Sleep disorders

Question 1

DSM5 insomnia disorder diagnosis

Answer 1

difficulties with sleep initiation, sleep maintenance, and/or early morning awakening

takes place at least 3 nights per week
and present for 3 months

Question 1

Medications, disease states, and substances that cause insomnia - EXAM Q

Answer 1

Anxiety and mood disorders

caffeine, modafinil, amphetamines, beta-agonists, nicotine, thyroid meds, bupropion, decongestants, methylphenidates

Question 2

Treatment of insomnia disorder

Answer 2

First line treatment is non pharm : want to assess the patients night time routine
If nonpharm does not work then Zolpidem, eszopiclone, zaleplon (z-hypnotics) are most commonly used
- 3A4 substrates
- SE: somnolence, dizziness, ataxia, headaches
- initial dose of zolpidem is lower in women and elderly - 5mg
- Eszopiclone (lunesta) has metallic taste
- Can cause parasomnias
- controlled substance
- additive effects with other CNS depressants

Question 3

Treatment of Insomnia disorder part 2

Answer 3

Temazepam is the benzodiazepine used for sleep
SE: drowsiness, dizziness, cognitive impairment, increased fall risk
ALL medications FDA-approved for insomnia have sleep behavior warnings (sleep sex, sleep driving)

Question 4

Melatonin receptor agonists

Answer 4

Ramelteon
- contraindicated with fluvoxamine
- GI upset, somnolence, hyperprolactinemia, prolactinoma

Tasimelteon
- FDA approved for non-24 sleep wake disorder in adults
1A2 substrate

Question 5

Orexin Receptor antagonists

Answer 5

Suvorexant - need atleast 7 hours of sleep, contraindicated in narcolepsy, 3A4 substrate

Lemborexant - need atleast 7 hours of sleep, contraindicated in narcolepsy, 3A4 substrate

Daridorexant - need atleast 7 hours of sleep, contraindicated in narcolepsy, 3A4 substrate

Question 6

Doxepin and trazodone

Answer 6

Doxepin - TCA - low doses exert effects through H1 receptor antagonism, anticholinergic side effects

Trazodone - not FDA approved for insomnia, long half-life may see daytime hangover

Question 7

Mirtazapine and quetiapine

Answer 7

Mirtazapine - clinically used as a sleep agent, especially in patients with depression who have difficulty sleeping

Quetiapine - low dose quetiapine is not recommended for use in insomnia unless there is a co-morbid psychiatric disorder

Question 8

OTC antihistamines and natural products

Answer 8

Diphenhydramine/Doxylamine - not recommended by AASM, anticholinergic side effects - avoid in elderly

Melatonin/valerian/chamomile - Melatonin can be considered in jet lag and patients with low melatonin levels
German chamomile; allergic reaction in patients with daisy or ragweed allergies

Question 9

Choosing treatment

Answer 9

CBT and behavioral therapies are first line

Question 10

DSM5 sleep apnea diagnosis

Answer 10

Patient must have evidence of at least 5 obstructive apneas per hour of sleep confirmed by polysomnography

Symptoms include excessive daytime sleepiness, snoring, pauses in breathing during sleep, headaches, irritability, sore throat, erectile dysfunction, impaired memory, GERD, mood disturbance

Clinically there is greater recognition that many patients have both apnea and insomnia - both need to be treated with apnea treated first

Question 11

AASM guidelines

Answer 11

Polysomnography only if there is significant cardiorespiratory disease, potential respiratory muscle weakness due to a neuromuscular condition, sleep related hypoventilation, chronic opioid medication use, history of stroke, or severe insomnia

Question 12

Treatment of sleep apnea

Answer 12

Weight loss, smoking cessation, avoid alcohol and CNS depressants, sleep on side rather than back
if a patient is overweight/obese and comes for evaluation for insomnia, consider assessment for sleep apnea prior to initiating medication

CPAP machine

Excessive daytime sleepiness can be treated with modafinil or armodafinil - need to review CPAP adherance first and possibility of RLS or PLMS

When considering treating apnea and insomnia, ensure that the obstructive apnea is addressed before recommending sedative/hypnotic drug therapy

Question 13

The narcolepsy tetrad symptoms

Answer 13

EDS
Cataplexy
Hallucinations
Sleep paralysis
10-33% of patients have all 4

Question 14

Treatment of narcolepsy Cataplexy

Answer 14

Sodium oxybate - high sodium content - GHB
Xywav - for adults and children aged 7 or older, also approved for idiopathic hypersomnia in adults - lower sodium content

Lumryz - for adults only - ER dosage form, once nightly dosing, high sodium content

Question 15

Treatment of narcolepsy excessive daytime sleepiness (EDS)

Answer 15

Modafinil/armodafinil : associated with possible life theratening rash
sodium oxybate
pitolisant and solriamfetol recently FDA approved for EDS

Question 16

Pitolisant (wakix)

Answer 16

AVOID use with centrally acting H1 receptor antagonists (OTC antihistamines) -EXAM Q
H3 receptor antagonist/ inverse agonist

Contraindicated in severe hepatic impairment

prolongs QT interval

Weak 3A4 inducer - may reduce effectiveness of oral contraceptives

2D6/3A4 substrate

Question 17

Solriamfetol (Sunosi)

Answer 17

Dopamine norepinephrine reuptake inhibitor

Indicated for improvement in wakefulness in adults with excessive daytime sleepiness due to narcolepsy or obstructive sleep apnea

Moderate renal impairment - start 37.5mg, may increase to 75mg after at least 7 days; severe renal impairment - starting and max dose = 37.5mg

Warning: B/P and HR increase Avoid use in patients with unstable CV disease and arrythmias and use caution with history of bipolar disorder (decrease dose if symptoms worsen for these patients or D/C if psychosis symptoms are unbearable)

Question 18

Shift work sleep disorder

Answer 18

Modafinil and armodafinil are the drugs of choice, take 1 hour before the work period starts during wake time

• for keeping patients awake for the weird night hour shifts where they cannot stay awake

Question 19

Restless leg syndrome

Answer 19

Before medications always check patients Iron levels and feriton levels as these can be the reason for RLS

Gabapentin enacarbil - FDA approved for RLS, may be considered first line
Dopamine agonists (IR formulation) - pramipexole or ropinirole

Iron supplementation may be considered