TRAT Insomnia Dr. Thomason Flashcards
What is the main action of benzodiazepines in treating insomnia?
Benzodiazepines (BZD) increase total sleep time:
-reduce sleep latency (the time needed to fall asleep)
-increase stage 2 sleep
-decrease delta sleep
Which nonbenzodiazepine medication is often used for middle-of-the-night dosing?
-Zaleplon
-Zolpidem (special formualtion)
Which sedating antidepressant is FDA-approved specifically for sleep maintenance insomnia?
Low dose Doxepin (3-6mg)
What is the mechanism of action for dual orexin receptor antagonists (DORAs) like suvorexant?
it turns off wakening signals
Which insomnia medication is classified as a melatonin receptor agonist?
Ramelteon
Name a commonly used antihistamine in over-the-counter sleep aids.
Diphenhydramine and doxylamine
patients quickly experience tolerance to the sedative effects
-they have anticholinergic side effects -> should be avoided in elderly
What side effect is particularly common with the nonbenzodiazepine eszopiclone?
-somnolence
-unpleasant taste !!!
-headache
-dry mouth
What is one reason benzodiazepines are not recommended for older adults with insomnia?
the half-life is prolonged in older patients -> increases the potential for medication accumulation -> side effects: prolonged sedation, cognitive and psychomotor impairment
Which class of insomnia medications is associated with less risk of tolerance and dependence?
nonbenzodiazepine hypnotics are associated with less withdrawal and tolerance and rebound insomnia
What are the main adverse effects of trazodone?
-carryover sedation
-alpha-adrenergic blockade
-orthostasis (dangerous in the elderly)
-priapism (prolonged erection, rare)
What is a potential serious side effect of dual orexin receptor antagonists (DORAs) that patients should be aware of?
-somnolence
rare:
-sleep paralysis
-cataplexy
caution use in patients with depression -> it can worsen mood and trigger thoughts of suicide (dose-dependent)
Which benzodiazepine receptor agonist has the shortest half-life, making it suitable for sleep onset insomnia?
Triazolam
Which benzo to pick to get through the night but has a longer onset?
Tamezapem (Restoril)
Name nonpharmacologic approaches that should be encouraged alongside insomnia medication.
-cognitive behavioral therapy
-stimulus control therapy
-sleep restriction
-relaxation therapy
-cognitive therapy
-paradoxical intention
-biofeedback
-education on sleep hygiene
What is a common adverse effect of antihistamine sleep aids, especially in older adults?
-tolerance to sedative effects
-anticholinergic side effects: drowsiness, dry mouth, constipation, urinary retention
->especially in elderly
Which sedating antidepressant has a risk of causing daytime sedation?
Mirtazapine
also causes weight gain
What adverse effect is associated with higher doses of zolpidem in women?
-drowsiness
-dizziness
-headache
-amnesia
-gastrointestinal complaints
->dose related
Which class of medications binds selectively to GABA receptors to induce sleep but lacks muscle relaxant properties?
newer nonbenzodiazepine GABA agonists only possess sedative properties
Which herbal remedy is sometimes used for insomnia but lacks strong evidence for effectiveness?
Valerian
What is the primary use of zolpidem in treating insomnia?
-reduces sleep latency
-nocturnal awakening
-increases total sleep time
-no significant side effect of next-day psychomotor performance
What effect does food have on the absorption of zolpidem?
decreases the absorption
-should be taken on an empty stomach
What is the recommended zolpidem dose for women due to differences in drug metabolism?
5 mg
10 mg for men
Which zolpidem formulation is specifically used for middle-of-the-night awakenings?
reduced strength formulation
1.75 mg
3.5 mg
-SR: for the increase of total sleep time
-sublingual: to reduce sleep latency
What unique behavior-related side effect is associated with zolpidem?
sleep eating (causes patients to eat while asleep)
Why might zaleplon be preferred over other sleep aids for sleep onset insomnia?
-quick onset
-because of its short half-life? (1 hour)
-metabolized to an inactive metabolite (none of the non-benzodiazepine GABA agonists have significant metabolites)
What is the typical half-life of zaleplon, making it effective for rapid sleep induction?
1 hour
Which two adverse effects are commonly reported with zaleplon use?
-dizziness
-headache
-somnolence
What drug interaction should be avoided with zaleplon due to increased plasma levels?
Cimetidine (CYP inhibitor)
(plasma level decreases with Rifampin use)
What is a common withdrawal symptom associated with abrupt discontinuation of benzodiazepines?
rebound insomnia (increased wakefulness may last for a few nights)
->use lowest effective dose
Which benzodiazepines have a long half-life, making it less suitable for elderly patients due to prolonged sedation?
flurazepam (Dalmane)
quazepam (Doral)
What is the primary reason benzodiazepines are not recommended for patients with a history of substance use disorders?
potential for abuse, dependence and addiction
Which specific cognitive side effect is commonly reported with benzodiazepines, especially at higher doses?
-daytime sedation
-psychomotor incoordination
-cognitive deficits
What FDA-required warning is included in the labeling of benzodiazepines and benzodiazepine receptor agonists like zolpidem?
-anaphylaxis
-angioedema
-complex sleep behaviors (sleep driving, phone calls, sleep eating)
Which class of medications, including zaleplon, is associated with less disruption of sleep architecture than traditional benzodiazepines?
nonbenzodiazepine GABA agonists
Zolpidem
What is a key difference in the duration of action between zolpidem and zaleplon?
Zolpidem has a duration of action of 6-8h
Zaleplon’s duration of action is shorter (3-4h?)
For what reason might zaleplon be used as a “rescue” sleep aid in the middle of the night?
-rapid-onset
-short half-life (1 hour)
-no effects on next-day psychomotor performance
