Drugs To Treat Insomnia Flashcards Preview

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Flashcards in Drugs To Treat Insomnia Deck (35):
1

Before prescribing sleeping pills...

1) Cognitive behavioral therapy and sleep hygiene
2) Work-up for underlying cause
3) Sedative-Hypnotic options

2

Potential underlying causes of insomnia:

Substance use disorder
Psychiatric illness (mood or anxiety disorders)
Medial illness
Restless leg syndrome

3

Sedative-Hypnotic Options

Benzodiazepines
Non-benzodiazepine agonists
Melatonin receptor agonists
Anti-histamines
Herbal preparations that affect GABA transmission

4

Will sleeping pills cure insomnia?
Can behavioral/psychological technqiues cure insomnia?

NO!
Sometimes

5

FDA approved benzodiazepines for insomnia Rx

Estazolam
Temazepam
Quazepam
Flurazepam
Triazelam
Lorazepam

6

Which FDA approved benzo is used most often to treat insomnia?

Temazepam

7

How long can benzos be used to treat insomnia?
How many days in a week can a pt use sleeping pills for insomnia?

Short term (1-3 months)
No more than 3 days/week

8

Which drugs should be used to treat insomnia in elderly pt?

LOT!
Lorazepam
Oxazepam
Temazepam

9

Problems with benzos

Rebound insombia
Psychological dependence
Tolerance
Physiological dependence
Risk of withdrawal
Substance abuse disorder

10

Which patients are at the high risk of substance abuse with benzos?

Pts with other substance issues

11

Signs of substance abuse:

Running out of meds early, wanting a higher dose, losing meds, going to multiple doctors for prescriptions (IL PMP)

12

Non-benzodiazepines agonists approved for sleep disorders

Imidazopyridine:
Zolpidem, Zaleplon
Pyrrolopyrazine:
Eszopiclone
"Z meds to get more zzz's"

13

Side effects of Non-benzo agonists

sleep walking, sleep driving, sleep eating

14

Relative costs of the non-benzo agonists vs. benzos

Benzos are the LEAST expensive
Zolpidem and Zaleplon are more expensive but no unreasonable
Eszopiclone is expensive

15

Ramelteon

M1 & M2 melatonin receptor agonist

16

Down side of Ramelteon

COST- typically requires prior approval by insurance company, or trying less expensive drugs first

17

Sedating drugs with anti-histamineric actions: Tricyclic antidepressants

Amitriptyline
Doxepin
Imipramine

18

Sedating drugs with anti-histamineric actions: Mixed action antidepressants

Mirtazapine
Trazadone

19

Benefit of using antidepressants to treat insomnia

Also treat depression and anxiety, which may be the underlying cause of patient's insomnia

20

Sedating drugs with anti-histamineric actions: H1 histamine receptor antagonists

Cyclobenzapine
Dihenhydramine
Hydroxyzine

21

Of the antihistamines, which is preferred for use in the elderly?

Hydroxyzine (NOT muscarinic)

22

Herbal Insomnia Rx: Valeriana officinalis

sesquiterpene: mediate GABA release and inhibit GABA breakdown
No morning after hangover
No aversive effects
No serious drug interactions
Useful for 4 weeks

23

Herbal Insomnia Rx: Chamomile

Apigenin: benzo agonist
relaxing

24

Herbal Insomnia Rx: Kava

Contains compounds that facilitate binding of GABA
Reported calming effects

25

Herbal Insomnia Rx: Passion Flower

Chrysin: a benzo partial agonist
Reported to be safe and effective (unsubstantiated)

26

Over the counter meds (no longer available)

Compoz (pyrilamine +methapyrilene)
Nytol (methapyrilene + salicylamide)
Sominex (methapyrilene + salicylamide + scopalamine)
Sleep-Eze (methapyrilene + scopalamine)

Produce tolerance and rebound insomnia, NOT more effective than placebo

27

Currently available OTC sleep aids

Unisom (doxylamine)
ZzzQuil (diphenhydramine)

*both antihistamines

28

Buspirone site of action

5HT-1A partial agonist

29

Buspirone t1/2

short (2.5 hours)

30

Buspirone Side Effects

Headaches, dizziness, nervousness, sedation, nausea

31

Buspirone DDI

DO NOT use with MAOI

32

Buspirone Clinical Consideration

Generalized Anxiety Disorder
C antidepressants for major depression
C antidepressants for anxiety disorders

33

Advantage of Buspirone vs. benzos

No risk of dependence, no withdrawal, no GABA cross tolerance

34

Advantage of Buspirone vs. anti-depressants

Low/no sexual side effects, weight neutral, no withdrawal

35

Disadvantages of Buspirone

Effectiveness?