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Pharm Exam 3 > Stimulants and Sleep Aid > Flashcards

Stimulants and Sleep Aid Flashcards

1
Q

ADHD Treatment

A

Stimulants

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

Nonstimulants

  • Atomoxetine (Strattera)
  • Antidepressants (Bupropion, Desipramine)
  • Antihypertensives (Guanfacine, Clonidine)
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2
Q

Stimulants

Mixed amphetamine salts (Adderall)
Dextroamphetamine (Dexedrine)
Lisdexamfetamine (Vyvanse)
Methylphenidate (Ritalin)
Dexmethylphenidate (Focalin)
A
  • 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
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3
Q

Non-stimulants

A

Atomoxetine (Strattera)

Antidepressants

  • Bupropion
  • Desipramine

Antihypertensives

  • Guanfacine
  • Clonidine
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4
Q

Atomexetine (Strattera)

A
  • 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
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5
Q

d

A

d

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6
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d

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7
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d

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8
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d

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d

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9
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d

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d

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10
Q

Treatment Guideline

A

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
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11
Q

Insomnia

A
  • 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
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12
Q

Insomnia diagnostic criteria

A

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
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13
Q

Sedative-Hypnotics

A

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
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14
Q

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

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

A
  • 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
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15
Q

Zolpidem (Ambien)

- For Sleep onset and sleep maintenance insomnia

A
  • 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)
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16
Q

Eszopiclone (Lunesta)

- For Sleep onset and sleep maintenance insomnia

A
  • ADR: UNPLEASANT TASTE, HA, infection, next day impairment, parasomnia, anaphylaxis, angioedema
  • 3A4 substrate
  • Interactions with CNS depressants like EtOH
  • Quick onset, longer t1/2
17
Q

Zaleplon (Sonata)

- For sleep latency with rare next day impairment

A
  • 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
18
Q

Misc sleep aids

A

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

19
Q

Melatonin

- For sleep latency (jet lag, insomnia)

A
  • 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
20
Q

Ramelteon (Rozerem)

- For sleep latency

A
  • MOA: Melatonin receptor agonist
  • ADR: somnolence, fatigue, dizziness
  • Take on empty stomach
  • Avoid in LIVER problems
  • Not a controlled substance
  • CYP 1A2
21
Q

Tasimelteon (Hetlioz)

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

A
  • 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
22
Q

Suvorexant (Belsomra)

- Sleep latency and sleep maintenance

A
  • 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)
23
Q

Antidepressants

A

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

24
Q

Antipychotics

A

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
25
Q

OTC sleep aids

Dihenhydramine
Doxylamine

A
  • Usually contain 1st generation antihistamines
26
Q

Valerian root

A
  • 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
27
Q

Insomnia Treatment Guideline

A
  • 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

28
Q

Chronic Insomnia Guideline

A

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)

Pharm Exam 3 (5 decks)

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