS), headache, insomnia, anxiety, nausea
Monitoring:
Pearls/Notes:
C-IV
Drug-Drug/Food interactions:
Nuvigil
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armodafinil
Class: stimulant for wakefulness
Indications: narcolepsy, obstructive sleep apnea (to help with daytime sleepiness) and shift work disorder.
MOA:
Dosage forms:
Dosing:
Max dose:
Contraindications:
Warnings:
Avoid with pre-existing cardiac conditions, caution with hepatic or renal dysfunction, psychiatric disorders and Tourette’s syndrome.
Side Effects:
*Severe rash, can be life threatening (SJS), headache, insomnia, anxiety, nausea
Monitoring:
Pearls/Notes:
C-IV
Drug-Drug/Food interactions:
Xyrem
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sodium oxybate
Class:
Indications: narcolepsy with cataplexy (sudden loss of muscle tone)
MOA:
Dosage forms:
Dosing:
Max dose:
Boxed warning:
Strong CNS depressant: respiratory depression, coma and death can result; risk is increased when taken with other CNS depressants.
Contraindications:
Use with sedative hypnotics or alcohol
Warnings:
depression, suicide, psychosis, anxiety, sleepwalking
Side Effects:
dizziness, confusion, nausea
Monitoring:
Pearls/Notes:
-derived from GABA
C-III
- **Restricted access through Xyrem REMS program - “date rape” drug
- drug helps with sleep at night and are generally used with daytime stimulants.
- High sodium content; limiting dietary sodium intake may be required
Drug-Drug/Food interactions:
Xywav
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calcium, magnesium, potassium and sodium oxybates (Xywav)
Class:
Indications: narcolepsy with cataplexy (sudden loss of muscle tone)
MOA:
Dosage forms:
Dosing:
Max dose:
Boxed warning:
Strong CNS depressant: respiratory depression, coma and death can result; risk is increased when taken with other CNS depressants.
Contraindications:
Use with sedative hypnotics or alcohol
Warnings:
depression, suicide, psychosis, anxiety, sleepwalking
Side Effects:
dizziness, confusion, nausea
Monitoring:
Pearls/Notes:
-derived from GABA
C-III
- **Restricted access through Xyrem REMS program - “date rape” drug
- drug helps with sleep at night and are generally used with daytime stimulants.
- High sodium content; limiting dietary sodium intake may be required
Drug-Drug/Food interactions:
Wakix
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pitolisant
Sunosi
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solriamfetol
