Sleep Disorders Treatment

Question 1

Goals of therapy

3

Answer 1

1. Promote patient’s ability to fall asleep, maintain sleep, and awaken refreshed
2. Use med for as short a time as possible
3. Use minimal dose with least amount of side-effects

Question 2

Benzodiazepines

7

Answer 2

1. Alprazolam (Xanax)
2. Estazolam (ProSom)
3. Flurazepam (Dalmane)
4. Lorazepam (Ativan)
5. Quazepam (Doral)
6. Temazepam (Restoril)
7. Triazolam (Halcion)

Question 3

Benzodiazepines MOA?

3

Answer 3

MOA
1. Selectively acts on polysynaptic neuronal pathways throughout the CNS

2. Enhance the effects of GABA (an inhibitory neurotransmitter) in the CNS
3. Insomnia
   - -Facilitate the effects of GABA in the ascending reticular activating system

Question 4

Benzos are divided into which three categories?

Answer 4

1. Short acting
2. Intermediate acting
3. Long acting

Question 5

Which drugs are in each category:
1. Short acting 1

2. Intermediate acting 2
3. Long acting 2

Answer 5

1. Triazolam (Halcion)
2. • Temazepam (Restoril)
   • Estazolam (ProSom)
3. • Flurazepam (Dalmane)
   • Quazepam (Doral)

Question 6

Benzo Adverse events

3

Answer 6

1. Drowsiness
2. Impaired motor function
3. Prolonged use
   - Physical dependency

Question 7

Benzos

1. Drug interactions? 2
2. Contraindications? 3

Answer 7

1. Interactions
   - Caution with alcohol
   - Low-dose contraceptives
2. Contraindications
   - Acute narrow-angle glaucoma
   - Preg X
   - Lactation

Question 8

Benzodiazepine Receptor Agonists (BRA)

1. Developed why?
2. Half life?
3. Has greater receptor specificity of the what?

Answer 8

1. to improve the safety profile of barbiturate-type compounds
2. Have short half-life
   5 hours
3. GABAa BZ complex

Question 9

Benzodiazepine Receptor Agonists (BRA): Drugs in this category?
3

Answer 9

Drugs

1. Eszopiclone (Lunesta)
2. Zolpidem (Ambien)
3. Zaleplon (Sonata)

Question 10

Eszopiclone (Lunesta)

MOA?

Answer 10

Interacts with GABA receptors located near benzodiazepine receptors

Question 11

BRAs: Dosage

1. Start with?
2. Can be started or increased to?
3. Elderly dosing?

Answer 11

1. Start at 2mg immediately before bed
2. Can be started or increased to 3mg to aid in sleep maintenance
3. Elderly
   Start 1mg to help fall asleep
   2mg for sleep maintenance

Question 12

Eszopiclone (Lunesta)

1. Adverse affects? 3
2. Contraindications? 1
3. Preg cat?

Answer 12

1. Adverse events
   - HA
   - Dry mouth
   - Dizziness
2. Contraindications
   - Hypersensitivity
3. Preg C

Question 13

Zolpidem (Ambien, Ambien CR)

1. MOA?
2. Dosage? 2

Answer 13

1. MOA
   Modulates the GABA receptors to suppress neurons
2. Dosage
   - 5-10mg PO qhs
   - Extended release
3. 25-12.5mg PO qhs

Question 14

Zolpidem

1. Adverse affects? 3
2. Contraindications? 1
3. Preg?

Answer 14

1. Adverse events
   - Morning drowsiness
   - Hangover
   - HA
2. Contraindications
   - Hypersensitivity
3. Preg C

Question 15

Zaleplon (Sonata)

1. MOA?
2. Dosage?
   - Start at?
   - Range from?

Answer 15

1. MOA
   Interacts with GABA-BZ omega 1 receptor
2. Dosage
   Start: 10mg PO qhs
   Range 5-20mg qhs

Question 16

Zaleplon

1. Adverse affects? 3
2. Contraindications? 1
3. Preg?

Answer 16

1. Adverse Events
   - Back or chest pain
   - Migraine
   - Constipation
2. Contraindications
   - Hypersensitivity
3. Preg C

Question 17

Most commonly used classes of OTC sleep-inducing agents?

Specific agent?

Answer 17

Antihistamines

Diphenhydramine (Benadryl)

Question 18

Antihistamines:
Diphenhydramine (Benadryl)
1. MOA?
2. Dosage?
3. Adverse affects? 2

Answer 18

1. MOA
   Unknown, but acts as a CNS depressant
2. Dosage
   - 25-50mg qhs
3. Adverse Events
   - Excessive daytime drowsiness
   - Impaired psychomotor function

Question 19

Antidepressants
3

Newer agents? 2

Answer 19

1. Imipramine (Tofranil)
2. Amitriptyline hydrochloride (Elavil)
3. Nortriptyline (Pamelor)

Newer agents

1. Nefazodone hydrochloride (Serzone)
2. Venlafaxine (Effexor)

Question 20

Doxepin (Silenor)

1. MOA?
2. Dosage?
3. Adverse effects? 4

Answer 20

1. MOA
   Increases synaptic concentrations of serotonin and norepinephrine in the CNS
2. Dosage
   - 3-6mg within 30 min of bedtime
3. Adverse Events
   - Drowsiness
   - Dizziness
   - Constipation
   - Blurred vision

Question 21

Doxepin (Silenor)

1. Contraindications? 2
2. BBW?
3. Preg cat?

Answer 21

1. Contraindications
   - Glaucoma
   - Urinary retention
2. Black Box Warning
   - Suicide thinking/behavior
3. Preg C

Question 22

Trazodone
MOA? 3

Dosage?

Answer 22

MOA

1. Inhibits reuptake of serotonin
2. Causes adrenoreceptor subsensitivity
3. Induces change in 5-HT presynaptic receptor adrenoreceptors

Dosage
50-100mg before bedtime

Question 23

Trazodone

1. Adverse affects?
2. Contraindications? 2
3. Preg cat?
4. BBW?

Answer 23

1. Adverse Events
   - Dizziness
   - drowsiness
2. Contraindications
   - Use of MAO inhibitors
   - Patients receiving linezolid or IV methylene blue
3. Preg C
4. Black box warning
   Suicidal thoughts

Question 24

Amitriptyline (Elavil)

1. MOA?
2. Dosage?
3. Adverse affects? 3

Answer 24

MOA
1. Increases synaptic concentration of serotonin and/or norepinephrine in CNS

2. Dosage
   25-50mg at bedtime
3. Adverse Events
   - Sedation
   - Dizziness
   - HA

Question 25

Amitriptyline 1. Contraindications? 2 2. Preg cat? 3. BBW?

Answer 25

1. Contraindications - History of MI - MAOIs 2. Preg C 3. Black box warning Suicidal thoughts

Question 26

Melatonin Agonist? 1

Answer 26

Ramelteon (Rozerem)

Question 27

Ramelteon (Rozerem) 1. MOA? 2. Dosage? 3. Adverse effects? 3 4. Contraindications? 1 5. Preg cat?

Answer 27

1. MOA Potent, selective agonist of melatonin receptors MT1 and MT2 within the suprachiasmic nucleus of the hypothalamus 2. Dosage 8mg daily within 30 min of bedtime 3. Adverse Events - Somnolence - HA - Fatigue 4. Contraindications Fluvoxamine (Luvox) 5. Preg C

Question 28

Orexin Receptor Antagonist?

Answer 28

Suvorexant (Belsomra)

Question 29

Suvorexant (Belsomra) 1. MOA? 2. Dosage?

Answer 29

1. MOA Blocks binding of wake-promoting neuropeptides orexin A and orexin B to receptors OZ1R and OX2R 2. Dosage 10mg once daily within 30min of bedtime (max 20mg)

Question 30

Suvorexant 1. Adverse effects? 3 2. Contraindications? 1 3. Preg cat?

Answer 30

1. Adverse Events - Drowsiness - HA - Abnormal dreams 2. Contraindications Narcolepsy 3. Preg C

Question 31

1. First line for narcopelsy? 2. MOA? 3. Adverse affects? 3 4. Preg cat?

Answer 31

1. Modafinil (Provigil)/Armodafinil (Nuvigil) 2. MOA: not well understood, but may increase dopaminergic signaling 3. Adverse Events - HA - Nausea - Nervousness - Dry mouth 4. Preg C

Question 32

1. Narcolepsy second line? 2. MOA? 3. Common side effects? 4. Preg cat? 5. BBW? 2

Answer 32

1. Dextroamphetamine 2. MOA: not well understood, but stimulates CNS activity; blocks reuptake and increases release of norepinephrine and dopamine in extraneuronal space (sympathomimetic) Dose: 10mg daily 3. Side-effects common - HTN - Anorexia - Addiction 4. Preg C Black Box -High abuse potential -Cardiac events

Question 33

REM Sleep Behavior Disorder 1. First line therapy? 2. MOA? 3. SE? 3

Answer 33

1. Melatonin (First-line therapy) 2. MOA: Prepares the body for sleep Doses: 0.5-10mg PO qhs 3. Side-effects - Abnormal heartbeat - Dizziness - fatigue

Question 34

Movement Disorder Dopaminergic agents? 3 MOA?

Answer 34

1. Pramipexole (Mirapex) 2. Ropinirole (Requip) 3. Rotigotine (Neupro) stimulation of postsynaptic dopamine D2-type receptors within the caudate putamen in the brain

Question 35

1. Dopaminergic agents SE? 2 | 2. Preg cat?

Answer 35

1. Adverse Events - Nausea - Lightheadedness 2. Preg C

Question 36

``` Movement disorder Anticonvulsants 1. Which drug? 2. MOA? 3. Adverse effects? 3 4. Preg cat? ```

Answer 36

1. Gabapentin (Neurontin) 2. MOA Thought to reduce presynaptic GABA release --Dosage Initial: 300mg daily 2 hours before bed 3. Adverse Events - Fatigue - Dizziness - Blurred vision 4. Preg C