Week 6: Insomnia and Nicotine Flashcards
1
Q
What are the stages of sleep?
A
NREM
1. Falling asleep
2. Light sleep
3 and 4: Deep sleep
REM
5: Neither light nor deep, the body is more physiologically active
2
Q
What is REM important for?
A
Regulation of mood and learning
3
Q
How long is a NREM and REM sleep cycle?
A
90-120 minute
3-7 cycles
REM becomes longer and deep sleep becomes shorter
4
Q
What is REM?
A
Dramatic physiological change from stage 4 NREM slow-wave sleep, to a state in which the brain becomes electrically and metabolically activated
5
Q
What are the sleeping patterns of young adults?
A
Difficulty falling asleep
6
Q
What are the sleeping patterns of middle age or older adults?
A
Staying asleep or decreased quantity
7
Q
What is insomnia?
A
- Difficulty falling asleep
- Difficulty maintaining sleep
- Experiencing non-restorative sleep (not feeling rested)
8
Q
What is primary insomnia?
A
Not caused by another sleep disorder, medical disorder, psychiatric disorder or mediation
9
Q
What are examples of primary insomnia?
A
Inadequate sleep hygiene, travel, death of a loved one
10
Q
What is secondary insomnia?
A
Caused by another sleep disorder, medical disorder, psychiatric disorder or medication
11
Q
What are the duration classifications of insomnia?
A
- Short term: less than 3 months
- Chronic: greater than 3 months
12
Q
What are the clinical presentation for insomnia?
A
- Difficulty falling asleep
- Short duration of sleep
3/ Frequent awakenings - Early morning awakenings
- Inability to fall back to sleep
- Impaired sleep quality due to dreams
- Impaired quality of life to sleep deprivation
13
Q
How should we assess and monitor insomnia?
A
- Determine if any exclusions to self-treatment exist
- If in doubt, refer
14
Q
What is the limit of self0treatment for insomnia?
A
10 days
15
Q
What are the exclusions of insomnia?
A
- <12 YO
- > 65 YO
- Pregnant or breastfeeding
- Frequent nocturnal awakenings or early morning awakening
- Chronic Insomnia
- Secondary insomnia
- Significant sleep disturbance as defined by sleep-onset latency > 30 minutes
- wake after sleep onset (WASO) > 30 minutes
- sleep efficiency < 85%, and/or total sleep time < 6.5 hours
16
Q
What should self-treatment insomnia be limited to?
A
Short term insomnia
17
Q
What is the non pharm treatment for insomnia?
A
- Cognitive behavior therapy
- Good sleep hygiene
18
Q
What is the pharm treatment for insomnia?
A
- Diphenhydramine
- Doxylamine
19
Q
What is good sleep hygiene?
A
- Use bed for sleeping or intimacy only
- Establish regular patterns
- Avoid daytime naps
- Make bedroom comfortable
- Do something relaxing
- Avoid electronics
- Avoid large quantities of liquids
- Avoid large meals
- Limit alcohol and caffeine
- Exercise regularly
20
Q
What is the MOA for diphenhydramine?
A
Ethanolamine antihistamine which block histamine 1 and muscarinic receptors
21
Q
What is diphenhydramine used for?
A
Short term insomnia
22
Q
What is the dose for diphenhydramine?
A
Take 30-60 minutes before bedtime
25-50 mg PO at bedtime
23
Q
Is Diphenhydramine recommended for pediatrics?
A
Not for those under 12. Refer to behaviors interventions and good sleep hygiene instead
24
Q
Is Diphenhydramine recommended for pregnancy?
A
Refer
25
Is Diphenhydramine recommended for lactation?
Refer
26
Is Diphenhydramine recommended for geriatric?
Refer to Beer's list
27
What are the contraindications for diphenhydramine?
1. BPH
2. Narrow angle glaucoma
3. CVD
4. Dementia
28
What are the warnings of diphenhydramine?
1. No alcohol
2. No driving or operating heavy machinery
29
What are ADR of diphenhydramine?
1. Paradoxical CNS stimulation
2. Anticholineric effects
3. Next morning hangover
30
What are the DDI of diphenhydramine?
Inhibits CYP2D6
31
What are complement therapies for insomnia?
1. Melatonin
2. Chamomile
3. Valerian
4. Kava
5. Alcohol
6. Mindfulness meditation
32
What are the available products for diphenhydramine?
1. Capsules
2. Gel caps
3. Tablets
4. Chewable
5. Solutions
6. Elixers
33
What is the etiology of drowsiness and fatigue?
1. Inadequate sleep
2/ Disease states
3. Drug induced drowsiness and fatigue
34
What are the symptoms of drowsiness and fatigue?
1. Yawning
2. Eye rubbing
3. Tendancy to fall asleep
4. Decreased ability to focus and concentrate
35
How should we assess and monitor drowsiness and fatigue?
1. Determine if any exclusions to self-treatment exist
2. If in doubt, REFER
3. Limit self-treatment to 10 days
36
What are the exclusions for drowsiness and fatigue self treatment?
1. <12YO
2. Pregnancy
3. Breast feeding
4. Heart disease
5. Anxiety disorder
6. Medication induced drowsiness
7. Chronic fatigue defined as >6 months fatigue
37
What is the non pharm for drowsiness and fatigue?
1. Identify and eliminate underlying cause
2. Good sleep hygiene
38
What are the pharm for drowsiness and fatigue?
Caffeine
39
What is the MOA for caffeine?
Xanthine derivative which nonselective antagonizes A1 and A2 receptors of adenosine
40
What is the indication for caffeine?
Occasional use to help patients stay awake and improve mental alertness
41
What is the dose of caffeine?
100-200 mg Q3-4H, Max 600mg/24hr
42
What should self treatment be limited for caffeine?
10 days
43
What is the caffeine treatment for children?
Not recommended for under 12
44
What is the caffeine treatment for pregnacy?
<200mg/day
45
What is the caffeine treatment for lactation?
200-300mg/day
Intake caffeine after breast feeding to reduce infant exposure
46
What is the caffeine treatment for geriatric?
<300mg/day
Clearance may be decreased
47
What are the withdrawal symptoms of caffeine?
1. Headache
2. Fatigue
3. Decreased concentration
4. Irritability
48
What are the precautions for caffeine?
1. Patients taking MAOIs
2. Coronary heart disease
3. Uncontrolled hypertension
4. Pre existing arrhthmias
49
What are adverse effects?
1. HA
2. Tachycardia
3. Increased BP
4. ANxiety
5. Insomnia
50
What are the DDI for caffeine?
1. Eliminated via CYP 1A2
2. Theophylline
3. Tobacco smoke
51
What are the forms of tobacco?
1. Cigarettes
2. Smokeless tobacco (chewing tobacco, oral snuff)
3. Pipes
4 Cigars5.
5. Clove cigarettes
6. Bidis
7. Hookah (water pipe smoking)
8. Electronic cigarettes (“e-cigarettes”)*
52
What are the physiological treatment of tobacco dependence?
1. The addiction to nicotine is treated by medications for cessation
53
What behavioral treatment of tobacco dependence?
The habit of using tobacco is treated by changing the problematic behavior
54
What should an effective tobacco treatment address?
Should address both the physiological and behavioral aspects of dependence
55
How do we address smoking behaviors?
Identify triggers as part of the quitting process
56
What are nicotine withdrawal symptoms?
1. Irritability
2. Frustration
3. Anger
4. Anxiety
5/ Difficulty concetrating
6. Insomnia
7. restlessness
57
When would physiologic withdrawal symptoms set in?
1. 1-2 days after stopping
2. Peak in the first week
3. Gradually decline over 2-4 weeks
58
What are the DDI of smoking and caffeine?
1. Smoke induce CYP1A2 enzymes that metabolizes caffeine
2. Nicotine enhances caffeine levels (56%)
3. Decrease caffeine intake by 50% when quitting, no caffiene in the evenings
59
What is the DDI of using nicotine while taking hormonal contraceptives?
Increased risk of:
1. Stroke
2. MI
3. Thromboembolism
However, it doesn't decrease the efficacy of hormonal contraceptives
60
What are the non pharm methods of nicotine quitting?
Counseling and non-drugs
61
What are the pharm methods of nicotine quitting?
FDA approved medications
62
How do we help a patient to quit smoking?
Ask: about tobacco use
Advise: tobacco users to quit
Assess: Readiness to make a quit attempt
Assist: with the quit attempt
Arrange: follow-up care
63
What are the stages of readiness to quit?
1. Not ready to quit in the next month
2. Ready to quit in next month
3. Recent quitter, quit within past 6 months
4: Former tobacco user, quit > 6 months ago
64
Why do we assess a patients readiness to quit?
Enables clinicians to deliver relevant, appropriate counseling messages
65
What is the cycle of quitting?
66
What are the counseling strategies for someone not ready to quit?
1. Relevance
2. Risks
3. Rewards
4. Roadblocks
5. Repetition
Using tailored, motivational messages
67
When do we refer someone with quitting?
Determine if any exclusions to self-treatment exist
If in doubt, REFER
68
What is the plan if someone wants to quit?
1. Set a quit date at least 2 days, no more than 2 weeks to allow time for patient to prepare
2. Remove tobacco products from home
3. Discuss plans with family and friends
4. Identify triggers
5. Follow up 1 week, 2 weeks, and 1 month, then prn
69
What are the exclsuions for tobacco dependence self-treatment?
1. Recent MI, Irregular heartbeat, severe angina
2. HBP
3. Pregnancy
4. Breastfeeding
5. <18YO
70
What is Nicotine replacement therapy not recommended for?
1. Pregnant smokers
2. Smokeless tobacco users
3. Individuals smoking fewer than 10 cigarettes per day
4. Adolescents
71
What are pharm therapy of NRT?
1. Nicotine polacrilex gum
2. Nicotine lozenge
3. Nicotine transdermal patch
72
What are examples of nicotine gum?
Nicorette and generic
73
What are examples of nicotine lozenge?
Nicorette, Generic nicotine lozenge
74
What are examples of nicotine patch?
NicoDerm, generic
75
What is the rationale use for NRT?
1. Reduce physical withdrawal from nicotine
2. Eliminated the immediate, reinforcing of nicotine
3. Allows patient to focus on behavioral and psychological aspects of tobacco cessation
76
What do nicotine gum contain?
Resin complex
77
What do nicotine gum contain?
Resin complex
1. Nicotine
2. Polacrilex
Sugar free gum base
Buffering agents to enhance buccal absoroption
Flavors: original, cinnamon, fruit, and mint
78
What are the strengths of nicotine gum?
2mg or 4mg
79
What is in a nicotine lozenge?
1. Nicotine polacrilex formulation (25% more nicotine than gum)
2. Contains buffering for enhance buccal absorption
Flavors: mint and cherry
Size: original and mini
80
What are the strengths of nicotine lozenge?
2mg and 4mg
81
How should we dose 2mg gum or lozenge?
If first cigarette of the day is smoked more than 30 minutes after waking
82
How should we dose 4mg gum or lozenge?
If first cigarette of the day is smoked less than 30 minutes after waking
83
What is the max amount of gum and lozenge?
gum: 24/day
Lozenge: 20/day
84
What is the recommended schedule for gum and lozenge?
85
What are the directions to use nicotine gum?
1. Chew slowly
2. Stop chewing at first sign of peppery taste or tingling sensation
3. Park between cheek and gum
4. Chew again when peppery taste or tingle fades
86
What are the directions to use nicotine lozenge?
1. Place in mouth and let it dissolve slowly
2. Do not chew or swallow
3. Roate to different areas of the mouth
4. 20-30 minutes
87
How should we educate a patient of a gum/lozenge?
1. Use at least nine (9) pieces daily during the first 6 weeks
2. Will not provide the same rapid satisfaction that smoking provides
3. The effectiveness of the nicotine gum/lozenge may be reduced by coffee, juice, wine, and soft drinkgs
4. Don't eat or drink for 15 minutes before or while using
88
What are the side effects of using gum and lozenges improperly?
1. Lightheadeness (dizzy)
2. Nausea and vomiting
3. Hiccups
4. Irritation of throat and mouth
89
What are the adverse effects both gum and lozenge?
1. Mouth and throat irritation
2. Hiccupts
3. GI complains
90
What are the effects associated with nicotine gum?
1. Jaw muscle ache
2. May stick to dental work
91
What are advantages of gum and lozenge?
1. Oral substitute
2. Delay weight gain
3. Can be titrated
4. Used with other agents
5. Inexpensive
92
What are the disadvantage of gum and lozenges?
1. Frequent dosing
2. GI adverse effects
93
What are the disadvantages of nicotine gum specifically?
1. Problem for people needing dental work
2. Needs proper chewing technique
3. Chewing might not be acceptable or desirable for some
94
What are transdermal nicotine patches?
1. 24 hr nicotine delivery
2. Well absorbed in skin
3. Avoids first pass
4. Plasma nicotine levels are lower and fluctuate less than smoking
95
How should we dose NicoDermCQ for a light smoker?
≤10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
96
How should we dose NicoDermCQ for a heavy smoker?
>10 cigarettes/day
Step 1 (21 mg x 6 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
97
How should we dose Generic for a light smoker?
≤10 cigarettes/day
Step 2 (14 mg x 6 weeks)
Step 3 (7 mg x 2 weeks)
98
How should we dose Generic for a heavy smoker?
>10 cigarettes/day
Step 1 (21 mg x 4 weeks)
Step 2 (14 mg x 2 weeks)
Step 3 (7 mg x 2 weeks)
99
What are the directions of transdermal nicotine patches?
1. Choose area of skin on upper body or arm
2. Skin needs to be clean, dry, hairless, and not irritated
3. Apply patch to different area each day
4. Do not use same area for at least 1 week
5. Remove protective liner and apply adhesive side of patch to skin
6. Peel off remaining protective covering
7. Press firmly with palm of hand for 10 seconds
8. Make sure patch sticks well to skin, especially around edges
9. Wash hands: Nicotine on hands can get into eyes or nose and cause stinging or redness
10. Do not leave patch on skin for more than 24 hours—doing so may lead to skin irritation
11. Adhesive remaining on skin may be removed with rubbing alcohol or acetone
12. Dispose of used patch by folding it onto itself, completely covering adhesive area
100
How should we counsel a patient education on patch?
1. Water will not harm the nicotine patch if it is applied correctly
2. Don't cut patches
3. Keep new and used patches out of the reach of children and pets
4. After patch removal, skin may appear red for 24 hours
5. If skin stays red more than 4 days or if it swells or a rash appears, contact health care provider—do not apply new patch
101
What is the local skin reactions of patches?
1. Adhesive
2. Up to 50% patients experience reaction
3. Avoid patients with dermatologic conditions
102
What are the clinical pearls of patches?
1. NRT helps with withdrawl
2. Combination therapy may be needed
3. Treatment for longer that indicated on the package may be needed to prevent relapse
4. Toxic effects may be seen when NRT is used incorrectly or excessively but more often patients do not use enough
