Sleep tx Flashcards by Brooke Thornburg

Things associated w insomnia

-anxiety
-hyperthyroidism
-caffeine
-modafinil
-amphetamines
-B-agonists
-B-blockers
-nicotine
-thyroid meds
-bupropion
-decongestants
-methylphenidate

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DSM5 insomnia disorders

-difficulties w sleep initiation, maintenance, waking
-3x week
-at least 3 months

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Sleep onset only rx options

-zaleplon
-traizolam
-ramelteon

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Sleep maintenance only rx options

-suvorexant
-doxepin

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Sleep onset AND maintenance options

-eszopiclone
-zolpidem
-temazepam

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Treatment of insomnia

-first line is non-pharm (CBT and behavior tx)
-z-hypnotics most commonly used
-benzos (temazepam) (insomnia)
-melatonin agonists (onset)
-orexin antagonists (onset/maintenance)
-doxepin

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z-hypnotic drugs

-zolpidem
-eszopiclone
-zaleplon

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z-hypnotic counseling points

-initial dose of zolpidem is lower (5mg) in women and elderly
-3a4 substrates, caution inhibition/induction
-controlled/abusable

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z-hypnotic side effects

-eszopiclone: metallic taste
-somnolence
-dizziness
-ataxia
-headaches
-parasomnias (sleepwalking-caution)
-additive effects with other CNS depressants

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All medications for insomnia warn for

-sleep behaviors

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Melatonin receptor agonists drugs

-Ramelteon
-Tasimelteon
-1A2 substrates

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Ramelteon

-melatonin receptor agonists
-AVOID w fluvoxamine
-GI upset, somnolence, hyperprolactinemia, prolactinoma
-1A2 substrate

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Tasimelteon

-melatonin agonist
-FDA for non-24 sleep wake disorder in adults
-1A2 substrates

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Orexin receptor antagonist drugs

-Suvorexant
-Lembroexant
-Daridorexant

-3A4 substrates

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Orexin antagonist counseling

-at least 7 hours to sleep
-AVOID in narcolepsy
-narcolepsy-like side effects
-3A4 substrates

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Doxepin

-TCA
-low dose work through H1 ANTAgonism
-anticholinergic effects

Trazodone

-not FDA for insomnia
-long half-life: day-time hangover

Mirtazapine

-sleep agent in pt w depression and insomnia

Quetiapine

-low dose not recommended unless co-morbid psychiatric disorder

Diphenhydramine/Doxylamine

-not recommended by AASM

Melatonin

-consider in jet lag and pt w low levels
-1A2

German chamomile

-allergy in pt w daisy/ragweed allergies

Kava

-not recommended bc hepatotoxicity

DSM-5 obstructive sleep apnea

-at least 5 apneas per hour confirmed by polysomnography
-excessive sleepiness
-snoring
-pauses in breathing
-headache
-irratibility
-sore throat
-erectile dysfunction
-memory probs
-GERD
-mood probs
-many pt have apnea and insomnia = treat apnea first

Diagnostic testing for apnea

-polycomnography only if: -significant cardiorespiratory disease -potential resp muscle weakness due to neuro-musc condition -sleep-related hypoventilation -chronic opiod med use -hx of stroke -severe insomnia

Sleep apnea tx

-wt loss -smoking cessation -avoid alc and CNS depressants -sleep on side -CPAP (continuous positive airway pressure) -excessive daytime sleepiness tx w modafnil or armodafnil (assess CPAP adherence first and possibility of RLS or PLMS)

Sleep apnea + insomnia tx

-tx apnea before insomnia -in obese pt w insomnia, rule out apnea

Excessive daytime sleepiness (EDS) tx in sleep apnea

-modafnil or armodafnil -reveiw CPCP adherence first and posibility of RLD or PLMS

DSM-5 Narcolepsy

-recurring episodes of irresistible need to sleep -3x week -past 3 months

Narcolepsy tetrad

-EDS in 100% of pt (more severe in type I (cataplexy or hypocretin deficiency) -cataplexy: sudden loss of muscle tone triggered by emotion (75%) -hallucinations 30-60% -sleep paralysis 25-50% -all four 10-33%

Narcolepsy tx

-tx cataplexy - tx EDS

Tx of cataplexy in narcolepsy

-sodium oxybate: GHB, high sodium -Xywav: ages 7+, tx idiopathichypersomnia in adults, lower sodium -Lumryz: adults only, ER dose, once nightly, high sodium

Excessive Daytime Sleepiness (EDS) tx in narcolepsy

-modafinil/armodafnil: possible fatal rash -sodium oxybate -pitolisant and solriamfetol recently approved

Pitolisant

-H3 antagonist/ inverse agonist -AVOID in hepatic impairment -prolongs QTc -AVOID H1 antagonists (antihistamines) -2d6/3A4 substrate -weak 3A4 inducer (may dec oral birth control effectiveness)

Solriamfetol

-dopamine NE reuptake inhibitor (DNRI) -indicated for improvement in wakefulness in adults w excessive daytime sleepiness due to narcolepsy or sleep apnea -if mod renal impairment: start 37.5mg inc to max 75mg after 7 days -if severe renal impairment: starting and max dose is 37.5mg

solriamfetol renal dosing

-if mod renal impairment: start 37.5mg inc to max 75mg after 7 days -if severe renal impairment: starting and max dose is 37.5mg

solriamfetol side effects

-BP and HR inc -AVOID in unstable CVD and arrhythmias -caution in psychosis/bipolar: dec dose if psyc sx develop -caution w dopaminergic drugs

Shift work sleep disorder tx (EDS except D is "wake-time")

-modafinil and armodafinil -take 1 hour before work period starts during "wake time"

Restless leg syndrome tx

-gabapentin enacarbil (prodrug of gabapentin, approved for RLS, may be first line) -dopamine agonists (IR): pramipexole or ropinirole -consider iron supplementation