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PHRM 845 > 4.6 Pharmacotherapy of sleep disorders > Flashcards

4.6 Pharmacotherapy of sleep disorders Flashcards

1
Q

What disease states, meds, and substances are associated w insomnia?

A
  • Anxiety, mood disorders
  • Caffeine, nicotine
  • Modafinil, beta agonists, BBs, thyroid meds, bupropion, decongestants, methylphenidate
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2
Q

What defines insomnia disorders?

A

Difficulties w sleep initiation, sleep maintenance, and/or early-morning awakening

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3
Q

How often and long must sxs occur for it to be an insomnia disorder?

A

Takes place at least 3 nights/week for at least 3 months

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4
Q

What is 1st line tx for insomnia disorders?

A

1st line tx is always non-pharm
- CBT and behavioral therapies ARE 1st LINE
- Sleep hygiene principles

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5
Q

Which drug class is the most commonly used sleep meds?

A

Z-hypnotics (zolpidem, eszopiclone, zaleplon)

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6
Q

What is the initial dose of zolpidem in women and elderly?

A

It is lower in these pt groups - 5 mg

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7
Q

What is a common SE of eszopiclone (lunesta)?

A

Metallic taste

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8
Q

What kind of substrates are z-hypnotics and how is their metabolism affected?

A

3A4 substrates - metabolism is impacted by 3A4 inhibition and induction

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9
Q

What are SEs of z-hypnotics?

A
  • Somnolence, dizziness, ataxia, headaches
  • Paracomnias: unusual actions while a person is sleeping; warning for all sleep meds
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10
Q

Is there an abuse potential w z-hypnotics?

A

Yes, they are controlled substances - potential for abuse

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11
Q

What happens if a pt uses z-hypnotics w other CNS depressants?

A

Additive effects - the effects of both drugs is greater

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12
Q

Which benzo is used for sleep?

A

Temazepam

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13
Q

What are the SEs of temazepam?

A

Drowsiness, dizziness, cognitive impairment, increased fall risk

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14
Q

What do all FDA approved meds for insomnia have?

A

Sleep behaviors warning

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15
Q

What meds are considered melatonin receptor agonists?

A
  • Ramelteon
  • Tasimelteon
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16
Q

What is ramelteon CI w?

A

Fluvoxamine

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17
Q

What are SEs of ramelteon?

A

GI upset, next day somnolence, hyperprolactinemia, prolactinoma

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18
Q

What is tasimelteon approved for?

A

FDA approved for non-24 sleep-wake disorder (blind) in adults

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19
Q

What substrates are ramelteon and tasimelteon and what is the caution w this?

A

1A2 substrates: watch for 1A2 inducers and inhibitors

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20
Q

What drugs are in the orexin receptor antagonists class?

A
  • Suvorexant
  • Lemborexant
  • Daridorexant
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21
Q

How much sleep should a pt taking orexin receptor antagonists get?

A

At least 7 hrs of sleep

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22
Q

What are orexin receptor antagonists CI in?

A

CI in narcolepsy - causes narcolepsy-like SEs

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23
Q

What substrate is orexin receptor antagonists?

A

3A4 substrate

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24
Q

What is the MOA of doxepin (silenor)?

A

TCA - low doses exert effect through H1 receptor antagonism

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25
Q

What are SEs of doxepin (silenor)?

A

Anticholinergic SEs

26
Q

What is trazodone not approved for but still used in?

A

Not FDA approved for insomnia but clinically still used for insomnia

27
Q

What is a SE of trazodone why?

A

May see daytime hangover due to long half life

28
Q

What is mirtazapine used for and when?

A

Clinically used as sleep agent, esp in pts w depression who have difficulty sleeping

29
Q

What is quetiapine not used for?

A

Low dose quetiapine is not recommended for use in insomnia UNLESS there is co-morbid psychiatric disorder

30
Q

Is diphenhydramine/doxylamine recommended for insomnia?

A

Not recommended by AASM

31
Q

When can melatonin be considered for insomnia?

A

Can be considered in jet lag and pts w low melatonin levels

32
Q

What substrate is melatonin?

A

1A2

33
Q

What can german chamomile cause?

A

Allergic rxns in pts w daisy or ragweed allergies

34
Q

What is the diagnosis criteria of obstructive sleep apnea?

A

Pt must have evidence of at least 5 obstructive apneas per hr of sleep confirmed by polysomnography

35
Q

What are SEs of OSA?

A
  • Excessive daytime sleepiness, snoring, pauses in breathing during sleep, headache, irritability
  • Sore throat, ED, impaired memory, GERD, mood disturbances
36
Q

Many pts have both apnea and insomnia. What should be treated first?

A

Apnea

37
Q

When should a pt undergo polysmonography?

A

ONLY if there is significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, sleep-related hypoventilation, chronic opioid med use, hx of stroke, severe insomnia

38
Q

What are txs of sleep apnea?

A
  • Weight loss (adjunctive rather than curative)
  • Smoking cessation
  • Alcohol and CNS depressants
  • Sleep on side rather than back
  • CPAP
39
Q

What should be done if an overweight/obese pt comes in for insomnia?

A

Consider assessment for sleep apnea prior to initiating meds

40
Q

What can excessive daytime sleepiness from OSA be treated w?

A

Modafinil or armodafinil
- Review CPAP adherence first and possibility of RLS or PLMS

41
Q

What should be done first if a pt is being treated for apnea and insomnia?

A

Ensure OSA is addressed first before recommending sedative/hypnotic drug therapy

42
Q

What is the narcolepsy triad?

A
  • Excessive daytime sleepiness
  • Cataplexy
  • Hallucinations
  • Sleep paralysis
43
Q

What are the txs for cataplexy from narcolepsy?

A
  • Sodium oxybate (xyrem): GHB, high sodium content
  • Xywav: for adults and children 7 yo 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
44
Q

What are the txs for excessive daytime sleepiness from narcolepsy?

A
  • Modafinil/armodafinil: associated w possible life threatening rash
  • Sodium oxybate
  • Pitolisant and solriamfetol recently FDA approved
45
Q

What is the MOA of pitolisant (wakix)?

A

H3 receptor antagonist/ inverse agonist

46
Q

What is pitolisant (wakix) CI in?

A

CI in severe hepatic impairment

47
Q

What does pitolisant (wakix) cause that’s CV related?

A

Prolongs QT interval

48
Q

What substrate is pitolisant (wakix)?

A
  • 2D6/3A4 substrate
49
Q

How does pitolisant (wakix) affect OCs?

A

It is a weak 3A4 inducer so it may reduce effectiveness of OCs

50
Q

Avoid use of pitolisant (wakix) w what drug class?

A

Avoid use w centrally-acting H1 receptor antagonists (OTC antihistamines)

51
Q

What is the MOA of solriamfetol (sunosi)?

A

DA NE reuptake inhibitor (DNRI)

52
Q

What is solriamfetol (sunosi) indicated for?

A

Indicated for improvement in wakefulness in adults w EDS due to narcolepsy or OSA

53
Q

What is the dosing of solriamfetol (sunosi) in pts w moderate renal impairment?

A
  • Start 37.5 mg
  • May increase to 75 mg after at least 7 days
54
Q

What is the dosing of solriamfetol (sunosi) in pts w severe renal impairment?

A

Starting and max dose is 37.5 mg

55
Q

What are warnings associated w solriamfetol (sunosi)?

A
  • BP, HR increases
  • Avoid in unstable CV disease and arrhythmias
56
Q

What are cautions associated w solriamfetol (sunosi)?

A
  • Caution in pts w hx of psychosis or bipolar disorder: decrease dose or d/c if psychiatric sxs develop
  • Caution w dopaminergic drugs
57
Q

What are drugs of choice for tx of shift work sleep disorder?

A

Modafinil and armodafinil are drugs of choice

58
Q

When should modafinil and armodafinil be taken to tx shift work sleep disorder?

A

Taken 1 hr before work period starts during “wake time”

59
Q

What are drug txs for restless legs syndrome?

A
  • Gabapentin enacarbil: prodrug of gabapentin, may be considered 1st line
  • DA agonists (IR): pramipexole, ropinirole
60
Q

What supp may be considered for restless legs syndrome?

A

Iron supp may be considered

PHRM 845 (51 decks)

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