Sleep tx Flashcards
Things associated w insomnia
-anxiety
-hyperthyroidism
-caffeine
-modafinil
-amphetamines
-B-agonists
-B-blockers
-nicotine
-thyroid meds
-bupropion
-decongestants
-methylphenidate
DSM5 insomnia disorders
-difficulties w sleep initiation, maintenance, waking
-3x week
-at least 3 months
Sleep onset only rx options
-zaleplon
-traizolam
-eszopiclone
-zolpidem
-ramelteon
Sleep maintenance only rx options
-suvorexant
-doxepin
-eszopiclone
-zolpidem
Sleep onset AND maintenance options
-eszopiclone
-zolpidem
-temazepam
Treatment of insomnia
-first line is non-pharm (CBT and behavior tx)
-z-hypnotics most commonly used
-benzos (temazepam) (insomnia)
-melatonin agonists (onset)
-orexin antagonists (onset/maintenance)
-doxepin
z-hypnotic drugs
-zolpidem
-eszopiclone
-zaleplon
z-hypnotic counseling points
-initial dose of zolpidem is lower (5mg) in women and elderly
-3a4 substrates, caution inhibition/induction
-controlled/abusable
z-hypnotic side effects
-eszopiclone: metallic taste
-somnolence
-dizziness
-ataxia
-headaches
-parasomnias (sleepwalking-caution)
-additive effects with other CNS depressants
All medications for insomnia warn for
-sleep behaviors
Melatonin receptor agonists drugs
-Ramelteon
-Tasimelteon
-1A2 substrates
Ramelteon
-melatonin receptor agonists
-AVOID w fluvoxamine
-GI upset, somnolence, hyperprolactinemia, prolactinoma
-1A2 substrate
Tasimelteon
-melatonin agonist
-FDA for non-24 sleep wake disorder in adults
-1A2 substrates
Orexin receptor antagonist drugs
-Suvorexant
-Lembroexant
-Daridorexant
-3A4 substrates
Orexin antagonist counseling
-at least 7 hours to sleep
-AVOID in narcolepsy
-narcolepsy-like side effects
-3A4 substrates
Doxepin
-TCA
-low dose work through H1 ANTAgonism
-anticholinergic effects
Trazodone
-not FDA for insomnia
-long half-life: day-time hangover
Mirtazapine
-sleep agent in pt w depression and insomnia
Quetiapine
-low dose not recommended unless co-morbid psychiatric disorder
Diphenhydramine/Doxylamine
-not recommended by AASM
Melatonin
-consider in jet lag and pt w low levels
-1A2
German chamomile
-allergy in pt w daisy/ragweed allergies
Kava
-not recommended bc hepatotoxicity
DSM-5 obstructive sleep apnea
-at least 5 apneas per hour confirmed by polysomnography
-excessive sleepiness
-snoring
-pauses in breathing
-headache
-irratibility
-sore throat
-erectile dysfunction
-memory probs
-GERD
-mood probs
-many pt have apnea and insomnia = treat apnea first
Diagnostic testing for apnea
-polycomnography only if:
-significant cardiorespiratory disease
-potential resp muscle weakness due to neuro-musc condition
-sleep-related hypoventilation
-chronic opiod med use
-hx of stroke
-severe insomnia
Sleep apnea tx
-wt loss
-smoking cessation
-avoid alc and CNS depressants
-sleep on side
-CPAP (continuous positive airway pressure)
-excessive daytime sleepiness tx w modafnil or armodafnil (assess CPAP adherence first and possibility of RLS or PLMS)
Sleep apnea + insomnia tx
-tx apnea before insomnia
-in obese pt w insomnia, rule out apnea
Excessive daytime sleepiness (EDS) tx in sleep apnea
-modafnil or armodafnil
-reveiw CPCP adherence first and posibility of RLD or PLMS
DSM-5 Narcolepsy
-recurring episodes of irresistible need to sleep
-3x week
-past 3 months
Narcolepsy tetrad
-EDS in 100% of pt (more severe in type I (cataplexy or hypocretin deficiency)
-cataplexy: sudden loss of muscle tone triggered by emotion (75%)
-hallucinations 30-60%
-sleep paralysis 25-50%
-all four 10-33%
Narcolepsy tx
-tx cataplexy
- tx EDS
Tx of cataplexy in narcolepsy
-sodium oxybate: GHB, high sodium
-Xywav: ages 7+, tx idiopathichypersomnia in adults, lower sodium
-Lumryz: adults only, ER dose, once nightly, high sodium
Excessive Daytime Sleepiness (EDS) tx in narcolepsy
-modafinil/armodafnil: possible fatal rash
-sodium oxybate
-pitolisant and solriamfetol recently approved
Pitolisant
-H3 antagonist/ inverse agonist
-AVOID in hepatic impairment
-prolongs QTc
-AVOID H1 antagonists (antihistamines)
-2d6/3A4 substrate
-weak 3A4 inducer (may dec oral birth control effectiveness)
Solriamfetol
-dopamine NE reuptake inhibitor (DNRI)
-indicated for improvement in wakefulness in adults w excessive daytime sleepiness due to narcolepsy or sleep apnea
-if mod renal impairment: start 37.5mg inc to max 75mg after 7 days
-if severe renal impairment: starting and max dose is 37.5mg
solriamfetol renal dosing
-if mod renal impairment: start 37.5mg inc to max 75mg after 7 days
-if severe renal impairment: starting and max dose is 37.5mg
solriamfetol side effects
-BP and HR inc
-AVOID in unstable CVD and arrhythmias
-caution in psychosis/bipolar: dec dose if psyc sx develop
-caution w dopaminergic drugs
Shift work sleep disorder tx (EDS except D is “wake-time”)
-modafinil and armodafinil
-take 1 hour before work period starts during “wake time”
Restless leg syndrome tx
-gabapentin enacarbil (prodrug of gabapentin, approved for RLS, may be first line)
-dopamine agonists (IR): pramipexole or ropinirole
-consider iron supplementation
