Sleep Disorders

Question 1

Wakefulness Neurotransmitters

Answer 1

Serotonin 
Norepinephrine 
Acetylcholine 
Dopamine 
Histamine
Orexin

Question 2

Sleepiness Neurotranmitters

Answer 2

GABA
Melatonin
Adenosine

Question 3

Short term insomnia resolves in ____ weeks

Answer 3

3

Question 4

How long does long term insomnia last

Answer 4

More than 1 month

Question 5

Contraindications for antihistamines

Answer 5

Closed angle glaucoma

Urinary obstruction

Question 6

Antidepressants for insomnia

Answer 6

TCA's: amitriptyline 25 mg
  -High anticholinergic effects, 
    cardiac conduction, hypotension
Trazodone (25-100 mg)
   -Hangover effect, hypotension, priapism (rare)
   -Serotonin syndrome –with others
Mirtazepine (15-45 mg ; in elderly start at 7.5 mg)
   -Wt gain
   -Sedation decreases as dose increases

Question 7

Herbal insomnia remedies

Answer 7

Valerian Root - Thought to effect GABA

• “possibly effective”
• Avoid: pregnancy, hepatic disease

Melatonin – restores circadian rhythm

• “ likely effective”
• Avoid: pregnancy (vasoconstriction properties)

L-Tryptophan – precursor to serotonin and melatonin

Question 8

Most Commonly used agents in treatment of insomnia

Answer 8

ALL GABA AGONISTS:
Traditional BZD's
Zolpidem
Zaleplon
Eszopiclone

Question 9

Traditional BZD’s ADE’s

Answer 9

Daytime sedation / Performance impairment 
Psychomotor incoordination
Decreased concentration/cognitive effects
Falls/hips fractures (long half-live)
Anterograde amnesia (triazolam)
Rebound insomnia (triazolam)
Hallucinations/bizarre behavior
Tolerance in 2 wks (triazolam) - 1 month

Question 10

Why do BZD’s have limited use?

Answer 10

Increase time in Stage 2 sleep but decrease

time in REM, Stage 3 and Stage 4 sleep

Question 11

BZD with t1/2 of 39 hrs

Answer 11

Quazepam

Question 12

Onset of BZD’s

Answer 12

1-2 hrs

Question 13

Nonbenzodiazepine GABA agonists

Answer 13

Zolpidem
Zaleplon
Eszopiclone

Question 14

Nonbenzodiazepine GABA agonists used only for sleep latency

Answer 14

Zaleplon

Question 15

Nonbenzodiazepine GABA agonists dosing limits in elderly

Answer 15

Zolpidem and Zaleplon 5mg (CR 6.25)

Eszopiclone 1mg

Question 16

Sleep apnea, h/o substance abuse, COPD drugs

Answer 16

Ramelteon (Rozerem)

Question 17

Rx for shift workers to reduce excessive sedation

Answer 17

armodafinil / modafinil

Question 18

Rx for Jet Lag

Answer 18

Short acing nonbenzodiazepine GABA agonists
-Zolpidem
Ramelteon
Melatonin

Take at targeted bedtime in new time zone

Question 19

Rx for sleep apnea

Answer 19

No pharm tx
Avoid CNS Depressants
-BZD’s and Alcohol

Question 20

Tx for sleep apnea

Answer 20

oxygen CPAP and Bi-level PAP

Question 21

EDS Tx

Answer 21

armodafinil
modafinil
amphetamine
methylphenidate

Question 22

REM sleep abnormalities tx

Answer 22

Sodium oxybate (hydroxybutyrate)
TCA (imipramine, nortriptyline)
Venlafaxine
Fluoxetine
Selegiline
 -Limited clinical experience with high doses required

Question 23

Sodium oxybate (hydroxybutyrate)

Answer 23

Enrolled in Xyrem Patient Success Program
Dosed “BID”
  prepare both doses prior to sleep 
   – use within 24 hours
at bedtime (in bed) – 30 minute peak
2-4 hours later (alarm clock)

Question 24

RLS

Answer 24

Due to low dopamine levels in hypothalamic cells

Iron deficiency within the CNS

Question 25

RLS Tx

Answer 25

DA Agonists:
Pramipexole IR 0.125 mg up to 2 mg to HS
Ropinirole IR – 0.25 mg up to 4 mg
Rotigotine transdermal – 1-3 mg/24h