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Sleep Disorders Flashcards

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1
Q

What occurs in NREM 1?

A

transition b/t wakefulness & sleeping

theta waves

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2
Q

What is an important characteristic of ALL NREM sleep stages?

A

muscles are NOT paralyzed

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3
Q

What occurs in NREM 2?

A

body temp drops & HR slows

sleep spindles & K complex

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4
Q

What occurs in NREM 3?

A

muscles relax, BP & breathing rate drops, deepest sleep occurs

delta waves

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5
Q

What are important characteristics of REM?

A

muscles are PARALYZED

brain is electrically & metabolically active (DREAMS)

occurs in bursts w/ an increase in cerebra; blood flow

controlled by cholinergic cells

beta waves

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6
Q

What is the category of insomnia that only lasts several days?

A

transient insomnia

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7
Q

What is the category of insomnia that is less than 3 months?

A

short term insomnia

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8
Q

What is the category of insomnia that occurs at least 3 nights/week for 3 months or more?

A

chronic insomnia

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9
Q

What drugs can cause or worsen insomnia? (there’s 19? guess as many as you can)

A
  • alcohol, caffeine, nicotine
  • anticholinergics
  • cholinesterase inhibitors
  • SSRI/SNRI
  • a & b blockers
  • ACE/ARB
  • bronchodilators
  • CNS stimulants
  • corticosteroids
  • decongestants
  • opioids
  • diuretics
  • H2RAs
  • statins
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10
Q

What is the first line therapy for chronic insomnia?

A

CBT for insomnia

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11
Q

Which benzo is only used for sleep onset?

rest are used for onset & maintenance

A

triazolam (Halcion)

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12
Q

What benzos are used for sleep onset & maintenance?

A
  1. estazolam (ProSom)
  2. flurazepam (Dalmane)
  3. quazepam (Doral)
  4. temazepam (Restoril)
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13
Q

What are the z-drugs? (3)

A
  1. eszopiclone (Lunesta)
  2. zaleplon (Sonata)
  3. zolpidem (Intermezzo, Edluar, Ambien CR, Ambien IR, generic IR, Zolpimist)
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14
Q

What insomnia types is Eszopiclone (Lunesta) indicated for?

What is it excellent for?

A

onset OR maintenance

maintenance & early morning awakenings

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15
Q

How is Eszopiclone (Lunesta) dosed?

How long can it be used for?

A

QHS

up to 6 mo

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16
Q

What Z-drugs are major CYP3A4 subs?

A
  1. Eszopiclone (Lunesta)
  2. Zaleplon (Sonata)
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17
Q

What insomnia types is Zaleplon (Sonata) indicated for?

A

onset only

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18
Q

How is Zaleplon (Sonata) dosed?

How long can it be used for?

A

QHS

up to 30 days

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19
Q

What zolpidem BRAND name & dosage FORM is indicated for maintenance only?

What does it specifically help with?

A

Intermezzo (sublingual)

middle of the night awakening

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20
Q

What zolpidem BRAND names & dosage FORMS are indicated for onset only? (4)

A
  1. Edluar (sublingual)
  2. Ambien IR (IR tab)
  3. generic IR (cap)
  4. zolpimist (spray)
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21
Q

What zolpidem BRAND name & dosage FORM are indicated for maintenance & onset?

A

Ambien CR (ER tab)

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22
Q

What zolpidem BRAND names & dosage FORMS are given QHS w/ 7-8 hours of planned sleep? (5)

A
  1. Edluar (sublingual)
  2. Ambien CR (CR tab)
  3. Ambien IR (IR tab)
  4. generic IR (cap)
  5. zolpimist (spray)
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23
Q

What zolpidem BRAND name & dosage FORM needs to be given at least 4 hours prior to wakening?

A

Intermezzo (sublingual)

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24
Q

What zolpidem BRAND names & dosage FORMS have different dosages according to gender?

A
  1. Intermezzo (sublingual)
  2. Ambien CR (CR tab)
  3. Ambien IR (IR tab)
  4. Zolpimist (spray)
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25
What insomnia types are DORAs (Dual Orexin A & B Receptor Antagonists) indicated for?
sleep onset or maintenance
26
What is the CI of DORAs (Dual Orexin A & B Receptor Antagonists)?
narcolepsy
27
How much planned sleep is needed for QHS dosing of DORAs (Dual Orexin A & B Receptor Antagonists)?
7 hours or more
28
List the DORAs (Dual Orexin A & B Receptor Antagonists): (3)
1. suvorexant (Belsomra) 2. lemborexant (DayVigo) 3. daridorexant (Quviviq)
29
What enzyme completes DORAs (Dual Orexin A & B Receptor Antagonists) metabolism?
CYP3A4
30
Which DORAs (Dual Orexin A & B Receptor Antagonists) are associated with awakening drowsiness (long t1/2)?
1. suvorexant (Belsomra) 2. lemborexant (DayVigo)
31
If a patient is taking a Z-drug and experiences a complex sleep behavior what should be done?
D/C immediately!!!
32
What is the BBW on all Z-drugs?
complex sleep behaviors
33
Which DORA (Dual Orexin A & B Receptor Antagonist) has a risk of CNS depression for up to several days after D/C?
lemborexant (DayVigo) **longest t 1/2**
34
Which insomnia classes are scheduled CIV?
1. all Benzos 2. all Z-drugs 3. all DORAs
35
What insomnia types is ramelteon (Rozerem) indicated for?
onset only
36
What is a potential caveat to intiating ramelteon (Rozerem) use?
its not effective in patients that have previously been on a benzo or Z-drug
37
What is the CI for ramelteon (Rozerem)?
fluvoxamine use (strong CYP 1A2 inhib)
38
What does stimulation of each melatonin receptor do? M1? induces sleepiness M2?
M1: induces sleepiness M2: regulates circadian rhythm
39
What is the MOA of ramelteon (Rozerem)?
melatonin receptor agonist (M1 > M2)
40
What TCA is used for sleep maintenance insomnia?
low dose doxepin
41
What insomnia agents have BBW for suicidality?
doxepin & trazodone
42
What is important when dosing doxepin for sleep maintenance insomnia?
DO NOT take within 3 hours of a meal slower absorption -> next day sleepiness
43
What sleep disorders is melatonin indicated for?
sleep onset latency shift workers jet lag
44
What patient population should melatonin be avoided?
pt w/ autoimmune conditions
45
What are 2 problems with using diphenhydramine or doxylamine for sleep?
1. tolerance to sedative effect develops quickly 2. anticholinergic (avoid in older adults)
46
In what circumstance is trazodone used for sleep?
OFF LABEL!
47
What is needed if stopping trazodone?
taper off over 2-4 weeks
48
What are the general mainstays of sleep onset therapy? What about for elderly or opioid users?
1st line Z-drugs - Ramelteon or DORA Ramelteon or DORA
49
What are the general mainstays of sleep maintenance or mixed therapy? What about for elderly or opioid users?
1st line Z-drugs - DORA or low dose doxepin DORA or low dose doxepin
50
What insomnia agents can be used in pregnancy?
1. diphenhydramine 2. doxylamine 3. low dose doxepin
51
What agents can exacerbate sleep apnea?
CNS depressants & alcohol
52
What is the standard treatment for sleep apnea?
positive airway pressure during sleep
53
What non-pharm changes can be made to improve sleep apnea?
1. weight loss 2. altered sleeping position 3. avoidance of alcohol & sedatives
54
What agents are used to treat excessive daytime sleepiness? **Note which are FDA approved for EDS in sleep apnea or narcolepsy**
1. modafinil (Provigil), armodafinil (Nuvigil) ------ BOTH 2. solriamfetol (Sunosi) ----- BOTH 3. pitolisant (Wakix) ----- NARCO (off label for sleep apnea)
55
How far from bedtime should solriamfetol (Sunosi) be administered?
9 hours or more from planned bedtime
56
Which EDS agent has a BBW for MAOI within 14 days?
solriamfetol (Sunosi)
57
Which EDS agent has been seen to cause mania or exacerbate psychotic/manic symptoms?
modafinil (Provigil) & armodafinil (Nuvigil)
58
Which EDS agent prolongs QT?
pitolisant (Wakix)
59
Which EDS agent is CI in severe hepatic impairment?
pitolisant (Wakix)
60
Which EDS is scheduled CIV?
modafinil (Provigil) & armodafinil (Nuvigil)
61
Which EDS is FED ONLY CIV?
solriamfetol (Sunosi)
62
What is the narcolepsy tetrad?
1. excessive & irresistible daytime sleepiness 2. cataplexy (muscle weakness in periods of strong emotion) 3. hypnagogic (vivid dreams at sleep onset) 4. sleep paralysis
63
What is the difference between type 1 and type 2 narcolepsy?
type 1 -> w/ cataplexy type 2 -> w/o cataplexy
64
List the 8 EDS agents for narcolepsy:
1. modafinil (Provigil) 2. armodafinil (Nuvigil) 3. solriamfetol (Sunosi) 4. pitolisant (Wakix) 5. amphetamines 6. methylphenidate 7. sodium oxybate 8. oxybate salts
65
What EDS agent is scheduled CIII?
sodium oxybate
66
What EDS agents also treat cataplexy?
sodium oxybate & pitolisant (Wakix)
67
What are the BBWs for sodium oxybate?
1. CNS depression 2. abuse/misuse 3. restricted access
68
What is restricted after administration of sodium oxybate due to CNS depression?
NO hazardous activities requiring mental alertness or motor coordination for at least 6h after admin
69
What formulations of sodium oxybate are available (include BRAND)?
Xyrem - IR soln Lumryz - ER suspension
70
How is Xyrem (sodium oxybate IR soln) administered?
take on empty stomach 2 hr or more after eating while in bed lie down immediately in bed after dose & stay in bed 2nd dose is given while still in bed 2.5-4 h later
71
How is Lumryz (sodium oxybate ER suspension) administered?
dose is suspended in 80 mL of water using provided mixing cup & must be used within 30 mins take on empty stomach 2 hr or more after eating while in bed lie down immediately in bed after dose & stay in bed
72
What is the difference of oxybate salts (Xywav) vs sodium oxybate?
oxybate salts contain more than just Na -> Ca, Mg, K as well
73
What agents are used for intermittent restless leg symptoms?
1. carb/levo 2. benzos (clonazepam is most well studied)
74
What agents are used for chronic & persistent restless leg symptoms?
1. pregabalin or gabapentin 2. dopamine agonists: IR pramipexole, ropinirole, rotigotine
75
Medication withdrawals that may cause restless leg syndrome:
- centrally acting antihistamines - antidepressants - antipsychotics - dopamine blocking anti-emetics

Therapeutics (18 decks)

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