Sleep

Question 1

Estazolam (ProSom)

Answer 1

Benzo (CIV); used for sleep onset or maintenance insomnia; CI in pegnancy or w/ Itraconazole/Ketoconazole; SE is Hypokinesia

Question 2

Eszopiclone (Lunesta)

Answer 2

Z-drug (CIV); Delayed onset of action if taken w/ food; used for sleep onset or maintenance insomnia; duration of 6-9 hours; can be used long term (<6 mo); monitor use w/ Itraconazole/Ketoconazole; SE are HA, dysgeusia, anxiety, xerostomnia, infection, stomach upset

Question 3

Zopiclone (Imovane)

Answer 3

Z-drug (CIV); treatment shouldn’t exceed 7-10d; CI in severe respiratory impairment, myasthenia gravis, severe hepatic insufficiency; excreted in human milk

Question 4

Zaleplon (Sonata)

Answer 4

Z-drug (CIV); short acting, rapid onset; avoid taking after high fat meal; used for short term treatment of onsomnia (Not for sleep maintenance); duration of effect 3-4 hrs; excreted in breat milk; SE are HA, nausea, abdominal pain; interacts with CYP3A4 inducers (cimetidine. rifampin)

Question 5

Zolpidem (Ambien)

Answer 5

Z-drug (CIV); avail IR tab/spray, ER tab, SL tab (Intermezzo – take if more than 4 hrs remain before waking + pt has trouble falling back asleep); used for sleep onset/maintenance; rapid onset, short t1/2, CI in severe hepatic impairment, SE are HA, nausea

Question 6

Trazodone

Answer 6

Off label use; BW for suicidal thoughts and behaviors; useful in pts with hx of substance abuse; SE are carry over sedation and alpha adrenergic blockade (possibly orthostasis, priaprism); when dc’ing gradually taper

Question 7

Suvorexant (Belsomra)

Answer 7

CIV DORA; assists in getting to sleep and maintaining sleep; <30min for onset of action, 12hr t1/2, interacts w/ CYP3A4 inhib/induc; SE are drowsiness, dizziness, HA, sleep paralysis, abnormal dreams, URTI; CI in narcolepsy

Question 8

Lemborexant (DayVigo)

Answer 8

CIV DORA; assists in getting to sleep and maintaining sleep; <30min for onset of action, 17-19hr t1/2, interacts w/ CYP3A4 inhib/induc; need at least 7 hours before planned time of awakening; NEXT DAY DROWSINESS and INC RISK OF FALLING; SE are drowsiness, dizziness, HA, complex sleep behaviors, abnormal dreams (nightmares); CI in narcolepsy

Question 9

Ramelteon (Rozerem)

Answer 9

Melatonin receptor agonist; onset of action 30min, t1/2 1-2.6hr; for sleep-onset insomnia and long term use; don’t use in pts w/ severe liver disease; not as effective in those already treated with a BZDRA; SE are HA, dizziness, somnolence; CI w/ Fluvoxamine

Question 10

Melatonin

Answer 10

Beneficial for sleep-onset latency, shift workers, jet lag; avoid in those with autoimmune conditions; don’t use in those w/ alzheimers

Question 11

Doxepin

Answer 11

TCA; used for sleep maintenance insomnia; SNRI; BBW for suicidality; don’t take w/in 3 hrs of a meal

Question 12

USE FOR ELDERLY

Answer 12

CBT-I, Ramelteon, Eszopiclone, Zolpidem, Low-dose doxepin

Question 13

USE FOR PREG

Answer 13

Diphenhydramine, Doxylamine, Low-dose doxepin

Question 14

Modafnil (Provigil)

Answer 14

CIV; effects on Dopamine, GABA, 5-HT; AE are HA, Nausea, Anx/nervousness, dizziness, Dyspepsia, xerostomia, back pain, rhinitis; don’t use in pregnancy; might dec contraceptive effectiveness; use w/ caution in pts w/ CVD

Question 15

Armodafinil (Nuvigil)

Answer 15

CIV; EDS; effects on Daopamine (R-enantiomer); AE: HA, insomnia, dizziness, Nausea, Xerostomia; don’t use in pregnancy; might dec contraceptive effectiveness; use w/ caution in pts w/ CVD

Question 16

Solriamfetol (Sunosi)

Answer 16

CIV; EDS; Dopamine ane NE reuptake inhib; CI w/ use of MAOI, AE are HA, anx, insomnia, dec appetitie, nausea; avoid in pts w/ unstable CVD/arrythmias

Question 17

Pitolisant (Wakix)

Answer 17

Histmaine-3 receptor antagonist/reverse agonist; EDS; lower MDD for CYP2D6 poor metab; CI in severe hepatic impairment; may prolong QT (avoid in pts w/ arrrythmias); AE are HA, anx, MUSKEL Pain, URI

Question 18

Amphetamines and Methylphenidate

Answer 18

Meds used for Narcolepsy

Question 19

Sodium Oxybate (Xyrem)

Answer 19

CIII; EDS; BBW for CNS Depression, Abuse/misuse, Restricted access; dosed at bedtime w/ 2nd dose 2.5-4 hrs later; AE: confusion, HA, Dizziness, weight loss/dec appetite, urinary incontinence, drowsiness, depression, somnambulism, anx; REMS program

Question 20

Meds used for Cataplexy in Narcolepsy

Answer 20

Fluoxetine, Venlafaxine, Atomoxetine, Clomipramine, Imipramine, Nortriptyline, Pitolisant, Sodium Oxybate

Question 21

Jet Lag

Answer 21

Napping, timed light exposure, Melatonin, Ramelteon, short acting BZDRA

Question 22

Shift Work Disorder

Answer 22

sleep scheduling, sleep hygiene, naps before or during shift, exposure to bright lights at night and darkness during the day, melatonin, ramelteon, short-acting BZDRA, Modafinil/Armodafinil to improve wakefulness

Question 23

Parasomnias

Answer 23

Benzos, SSRIs, TCAs

Question 24

Intermittent RLS Sympt

Answer 24

Carbidopa-levodopa, BZDRA (Clonazepam), low-dose opioid

Question 25

Chronic and Persistent RLS Sympt

Answer 25

Pregabalin, Gabapentin, immediate-release pramipexole, ropinirole, rotigotine