Ch. 68 Sleep Disorders

Insomnia

Difficulty falling asleep, reduced sleeping duration, and/or poor sleep quality

Insomnia diagnosis

Symptoms 3+ times/week for 3+ months

Non-Drug Treatment for chronic insomnia

Cognitive Behavioral Therapy and changes to sleep hygiene

Drugs that can worsen insomnia

- AChE inhibitors (donepezil)

- Alcohol

- Aripiprazole

- Atomoxetine

- Bupropion

- Caffeine

- Decongestants

- Diuretics

- Fluoxetine

- Nicotine

- Integrase strand transfer inhibitors (INSTIs)

- Steroids

- Stimulants

- Varenicline

Natural products for insomnia

- Melatonin

- Chamomile Tea

- Valerian (but avoid bc hepatotoxicity)

- kava (but avoid bc hepatotoxicity)

Sleep Hygiene Tips

- Bedroom kept dark, comfy, quiet

- Regular sleep schedule

- Avoid daytime naps

- Reserve bedroom for sleep & other appropriate activity

- Turn face of clock aside

- Get up and do something if unable to fall asleep

- Avoid exercise before bed

- Avoid heavy meals before bed

- Avoid afternoon caffeine

Insomnia treatment

- Help falling asleep

- Eszopiclone (Lunesta)

- Zolpidem

- Ramelteon (Rozerem)

- Zaleplon (Sonata)

Insomnia treatment

- Help staying asleep

- Eszopiclone

- Zolpidem

- Doxepin

- Suvorexant

Insomnia treatment

- Help falling & staying asleep

- Eszopiclone

- Zolpidem

OTC products for insomnia that may be used short term?

- Diphenhydramine

- Doxylamine

According to the Beers Criteria, what drug classes are considered potentially inappropriate in patients aged 65 years and older

• Benzodiazepines

• Non-benzodiazepine hypnotics (e.g., zolpidem)

• First-Generation antihistamines

If benzodiazepines are used, which ones are preferred?

L-O-T

• Lorazepam

• Oxazepam

• Temazepam

Non-benzodiazepine hypnotics MOA

Act selectively at benzodiazepine receptors to increase GABA

Non-BZD hypnotics (List Them)

• Eszopiclone (Lunesta)

• Zolpidem (Ambien, Edluar)

• Zaleplon

BBW for Lunesta, Ambien, and Sonata

complex sleep behavior that can lead to injury

-sleep walking, sleep driving, activity while not fully conscious

CI if history of this

Non-BZD Hypnotic Drugs (C-IV)

Side effects:

- Somnolence

- Dizziness

- Ataxia

- HA

Non-BZD hypnotics

Warnings

• Increased risk of CNS depression

• Potential for abuse and dependence

Non-BZD hypnotics

Notes

• Preferred over benzodiazepines for first-line treatment due to decreased abuse, dependence and tolerance

Orexin receptor antagonists

Lemborexant, Suvorexant

Side effects:

- Somnolence

- HA

- Dizziness

- Abnormal dreams

How do Orexin receptor antagonists work?

Orexin is a molecule promoting wakefulness. By blocking this, it results in drowsiness

orexin receptor antagonists

lemborexant (DayVigo)

suvorexant (Belsomra)

take on empty stomach

not for severe hepatic impairment

CI to DayVigo and Belsomra

narcolepsy

Melatonin receptor agonists

Ramelteon, Tasimelteon

Side effects:

- Somnolence

- Dizziness

How do Melatonin receptor agonists work?

Agonize melatonin receptors and promote sleepiness & regulate circadian rhythm

TCA approved for insomnia

doxepin (Silenor)

BBW for suicidal thoughts

CI for use within 2 weeks of an MAO inhibitor

SE is seizures

Benzos approved for insomnia

temazepam (Restoril)

estrazolam

quazepam (Doral)

flurazepam

triazolam (Halcion)

Benzodiazepines

Boxed Warnings

• Use with opioids can result in sedation, respiratory depression, coma and death

• Risk for abuse, misuse and addiction

• Continued use can lead to physical dependence; abrupt discontinuation can cause life-threatening withdrawal symptoms (taper off slowly)

BZD

Contraindications

Pregnancy

BZD

Side Effects

• Drowsiness

• Dizziness/Increased fall risk

• Cognitive impairment

Antihistamines

MOA

• Bluck H1 histamine receptors

Antihistamines (List Them)

• Diphenhydramine (Benadryl)

• Doxylamine (Unisom, SleepTabs)

Antihistamines

Side Effects/Notes

Side Effects

• Sedation

• Peripheral anticholinergic side effects: urinary retention

Notes

• Avoid use in BPH and glaucoma

Restless legs syndrome

a neurological disorder characterized by uncomfortable feelings in the legs, producing a strong urge to move them

Restless Legs Syndrome

Treatment:

- DA agonists (Ropinirole, Pramipexole, Rotigotine patch) IR

- Gabapentin enacarbil (Horizant)

Horizant

gabapentin enacarbil

used for postherpetic neuralgia and RLS

taken with food at 5 pm

Narcolepsy

excessive daytime sleepiness with cataplexy (sudden loss of muscle tone)

Narcolepsy treatment

- Modafinil, Armodafinil (Stimulants for wakefulness)

- Sodium oxybate

- Pitolisant (H3 antagonist/inverse agonist)

- Solriamfetol (DA & NE reuptake inhibitor)

- Some Stimulants for ADHD also have indication for narcolepsy

BBW Provigil and Nuvigil

modafinil, armodafinil

avoid with cardiac conditions, hepatic/renal dysfunction, psychiatric conditions, Tourettes

rash can can life threatening (SJS)

sodium oxybates

help with sleep at night. used with stimulants for the day

sodium oxybate (Xyrem)

calcium, magnesium, potassium, & sodium oxybates (Xywav)

these are date rape drugs so require REMS program