Sleep Disorder - Dr. G Study Guide

What is the recommendation for advanced sleep phase disorder associated with many geriatric people (e.g., asleep by 7pm and wake up at 3am)?

Late sunset walk to delay melatonin

What is the recommendation for delayed sleep phase disorder associated with many teenagers (e.g., not sleepy until 3 am and sleep till noon)?

Early daylight exposure

REM rebound from d/c of alcohol or BZDs can cause what sleep disturbances?

nightmares

What is sleep apnea?

episodes of cessation of breathing, terminated by a brief arousal from sleep which the patient gasps for air and resumes breathing

What is the treatment of choice for sleep apnea?

CPAP

Why is it important to avoid CNS depressants (including alcohol) for people with sleep apnea?

prevents mini arousal that help the person continue breathing

What stages of sleep are considered restorative sleep (AKA delta sleep)?

Stage 3

Explain why patients with sleep apnea are so tired in the daytime despite appearing to sleep for 7-8 hours?

Patients with sleep apnea never reach deep sleep and always fluctuates in light sleep

Which hypnotic classes should be avoided for treatment of insomnia for the elderly? Why?

BZDs (especially long acting). Anti-SLUD and decrease ACh --> memory impairment

How does caffeine work to increase wakefulness?

Blocks adenosine

What is the half-life of caffeine?

~ 5 hours

What medications can cause insomnia?

Prozac (Fluoxetine), Bupropion (Wellbutrin), Sudafed

What is Narcolepsy?

- excessive daytime sleepiness

- often with cataplexy

- caused by deficiency of orexin- producing neurons in hypothalmus

What are treatment options of Narcolepsy?

Cataplexy: protriptyline or SSRIs

Excessive daytime sleepiness: psychostimulants, modafinil (Provigil) and Armodafinil (Nuvigil)

Which FDA-approved benzodiazepines hypnotics would be a better choice for patients with hepatic impairment?

Temazepam (Restoril)

Explain why alcoholic patients need higher doses of benzodiazepines to achieve therapeutic effects?

cross-tolerance

Why is it important to taper temazepam 30 mg po qhs prn insomnia (used nightly for > 1 year) to zolpidem 10 mg po qhs prn insomnia?

Temazepam is a BZD --> prevent AIMS

Among the 3 Z-hypnotic agents (Ambien - zolpidem, Sonata - zaleplon, Lunesta - eszopiclone), which one is FDA-approved for long-term use? What is a common side effect of this Z-hypnotic agent?

Eszopiclone (Lunesta) - bitter taste

Name the 2 melatonin receptor agonist hypnotic agents that are FDA-approved for long-term use.

Ramelteon (Rozerem) and Tasimelteon (Hetlioz)

Which melatonin receptor agonist is FDA-approved for non-24 hour sleep wake disorder (e.g., blind people)?

Tasimelteon (Hetlioz)

Which Z-hypnotic can be taken in the middle of the night provided they have 4 hours before time to wake up?

Sonata (Zaleplon)

Patients taking the Z-hypnotics should not drink grapefruit juice and alcohol. Explain why?

Grapefruit juice: can increase drug concentration

Alcohol: too much CNS depression

Which class of hypnotics has the most reported CNS ADRs, such as sleep eating, walking, or driving?

Z- hypnotics

Your patient asked if she could take 2 of the 8 mg ramelteon if she cannot stay asleep with this medication. What would you recommend?

No. Starting and max dose is 8 mg

Which is the most common hypnotic agent prescribed now that is used to be a sedating antidepressant?

Trazodone (Desyrel)

What is the most common side effect, other than sedation, associated with this agent?

Minimal cardiac conduction problems

What is the active ingredient in Unisom?

Diphenhydramine and/or Doxylamine

What is the active ingredient in Advil PM for sleep?

Diphenhydramin

What are the common side effects for Unisom and Advil PM?

Anti-SLUD, next day grogginess

Comment on the dose of this Advil PM product with instructions to take 2 caplets QHS.

Advil PM - 76 mg/day if following instructions which is extremely high → Anti-SLUD and excessively overdose

What is Silenor? Comment on Silenor's dosing vs. its use in the past as an antidepressant

Doxepine (Silenor) is used for sleep as a TCA. Used in much lower doses than its use as an antidepressant

Patient brings in a new Rx for Provigil 200 mg po q6pm. What is the most likely indication in this case?

Shift work disorder

Why do you need to inform patients on Provigil (modanfinil) or Nuvigil (armodafanil) to report rashes?

SJS

What are the potential DDIs associated with Provigil (modanfinil) or Nuvigil (armodafanil)?

Inhibits CYP2C19 ; co-admin with drug such as diazepam --> increase drug conc.

Induce CYP3A4 ; Modafinil can decrease concentrations or CYP3A4 substrates (e.g. oral contraceptives, alprazolam).

Your patient with Alzheimer's disease was given Tylenol PM for sleep. Any potential problem?

Diphenhydramine decreases ACh → worsens memory

What is the mechanism of action of suvorexant (Belsomra) and lemborexant (Dayvigo)?

Orexin antagonists that block wake-promoting neuropeptides

What is the interaction of suvorexant (Belsomra) and lemborexant (Dayvigo) with grapefruit juice?

Grapefruit juice (3A4 inhibitor) causes higher concentrations.

What is a contraindication for suvorexant (Belsomra) and lemborexant (Dayvigo)?

Narcolepsy

What is the max dose of Belsomra (suvorexant)? Why did FDA lowered the max dose by half before it was approved.

20 mg. Lowered due to poor efficacy.

What are the non-pharmacologic options for the treatment of insomnia?

CBT-I

Other than the FDA-approved hypnotics, name the 3 psychiatric drugs that are commonly used at lower doses off-label for insomnia.

trazodone (desyrl), mirtazapine (Remeron), quetiapine (Seroquel)