Sleep Therapeutics Flashcards by amanda kastel

name 4 sleep disorders

insomnia
narcolepsy
obstructive sleep apnea
circadian rhythm disorders

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true or false

snoring is always harmless

false - not always

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true or false

grogginess is always a cause for concern

false - it’s not

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true or false

waking up during the night is NOT always a sign of poor sleep

true

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define sleep latency vs sleep maintenance

what kind of sleep disorder do these apply to?

latency - length of time to fall asleep

maintenance - staying asleep

issues with these = insomia

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transient vs short term vs chronic insomnia

transient - less than a week

short term - 1-4 weeks

chronic - over 1 month

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differentiate between primary and secondary insomnia

primary - no known cause.

secondary - due to a medical condition, psych condition, a substance, or inadequate sleep hygiene. HAVE TO ADDRESS THESE THINGS BEFORE STARTING THERAPY!!!!

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true or false

we cannot immediately start medication for secondary insomnia

TRUE - MUST ADDRESS THE CAUSE FIRST!

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true or false

SSRIs and buproprion can cause insomnia

true

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true or false

cigarettes can help you fall asleep

false - can cause insomnia

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can alcohol cause insomnia

yes

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name some nonpharm therapy for insomnia

sleep hygiene!

bed should only be used what a bed is meant for

avoid naps! if you need to - should only be 30-60minutes long and before 3pm

if can’t fall asleep in over 20mins - leave the bedroom

be physically active - but not close to bedtime!

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3 general steps in the treatment approach to a patient with insomnia

assess duration - is it transient, short term, or chronic?

identify any secondary causes and treat these

make pharm/nonpharm recommendations

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true or false

medications for sleep onset are meant to increase sleep latency

false - decrease sleep latency

decrease amount of time it takes ot fall asleep

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what is another name for the “benzodiazepine receptor agonists”

Z hypnotics

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true or false

orexin agonists are used for sleep

FALSE - orexin antagonists

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sedating _______- and _________ are pharmacologic options for sleep

antidepressants and antihistamines

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true or false

it is desirable to have immediate offset of sleep medications

true

don’t want next day grogginess

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benzodiazepines and the z-hypnotics target what part(s) of sleep

sleep onset AND sleep maintenance

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differentiate between the MOA of benzodiazepines vs the Z hypnotics

benzodiazepines - NONSELECTIVELY bind to GABA receptor subunits to increase GABA – can be used for many different things

Z hypnotics - bind SELECTIVELY to the benzo omega-1 receptor subtype - so ONLY USED FOR SLEEP

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a patient is using a benzo or Z hypnotic for sleep.

if their insomnia still persists for over _____, we should consider any alternative causes for the insomnia

over 10 days

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true or false

alprazolam is not approved for sleep

true - it’s not, but ppl still use it

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important note about benzodiazepines and sleep

only should be used short term!!

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which benzodiazepine is for sleep onset ONLY (not maintenance) and why

triazolam

has a short half life

the other benzos approved for sleep are used for both sleep onset and maintenance bc they have a longer half life

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name 3 Z hypnotics Which is/are for sleep onset and maintenance? which is/are for sleep onset and middle of the night awakenings?

zolpidem eszopiclone (lunesta) zaleplon zolpidem/lunesta zaleplon - middle of night awakenings. doesnt decrease them, but can be readministered if it occurs

initial IR/CR zolpidem dosing

IR for women: 5mg IR for men: 5-10mg CR for women: 6.25mg CR for men: 6.25-12.5mg

name some AE of the benzos/Z hypnotics

dizzy and drowsy lightheaded cognitive impairments anterograde amnesia (blank for 1st couple hours of day) rebound insomnia when d/c'ed

boxed warning SPECIFIC to the Z hypnotics (not benzo)

complex sleep behaviors followed by amnesia! do things like sleep driving and other activities while sleeping. don't even remember that you did them

Z hypnotics contraindication

patients who have had a prior episode of complex sleep behaviors

3 DDI of benzos and Z hypnotics

CNS depressants strong 3A4 inhibitors or inducers

melatonin receptor agonists target what part of sleep

sleep ONSET

true or false melatonin is ineffective for jet lag

false - effective

melatonin modulates what

circadian rhythm

can melatonin be used for shift work disorder

yes

dosing of melatonin

0.5-10mg before bedtime

name a melatonin receptor agonist

ramelteon

name some advantages of ramelteon (melatonin receptor agonist) over other agents

no abuse potential less hangover effect no rebound insomnia there is data to support its long term use!

an AE of ramelteon is that it increases _____

prolactin

place in sleep therapy for ramelteon

possibly can try if melatonin doesnt work - but it's very expensive

the orexin receptor antagonists target what part (s) of sleep

both sleep onset and maintenance

name 3 orexin receptor antagonists

belsomra dayvigo quviviq

disadvantages of orexin receptor antagonists

$$$$ schedule IV controlls risk of dependence really only consider after failing multiple other meds

name some AE of the orexin receptor antagonists

sleep paralysis somnolence CNS depression (respiratory depression is a concern!) can cause worsening depression

should the orexin receptor antagonists be taken with a meal

NO the time for it to work may be delayed if taken with a meal

the orexin receptor antagonists are not recommended in...

severe hepatic impairment also, only taken when 7+ hours of sleep is expected

name 3 classes of antidepressants that can potentially be used for sleep

trazodone mirtazapine (remeron) the tricyclics

AE of trazodone

orthostasis, dry mouth, hangover effect constipation priapism QT prolongation

how does trazodone help sleep

reduces sleep latency and increases total sleep time

true or false mirtazapine should NOT only be used for insomnia

true really only if the pt has both depression + insomnia also has a niche use for older adults with or without depression and with or without decreased appetite (mirtazapine makes you hungry)

the tricyclic antidepressants can be considered for sleep in pts with comorbid..... (4 things)

depression pain migraines anxiety

name 3 tricyclics that can potentially be used for sleep

doxepin (low dose - 3-6mg for sleep. less AE) amitriptyline nortriptyline

AE of the tricyclics

anticholinergic CV effects weight gain

advantages and disadvantages of using the tricyclics for sleep

-no abuse potential, inexpensive, and can treat comorbid disorders however, they do have some AE and are lethal in overdose (low dose doxepin isn't a prob). also, using them for sleep is technically off label

true or false antihistamines are recommended for routine use for sleep

FALSE - not recommended bc of AE and tolerance

name 3 antihistamines that are POTENTIALLY used in sleep (not recommended bc of anticholinergic effects)

diphenhydramine doxylamine hydroxyzine

2 general AE of antihistamines for sleep

anticholinergic hangover effect

3 POTENTIAL OTC agents for sleep name their AE

valerian - headache, GI, heart issues kava kava - not rec. hepatotoxicity magnesium glycinate/citrate - check mg levels! ok to use if no cardiac issues

OTC item that MAY help with sleep (evidence is weak) and may help restless leg syndrome

magnesium glycinate/citrate

antipsychotic that is NOT recommended for insomnia and why? who MIGHT we consider using it in

quetiapine has lot of AE - metabolic syndrome, orthostasis, dry mouth, constipation. use w caution in older adults - esp with dementia (boxed warning for increased mortality in older pts!) MIGHT consider for patients who have comorbid psych disorders. use lower doses

true or false there is no first line agent for insomnia

TRUE - have to select based on individualized factors

in regards to sleep, what should always be emphasized first

sleep hygeine

name 5 things that improve both sleep onset AND maintenance

benzos z hypnotics orexin antagonists trazodone doxepin

____ only improves sleep onset and not maintenance bc of its short half life _____ does not decrease middle of the night awakening (WASO), but may be readministered if it occurs

triazolam zaleplon

true or false melatonin/melatonin receptor agonists only target sleep onset

true

valerian only may improve....

sleep onset

treatments for obstructive sleep apnea what particular meds should be avoided and why

nasal/oral CPAP surgery, weight loss med - modafinil as an adjunct to CPAP. taken in morning AVOID BENZOS!!!! SUPPRESSES RESPIRATION

what occurs in 70-90% of narcolepsy patients and what is used to treat it

cataplexy - sudden loss of muscle tone sodium oxybate (Low dose antidepressant)

nonpharm narcolepsy treatment

daytime naps (15-20ming at lunch and again at 530) avoid alcohol or caffeine before bed avoid smoking and other nicotine

4 meds that may be used to treat sleep attacks in narcolepsy

modafinil armodafinil methylphenidate dextroamphetamine

explain what restless leg syndrome is

urge to move limbs - uncomfortable gets worse in the evening, temporarily is relieved by movement

name some things that make RLS worse

caffeine stress alcohol fatigue

potential treatments for RLS

dopamine agonists (ropinirole, pramipexole, neupro) gabapentin/pregabalin iron if deficient less common - klonopin, zolpidem, methadone

Sleep Therapeutics Flashcards

(73 cards)