Sleep/Wake Disorders

Question 1

Benzodiazepines (BZDs)

Answer 1

Temazepam, Triazolam

Question 2

Nonbenzodiazepine GABAa Agonists

Answer 2

Eszopiclone, zaleplon, zolpidem

Question 3

Melatonin receptor agonist

Answer 3

Ramelteon

Question 4

Nonprescription/OTC sleeping aids

Answer 4

Diphenhydramine, melatonin, valerian root

Question 5

Orexin receptor antagonist

Answer 5

Suvorexant, Lemborexant

Question 6

Sedating antidepressants

Answer 6

Doxepin

Question 7

BZD Hypnotics

Answer 7

-relieve insomnia by reducing sleep latency and increasing total sleep time
-triazolam (Halcion), temazepam (Restoril), estazolam (ProSom)

Question 8

Contraindications of BZD Hypnotics

Answer 8

-pregnancy
-untreated sleep apnea
-hx of substance abuse
-obstructive sleep apnea
–AVOID alcohol and other CNS depressants

Question 9

BZD Hypnotics con’t
-use in elderly population

Answer 9

-half-lives are prolonged in older patients which increases incidence of CNS SE
—flurazepam and quazepam are not recommended (assoc. w/ increased risk of falls and hip fractures)

Question 10

Nonbenzodiazepine GABA-A Agonists used to treat…

Answer 10

-useful for decrease sleep latency
-selectively bind to GABA-A receptors and effectively include sleepiness
-no significant active metabolites

Question 11

Zolpidem (Ambien, Ambient CR, Intermezzo, Edluar)

Answer 11

-effective at reducing sleep latency. nocturnal awakenings, increasing total slow time. no significant effects on next-day psychomotor performance

Question 12

Zolpidem AE

Answer 12

drowsiness, amnesia, dizziness, HA, GI complaints (dose-related)
sleep eating –> weight gain

Question 13

What NBZD formulation has the fastest onset of action and helps with middle of night awakening?

Answer 13

Zolpidem sublingual

Question 14

Rozerem (Ramelteon)

Answer 14

• A melatonin receptor agents approved for the treatment of sleep onset insomnia
  — selective for the MT1 and MT2 melatonin receptors, thought to regulate the circadian rhythm and sleep onset for use up to six months

Question 15

Rozerem (Ramelteon) AE

Answer 15

-HA, dizziness, somnolence
(generally well-tolerated)

Question 16

Meds recommended for sleep onset Insomnia

Answer 16

• eszopiclone (Lunesta)
• Ramelteon (Rozerem)
• Temazepam (Restoril)
• Triazolam (Halcion)
• Zaleplon (Sonata)
• Zolpiden (Ambient, Intermezzo)

Question 17

Meds recommended for sleep maintenance Insomnia

Answer 17

• Doxepin (Silenor)
• Eszopiclone (Lunesta)
• Temazepam (Restoril)
• Suvorexant (Belsomra)
• Zolpidem (Ambient, Intermezzo)

Question 18

What consists of the Narcolepsy Tetrad?

Answer 18

• excessive daytime sleepiness (EDS)
• hallucinations
• sleep paralysis
• cataplexy

Question 19

Narcolepsy non-pharmacological approach

Answer 19

• pt counseling
• good sleep hygiene
• family awareness to alleviate misconceptions about individual’s behavior
• two or more schedule daytime naps lasting 15 minutes each

Question 20

Pharmacologic Mgmt. of Narcolepsy:
Treatment of Excessive Daytime Sleepiness

Answer 20

Modafinil; Armodafinil
Methylphenidate
Dextroamphetamines
Amphetamine-Dextroamphetamine

Question 21

Pharmacologic Mgmt. of Narcolepsy:
For Cataplexy

Answer 21

Venlafaxine
Fluoxetine
Clomipramine

Question 22

Stimulants MOA

Answer 22

CII
-promote wakefulness by blocking the reuptake of/and increase the release of dopamine

Question 23

Cataplexy Treatment

Answer 23

most common treatments is TCAs (clomipramine (off-label use), imipramine, nortripyline)
- moa: through blockade of serotonin and norepinephrine reuptake in the brain to suppress REM sleep

Question 24

FDA approved meds for Narcolepsy

Answer 24

• sodium oxybate (Xylem)
• Ca/Mg/K/Na oxybate (Xywav)
• Solriamfetol (Sunosi)
• Pitolisant (Wakix)
  *all used for both with the exception of Solriamfetol–EDS only-not Cataplexy

Question 25

Sodium oxybate (Xyrem)

Answer 25

- improves EDS, decreases episode of sleep paralysis, cataplexy, hypnagogic hallucinations

Question 26

Sodium oxybate (Xyrem) MOA

Answer 26

MOA: GABA-B agonist that modulates GABA-A and GABA-C -changes sleep architecture to resemble normal sleep -increases slow-wave sleep, decreases nighttime awakenings, and increase REM efficiency

Question 27

Sodium oxybate (Xyrem) CI, SE, etc.

Answer 27

CI: avoid use with other CNS depressants SE: nausea, somnolence, confusion, dizziness, and incontinence **REMS drug! - only available as liquid

Question 28

What is sodium oxybate (Xyrem) FDA approved for?

Answer 28

cataplexy and narcolepsy excessive somnolence - narcolepsy

Question 29

Restless Legg Syndrome

Answer 29

first line: Dopamine Agonists & Anticonvulsants

Question 30

Dopamine Agonists

Answer 30

- pramipexole, ropinirole, rotigotine patch - Adverse Rxn: compulsive behavior

Question 31

Anticonvulsants

Answer 31

- gabapentin, pregabalin - adverse rxn: dizziness

Question 32

Iron therapy in RLS

Answer 32

Data suggests that RLS can be caused by iron deficiency in the substantial nigra in the CNS

Question 33

Parasomnias non-pharm. treatments

Answer 33

- putting safety latches on doors windows - removing hazardous. objects from bedrooms - covering glass doors with heavy curtains

Question 34

Parasomnias pharm. treatment

Answer 34

- BZD (FOR slp terrors and sleepwalking) ---- > Clonazepam is the treatment of choice for REM behavior disorder - SSRIs (NREM behavior disorders + sleepwalking) - TCAs (NREM behavior disorders + sleepwalking) - Melatonin (REM behavior disorders) - Pramipexole (REM behavior disorders)