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Therapeutics > Sleep Disorders > Flashcards

Sleep Disorders Flashcards

1
Q

What occurs in NREM 1?

A

transition b/t wakefulness & sleeping

theta waves

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2
Q

What is an important characteristic of ALL NREM sleep stages?

A

muscles are NOT paralyzed

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3
Q

What occurs in NREM 2?

A

body temp drops & HR slows

sleep spindles & K complex

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4
Q

What occurs in NREM 3?

A

muscles relax, BP & breathing rate drops, deepest sleep occurs

delta waves

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5
Q

What are important characteristics of REM?

A

muscles are PARALYZED

brain is electrically & metabolically active (DREAMS)

occurs in bursts w/ an increase in cerebra; blood flow

controlled by cholinergic cells

beta waves

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6
Q

What is the category of insomnia that only lasts several days?

A

transient insomnia

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7
Q

What is the category of insomnia that is less than 3 months?

A

short term insomnia

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8
Q

What is the category of insomnia that occurs at least 3 nights/week for 3 months or more?

A

chronic insomnia

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9
Q

What drugs can cause or worsen insomnia? (there’s 19? guess as many as you can)

A
  • alcohol, caffeine, nicotine
  • anticholinergics
  • cholinesterase inhibitors
  • SSRI/SNRI
  • a & b blockers
  • ACE/ARB
  • bronchodilators
  • CNS stimulants
  • corticosteroids
  • decongestants
  • opioids
  • diuretics
  • H2RAs
  • statins
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10
Q

What is the first line therapy for chronic insomnia?

A

CBT for insomnia

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11
Q

Which benzo is only used for sleep onset?

rest are used for onset & maintenance

A

triazolam (Halcion)

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12
Q

What benzos are used for sleep onset & maintenance?

A
  1. estazolam (ProSom)
  2. flurazepam (Dalmane)
  3. quazepam (Doral)
  4. temazepam (Restoril)
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13
Q

What are the z-drugs? (3)

A
  1. eszopiclone (Lunesta)
  2. zaleplon (Sonata)
  3. zolpidem (Intermezzo, Edluar, Ambien CR, Ambien IR, generic IR, Zolpimist)
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14
Q

What insomnia types is Eszopiclone (Lunesta) indicated for?

What is it excellent for?

A

onset OR maintenance

maintenance & early morning awakenings

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15
Q

How is Eszopiclone (Lunesta) dosed?

How long can it be used for?

A

QHS

up to 6 mo

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16
Q

What Z-drugs are major CYP3A4 subs?

A
  1. Eszopiclone (Lunesta)
  2. Zaleplon (Sonata)
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17
Q

What insomnia types is Zaleplon (Sonata) indicated for?

A

onset only

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18
Q

How is Zaleplon (Sonata) dosed?

How long can it be used for?

A

QHS

up to 30 days

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19
Q

What zolpidem BRAND name & dosage FORM is indicated for maintenance only?

What does it specifically help with?

A

Intermezzo (sublingual)

middle of the night awakening

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20
Q

What zolpidem BRAND names & dosage FORMS are indicated for onset only? (4)

A
  1. Edluar (sublingual)
  2. Ambien IR (IR tab)
  3. generic IR (cap)
  4. zolpimist (spray)
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21
Q

What zolpidem BRAND name & dosage FORM are indicated for maintenance & onset?

A

Ambien CR (ER tab)

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22
Q

What zolpidem BRAND names & dosage FORMS are given QHS w/ 7-8 hours of planned sleep? (5)

A
  1. Edluar (sublingual)
  2. Ambien CR (CR tab)
  3. Ambien IR (IR tab)
  4. generic IR (cap)
  5. zolpimist (spray)
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23
Q

What zolpidem BRAND name & dosage FORM needs to be given at least 4 hours prior to wakening?

A

Intermezzo (sublingual)

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24
Q

What zolpidem BRAND names & dosage FORMS have different dosages according to gender?

A
  1. Intermezzo (sublingual)
  2. Ambien CR (CR tab)
  3. Ambien IR (IR tab)
  4. Zolpimist (spray)
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25
Q

What insomnia types are DORAs (Dual Orexin A & B Receptor Antagonists) indicated for?

A

sleep onset or maintenance

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26
Q

What is the CI of DORAs (Dual Orexin A & B Receptor Antagonists)?

A

narcolepsy

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27
Q

How much planned sleep is needed for QHS dosing of DORAs (Dual Orexin A & B Receptor Antagonists)?

A

7 hours or more

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28
Q

List the DORAs (Dual Orexin A & B Receptor Antagonists):
(3)

A
  1. suvorexant (Belsomra)
  2. lemborexant (DayVigo)
  3. daridorexant (Quviviq)
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29
Q

What enzyme completes DORAs (Dual Orexin A & B Receptor Antagonists) metabolism?

A

CYP3A4

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30
Q

Which DORAs (Dual Orexin A & B Receptor Antagonists) are associated with awakening drowsiness (long t1/2)?

A
  1. suvorexant (Belsomra)
  2. lemborexant (DayVigo)
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31
Q

If a patient is taking a Z-drug and experiences a complex sleep behavior what should be done?

A

D/C immediately!!!

32
Q

What is the BBW on all Z-drugs?

A

complex sleep behaviors

33
Q

Which DORA (Dual Orexin A & B Receptor Antagonist) has a risk of CNS depression for up to several days after D/C?

A

lemborexant (DayVigo)

longest t 1/2

34
Q

Which insomnia classes are scheduled CIV?

A
  1. all Benzos
  2. all Z-drugs
  3. all DORAs
35
Q

What insomnia types is ramelteon (Rozerem) indicated for?

A

onset only

36
Q

What is a potential caveat to intiating ramelteon (Rozerem) use?

A

its not effective in patients that have previously been on a benzo or Z-drug

37
Q

What is the CI for ramelteon (Rozerem)?

A

fluvoxamine use (strong CYP 1A2 inhib)

38
Q

What does stimulation of each melatonin receptor do?

M1? induces sleepiness

M2?

A

M1: induces sleepiness

M2: regulates circadian rhythm

39
Q

What is the MOA of ramelteon (Rozerem)?

A

melatonin receptor agonist (M1 > M2)

40
Q

What TCA is used for sleep maintenance insomnia?

A

low dose doxepin

41
Q

What insomnia agents have BBW for suicidality?

A

doxepin & trazodone

42
Q

What is important when dosing doxepin for sleep maintenance insomnia?

A

DO NOT take within 3 hours of a meal

slower absorption -> next day sleepiness

43
Q

What sleep disorders is melatonin indicated for?

A

sleep onset latency

shift workers

jet lag

44
Q

What patient population should melatonin be avoided?

A

pt w/ autoimmune conditions

45
Q

What are 2 problems with using diphenhydramine or doxylamine for sleep?

A
  1. tolerance to sedative effect develops quickly
  2. anticholinergic (avoid in older adults)
46
Q

In what circumstance is trazodone used for sleep?

A

OFF LABEL!

47
Q

What is needed if stopping trazodone?

A

taper off over 2-4 weeks

48
Q

What are the general mainstays of sleep onset therapy?

What about for elderly or opioid users?

A

1st line Z-drugs
- Ramelteon or DORA

Ramelteon or DORA

49
Q

What are the general mainstays of sleep maintenance or mixed therapy?

What about for elderly or opioid users?

A

1st line Z-drugs
- DORA or low dose doxepin

DORA or low dose doxepin

50
Q

What insomnia agents can be used in pregnancy?

A
  1. diphenhydramine
  2. doxylamine
  3. low dose doxepin
51
Q

What agents can exacerbate sleep apnea?

A

CNS depressants & alcohol

52
Q

What is the standard treatment for sleep apnea?

A

positive airway pressure during sleep

53
Q

What non-pharm changes can be made to improve sleep apnea?

A
  1. weight loss
  2. altered sleeping position
  3. avoidance of alcohol & sedatives
54
Q

What agents are used to treat excessive daytime sleepiness?

Note which are FDA approved for EDS in sleep apnea or narcolepsy

A
  1. modafinil (Provigil), armodafinil (Nuvigil)
    —— BOTH
  2. solriamfetol (Sunosi) —– BOTH
  3. pitolisant (Wakix) —– NARCO (off label for sleep apnea)
55
Q

How far from bedtime should solriamfetol (Sunosi) be administered?

A

9 hours or more from planned bedtime

56
Q

Which EDS agent has a BBW for MAOI within 14 days?

A

solriamfetol (Sunosi)

57
Q

Which EDS agent has been seen to cause mania or exacerbate psychotic/manic symptoms?

A

modafinil (Provigil) & armodafinil (Nuvigil)

58
Q

Which EDS agent prolongs QT?

A

pitolisant (Wakix)

59
Q

Which EDS agent is CI in severe hepatic impairment?

A

pitolisant (Wakix)

60
Q

Which EDS is scheduled CIV?

A

modafinil (Provigil) & armodafinil (Nuvigil)

61
Q

Which EDS is FED ONLY CIV?

A

solriamfetol (Sunosi)

62
Q

What is the narcolepsy tetrad?

A
  1. excessive & irresistible daytime sleepiness
  2. cataplexy (muscle weakness in periods of strong emotion)
  3. hypnagogic (vivid dreams at sleep onset)
  4. sleep paralysis
63
Q

What is the difference between type 1 and type 2 narcolepsy?

A

type 1 -> w/ cataplexy

type 2 -> w/o cataplexy

64
Q

List the 8 EDS agents for narcolepsy:

A
  1. modafinil (Provigil)
  2. armodafinil (Nuvigil)
  3. solriamfetol (Sunosi)
  4. pitolisant (Wakix)
  5. amphetamines
  6. methylphenidate
  7. sodium oxybate
  8. oxybate salts
65
Q

What EDS agent is scheduled CIII?

A

sodium oxybate

66
Q

What EDS agents also treat cataplexy?

A

sodium oxybate & pitolisant (Wakix)

67
Q

What are the BBWs for sodium oxybate?

A
  1. CNS depression
  2. abuse/misuse
  3. restricted access
68
Q

What is restricted after administration of sodium oxybate due to CNS depression?

A

NO hazardous activities requiring mental alertness or motor coordination for at least 6h after admin

69
Q

What formulations of sodium oxybate are available (include BRAND)?

A

Xyrem - IR soln

Lumryz - ER suspension

70
Q

How is Xyrem (sodium oxybate IR soln) administered?

A

take on empty stomach 2 hr or more after eating while in bed

lie down immediately in bed after dose & stay in bed

2nd dose is given while still in bed 2.5-4 h later

71
Q

How is Lumryz (sodium oxybate ER suspension) administered?

A

dose is suspended in 80 mL of water using provided mixing cup & must be used within 30 mins

take on empty stomach 2 hr or more after eating while in bed

lie down immediately in bed after dose & stay in bed

72
Q

What is the difference of oxybate salts (Xywav) vs sodium oxybate?

A

oxybate salts contain more than just Na -> Ca, Mg, K as well

73
Q

What agents are used for intermittent restless leg symptoms?

A
  1. carb/levo
  2. benzos (clonazepam is most well studied)
74
Q

What agents are used for chronic & persistent restless leg symptoms?

A
  1. pregabalin or gabapentin
  2. dopamine agonists: IR pramipexole, ropinirole, rotigotine
75
Q

Medication withdrawals that may cause restless leg syndrome:

A
  • centrally acting antihistamines
  • antidepressants
  • antipsychotics
  • dopamine blocking anti-emetics

Therapeutics (17 decks)

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