Stimulants - Mixed amphetamine salts (Adderall) - Dextroamphetamine (Dexedrine) - Lisdexamfetamine (Vyvanse) - Methylphenidate (Ritalin) - Dexmethylphenidate (Focalin) Nonstimulants - Atomoxetine (Strattera) - Antidepressants (Bupropion, Desipramine) - Antihypertensives (Guanfacine, Clonidine)

Atomoxetine (Strattera) Antidepressants - Bupropion - Desipramine Antihypertensives - Guanfacine - Clonidine

Peds - First line: Cognitive Behavioral Therapy, stimulants - Second line: Atomoxetine - Third line: Alpha agonist, antidepressants Preschool kids: behavioral therapy, meds if moderate to severe sx Adults - First line: stimulants - Second line: antidepressants

- Most common sleep disorder in general population - Dissatisfaction with sleep quality or quantity - Difficulty with sleep initiation, duration or quality despite adequate opportunity for sleep - More common in women and older adults - Fatigue, poor cognitive function, mood disturbance, distress, interference with personal functioning

Benzodiazepines - No longer used frequently - Daytime sedation, cognitive impairment, increased risk of falls in elderly, tolerance, dependence Temazepam (Restoril) - Still used - Short term treatment up to 2 weeks Triazolam (Halcion) - Amnestic - Used for pre op anxiety

Stimulants and Sleep Aid Flashcards by Amy Yu

ADHD Treatment

Stimulants

Mixed amphetamine salts (Adderall)
Dextroamphetamine (Dexedrine)
Lisdexamfetamine (Vyvanse)
Methylphenidate (Ritalin)
Dexmethylphenidate (Focalin)

Nonstimulants

Atomoxetine (Strattera)
Antidepressants (Bupropion, Desipramine)
Antihypertensives (Guanfacine, Clonidine)

How well did you know this?

Not at all

Perfectly

Stimulants

Mixed amphetamine salts (Adderall)
Dextroamphetamine (Dexedrine)
Lisdexamfetamine (Vyvanse)
Methylphenidate (Ritalin)
Dexmethylphenidate (Focalin)

MOA: Sympathomimetics (increase NE/DA in brain by blocking reuptake)
ADR: INSOMNIA, DECREASED APPETITE, WT LOSS, HTN, arrhythmia, anxiety, panic, agitation
WARNING: CV (Sudden death/CVA/MI in adults; Sudden death in kids with structural abnormalities; need CV history); Psychosis exacerbation; Growth suppression; Peripheral vasculopathy (Raynaud’s)
CONTRAINDICATION: MAOIs, anxiety, agitation
CII

How well did you know this?

Not at all

Perfectly

Non-stimulants

Atomoxetine (Strattera)

Antidepressants

Bupropion
Desipramine

Antihypertensives

Guanfacine
Clonidine

How well did you know this?

Not at all

Perfectly

Atomexetine (Strattera)

MOA: selective NE reuptake inhibiter
PEDS ADR: N/V, decreased appetite, fatigue, somnolence
ADULT ADR: decreased appetite, insomnia, N/C, dry mouth, fatigue, erectile dysfunction, urinary hesitation, urinary retention, dysuria, dysmenorrhea, flushing
WARNING: increased risk of suicidal ideation in children and adolescents; CV events; Increased BP and HR; Liver injury; Psychosis; Urinary retention, priapism
DRUG INTERACTION: 2D6 inhibitors, MAOIs, albuterol (also stimulating)
Not controlled substance

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

How well did you know this?

Not at all

Perfectly

Treatment Guideline

Peds

First line: Cognitive Behavioral Therapy, stimulants
Second line: Atomoxetine
Third line: Alpha agonist, antidepressants

*Preschool kids: behavioral therapy, meds if moderate to severe sx

Adults

First line: stimulants
Second line: antidepressants

How well did you know this?

Not at all

Perfectly

Insomnia

Most common sleep disorder in general population
Dissatisfaction with sleep quality or quantity
Difficulty with sleep initiation, duration or quality despite adequate opportunity for sleep
More common in women and older adults
Fatigue, poor cognitive function, mood disturbance, distress, interference with personal functioning

How well did you know this?

Not at all

Perfectly

Insomnia diagnostic criteria

Symptoms

Cause significant functional distress or impairment
Present for > 3 nights per week for at least 3 months
Not be linked to other disorders
Older pts more likely to have difficulty maintaining sleep

How well did you know this?

Not at all

Perfectly

Sedative-Hypnotics

Benzodiazepines

No longer used frequently
Daytime sedation, cognitive impairment, increased risk of falls in elderly, tolerance, dependence

Temazepam (Restoril)

Still used
Short term treatment up to 2 weeks

Triazolam (Halcion)

Amnestic
Used for pre op anxiety

How well did you know this?

Not at all

Perfectly

BDZ receptor agonist (BZRAS)
- First line for short term treatment of insomnia

Zolpidem (Ambien)
Escopiclone (Lunesta)
Zaleplon (Sonata)

MOA: selectively binds GABA receptor at BDZ 1 site; targeted to sedation (no anxiolysis, anticonvulsant effects)
Taken on empty stomach
No EtOH
Lower risk of dependence than BDZ
CIV

How well did you know this?

Not at all

Perfectly

Zolpidem (Ambien)

- For Sleep onset and sleep maintenance insomnia

ADR: rebound insomnia; PARASOMNIA (sleep driving, sleep eating); drowsiness, dizziness; allergic reaction, angioedema; dry mouth; abd pain; HA; abnormal thinking; strange behavior; next day impairment (counsel pts on avoiding driving next day, particularly with CR formulation)
DRUG INTERACTIONS: 3A4 substrate
Preg Cat C
Short t1/2, so need CR form for sleep maintenance
Take immediately before bedtime
Best to limit use to 2-4 weeks (CR form up to 6 months)

How well did you know this?

Not at all

Perfectly

Eszopiclone (Lunesta)

- For Sleep onset and sleep maintenance insomnia

ADR: UNPLEASANT TASTE, HA, infection, next day impairment, parasomnia, anaphylaxis, angioedema
3A4 substrate
Interactions with CNS depressants like EtOH
Quick onset, longer t1/2

Zaleplon (Sonata)

- For sleep latency with rare next day impairment

Can be taken upon nocturnal awakening if pt has 4 hrs left to sleep
ADR: HA, dizziness, somnolence, complex behaviors, anaphylaxis
Rapid onset, short t1/2

Misc sleep aids

Melatonin
Ramelteon (Rozerem)
Tasimelteon (Hetlioz)
Suvorexant (Belsomra)

Melatonin

- For sleep latency (jet lag, insomnia)

MOA: Hormone produced by pineal gland
ADR: daytime drowsiness, HA, dizziness
No driving or operating heavy machinery 4-5 hrs after use
Perimenopausal women: resumption of menstrual flow
DRUG INTERACTION: potentiates anticoagulants, inhibits AEDs, decreased BP, increased hyperglycemia

Ramelteon (Rozerem)

- For sleep latency

MOA: Melatonin receptor agonist
ADR: somnolence, fatigue, dizziness
Take on empty stomach
Avoid in LIVER problems
Not a controlled substance
CYP 1A2

Tasimelteon (Hetlioz)

- First treatment for non 24 hr sleep-wake disorder (ppl with total blindness)

MOA: Melatonin receptor agonist
ADR: Somnolence, HA, increase LFT, nightmares, unusual dreams, URI, UTI
DRUG INTERACTIONS: strong CYP 1A2 inhibitors, strong CYP 3A4 inducers
Potential harm during pregnancy
Not for HEPATIC impairment

Suvorexant (Belsomra)

- Sleep latency and sleep maintenance

MOA: Orexin receptor antagonist (suppress wake drive)
ADR (dose dependent): next day impairment; complex behaviors; depression; decreased resp fxn; hallucinations; sleep paralysis
CONTRAINDICATION: narcolepsy
CIV
3A4 substrate: lower dose with inhibitors
Take no more than 30 min before bed (Need > 7 hrs available for sleep)

Antidepressants

Doxepin (Silenor)

USE: Antihistamine effects for sleep onset and maintenance
ADR: daytime sedation, dry mouth, dry eyes, orthostasis, arrhythmias
CONTRAINDICATION: urinary retention, glaucoma, MAOIs
WARNING: suicide risk

Other antidepressants: amitriptyline, nortripyline, mirtazapine

Antipychotics

Low dose Quetiapine/Olanzapine
- Metabolic and neurologic side effects (major concern even at low doses)

More effective

Comorbid psychosis or bipolar disorder
Refractory insomnia
Comorbid substance abuse

OTC sleep aids Dihenhydramine Doxylamine

- Usually contain 1st generation antihistamines

Valerian root

- Sedative hypmotic, anxiolytic, antidepressant, anticonvulsant, antispasmodic effects - Modest improvement in sleep latency - ADR: HA, GI upset, mental dullness, excitability, uneasiness, cardiac disturbances, insomnia - Associated hepatotoxicity but may have been adulterating substances

Insomnia Treatment Guideline

* Goals* - Improve sleep quality and quantity - Improve insomnia-related daytime impairments * Cognitive behavioral therapy* - Good sleep hygiene *Pharmacologic Treatment* First line - BZD (Temazepam) or BZRA (Zolpidem, eszopiclone, zaleplon) or Ramelteon - Alternate if initial treatment unsuccessful Second line - Sedating antidepressant - BZRA + sedating antidepressant - Atypical antipsychotics if used for other indication Antihistamines not recommended for chronic insomnia

Chronic Insomnia Guideline

First line: CBT (sleep hygiene) Meds for 4-5 weeks - Eszopiclone, zolpidem, suvorexant Use of hypnotics for insomnia associated with risk for dementia, fractures, major injury (Cognitive impairment-- including driving)