Sleep disorders/ADHD Flashcards
Insomnia disorders
chronic
short-term
“other” sleep disorders
restless leg syndrome (Willis-Ekbom disease)
obstructive sleep apnea
REM v NREM sleep
REM brain is active and dreaming occurs (20% of sleep)
NREM deep rest where pulse, respiration, and brain activity slow (80% of sleep)
sleep cycle
light NREM, deep NREM, REM, repeat
hypnotic use for insomnia
lowest effective dose for shortest duration of time
intermediate acting BZDs
temazepam
lorazepam
long acting BZD
flurazepam
triazolam and erythromycin
must reduce triazolam dose by 50%
oral contraceptives and BZDs
low dose contraceptives may decrease clearance of lorazepam and temazepam
main differences between BZDs and BZRAs
BZRAs do not induce anxiolysis or muscle relaxation
BZRA drugs
eszopiclone (Lunesta)
zolpidem (Ambien)
zolpidem tartrate (Intermezzo)
zaleplon (Sonata)
eszopiclone (Lunesta) and high fat meal
peak concentration can be delayed if taken with a high fat meal
starting dose of zolpidem
lower for females than males
zaleplon (Sonata) dosing
can be dosed a second time during the night as long as there is at least 4-5 hours of sleep time remaining
contraindications for zaleplon (Sonata)
concomitant use of sodium oxybate (Xyrem) or any type of fentanyl or valerian
Orexin receptor antagonist medication
suvorexant (Belsomra)
planned sleep time for Belsomra
at least 7 hours d/t risk of complex sleep behaviors
suvorexant (Belsomra) contraindications
narcolepsy
alcohol use
melatonin receptor agonist
ramelteon (Rozerem)
administration of ramelteon (Rozerem)
avoid with high fat meal
contraindications for ramelteon (Rozerem)
severe sleep apnea
severe hepatic impairment
angioedema
antihistamines used for sleep
diphenhydramine typically
most common antidepressants used for sleep
mirtazepine trazadone doxepine (Silenor)
1st line therapy for short term insomnia
BZD
BZRA
ramelteon
only sleep med designated as pregnancy category A
doxylamine
2nd line therapy for insomnia
alternate short acting BZRA or ramelteon
3rd line therapy for insomnia
consider other sedating agents such as gabapentin or AAP
what medications should be avoided in the elderly for insomnia
first-generation antihistamines
short or intermediate acting BZDs
difference between restless leg and periodic limb movement disorder
PLMD occurs exclusively during sleep
medications that may precipitate or worsen RLS/WED
antidepressants
dopamine antagonists
pharmacologic agents for RLS/WED
dopaminergic agents dopamine agonists opioids BZDs anticonvulsants Iron
dopamine agonists used for RLS/WED
ropinirole (Requip)
pramipexole (Mirapex)
rotigotine transdermal (Neupro)
BZDs in RLS/WED
used as adjunctive therapy with a dopaminergic drug when monotherapy has failed
when would you use an anticonvulsant for RLS/WED
when they describe the sensation as pain (gabapentin enacarbil)
“other” features of narcolepsy
excessive daytime sleepiness
cataplexy (attacks of muscle weakness)
sleep paralysis
hypnagogic hallucination
cataplexy attacks in narcolepsy
typically precipitated by highly specific situations or triggers of strong emotion
pharmacologic agnets for tx of narcolepsy
psychostimulants
amphetamines
sodium oxybate
antidepressants
psychostimulants for narcolepsy
Modafinil and armodafinil
most commonly used amphetamine to tx narcolepsy
methylphenidate (Ritalin)
antidepressants that may be useful when cataplexy is present
venlafaxine (Effexor)
duloxetine (Cymbalta)
what influences the expression of ADHD symptoms
concentrations of available dopamine and norepinephrine and the functionality of their receptors
initiation of methylphenidate in children with ADHD
4-5 CBT and methylphenidate if symptoms are severe
5+ meds if symptoms severe =/- CBT
in children >6 no preference is given to one stimulant over another
mechanism of action of stimulants for ADHD
amphetamines directly stimulate release of dopamine and norepinephrine and inhibit their reuptake
contraindication to stimulant medication for ADHD
marked anxiety, tension, or agitation glaucoma hx of ticks cardio disease/mod-severe HTN hyperthyroidism hx of substance abuse
nonstimulant medications for ADHD
atomoxetine (Strattera) guanfacine IR and ER (Tenex, Intuniv) Clonidine IR and ER (Catapres, Kapvay) bupropion (Wellbutrin) TCA antidepressants
divergence in normal dosing of atomoxetine (Strattera)
starting dose should be maintained x4 weeks before titration in slow metabolizers or in patients taking agents with strong CYP2D6 effects (fluoxetine, paroxetine)
typical time frame to make dose adjustments in strattera
within the first week
contraindications to atomoxetine (Strattera)
MAOIs, narrow-angle glaucoma
who should you prescribe Strattera to cautiously
HTN and underlying cardio disorders
boxed warning for Strattera
may cause hepatotoxicity and SI in children and adolescents
indication for prescribing a-agonists (clonidine, guanfacine)
adjunctive for ADHD (particularly in children) to tx behavioral manifestations, aggression, insomnia, tics
abrupt discontinuation of clonidine or guanfacine
may precipitate HTN crisis
guanfacine and clonidine interactions
avoid concomitant use of other CNS depressants
1st line therapy for ADHD
stimulants unless there are contraindications
2nd line therapy for ADHD
atomoxetine (Strattera)
3rd line therapy for ADHD
bupropion or a2-agnonists (clonidine, guanfacine) may be considered as monotherapy or adjunctive therapy
