Sleep Disorders - Treatment

Question 1

What is the recommended treatment for transient, acute insomnia?

Answer 1

• Sleep hygiene
• Usually self-limiting

Question 2

What is the recommended treatment for short-term acute insomnia?

Answer 2

• Sleep hygiene
• Short PRN course of hypnotic may be considered – x7-10/7 (up to 2-4/52)

Question 3

What is the recommended management for chronic insomnia?

Answer 3

• Investigate and manage underlying causes/conditions
• Sleep hygiene
• Discourage long-term use of hypnotics

Question 4

Who should benzodiazepines be avoided in?

Answer 4

• Renal or hepatic impairment (avoid if severe), children, elderly and the debilitated
• Pregnancy and breastfeeding: avoid use unless potential benefits clearly outweigh risks
• Hx of drug/alcohol abuse or psychiatric disorders
• Omit Benzodiazepine dose before ECT
• Benzodiazepines + Opioids = Inc mortality (profound CNS depression, avoid combination if possible, or limit doses and duration)

Do not admin in acute narrow angle glaucoma, acute pulmonary insufficiency, resp depression, sleep apnea, marked neuromuscular resp weakness inc unstable myasthenia gravis

Question 5

How should benzodiazepines be tapered?

Answer 5

• Low-mod dose: ↓TDD 20-25% Q1/52 (keep in mind available strengths)
• Extended-high dose: ↓TDD 25% Q1-2/52 – more aggressive at start, then slow down (warn at beginning of mild withdrawal Sx, can consider long-acting BZD to help)

Question 6

What is the MOA of Z-hypnotics?

Answer 6

Preferentially binds to BZD-binding sites w γ and α1 subunits (causes sedation)

Question 7

What are the side effects of the Z-hypnotics?

Answer 7

Taste disturbance (zopiclone)

Less commonly N/V, dizziness, drowsiness, dry mouth, headache

Rarely amnesia, confusion, hallucinations, nightmares, complex sleep behaviours

Question 8

What is the MOA of melatonin receptor agonists?

Answer 8

MT1 & MT2 agonist, relieves insomnia

Question 9

What are the side effects of melatonin receptor agonists?

Answer 9

Headache

Question 10

What is the MOA of Lemborexant?

Answer 10

OX1 and OX2 orexin receptor antagonist

Question 11

What are the side effects of lemborexant?

Answer 11

Somnolence, nightmare

Uncommon: sleep paralysis, hypnagogic, hypnopompic hallucinations, cataplexy-like Sx

Question 12

Who should lemborexant be avoided in?

Answer 12

Avoid in narcolepsy, moderate-strong CYP3A inhibitors/inducers, severe hepatic impairment

Question 13

What is the MOA of Trazodone for insomnia?

Answer 13

Inhibit 5HT reuptake
Antagonize 5HT2A, H1, α1 receptors

Question 14

What are the side effects of trazodone for insomnia

Answer 14

Sedation, orthostatic hypotension
Rarely, priapism

Question 15

What is the difference between Zopiclone and Zolpidem?

Answer 15

Zolpidem is shorter acting than zopiclone
* If issue is falling asleep AND THEN unable to stay asleep, zopiclone is better
* If staying asleep not an issue, zolpidem better