Treatment of sleep disorders 3/20-25

What are the main pharmacological differences between OTC and RX sleep aids

OTC sleep aids are primarily antihistamines (e.g.

Why might RX sleep aids be preferred over OTC options

RX sleep aids provide targeted action for sleep onset or maintenance with potentially fewer anticholinergic effects than OTC antihistamines and options tailored to specific insomnia types

What is the recommendation for advanced sleep phase disorder in geriatric patients

Evening bright light therapy to delay the circadian rhythm and sleep onset

What is the recommendation for delayed sleep phase disorder in teenagers

Morning bright light therapy and possibly melatonin in the evening to advance the sleep phase

What sleep disturbances can REM rebound from discontinuing alcohol or benzodiazepines cause

Vivid dreams or nightmares due to increased REM sleep

What is sleep apnea and what is its treatment of choice

Sleep apnea is a disorder with breathing pauses during sleep often due to airway obstruction and treatment of choice is Continuous Positive Airway Pressure (CPAP)

Why should people with sleep apnea avoid CNS depressants like alcohol

CNS depressants relax airway muscles worsening obstruction and increasing apneic episodes

Which sleep stage is considered restorative (delta sleep)

NREM Stage 3

Why are sleep apnea patients tired despite 7-8 hours of sleep

Frequent awakenings from apneic episodes prevent deep restorative sleep

Which hypnotic classes should be avoided in the elderly for insomnia and why

Long-acting benzodiazepines and anticholinergic agents (e.g.

How does caffeine increase wakefulness and what is its half-life

Caffeine blocks adenosine receptors preventing sleep promotion with a half-life of 3-7 hours

Name some medications that can cause insomnia

Stimulants SSRIs bupropion corticosteroids decongestants

What is narcolepsy and what are its treatment options

Narcolepsy is excessive daytime sleepiness with cataplexy sleep paralysis and hallucinations treated with stimulants (e.g.

Which benzodiazepine hypnotic is better for patients with hepatic impairment

Temazepam (metabolized via glucuronidation)

Why do alcoholic patients need higher benzodiazepine doses

Cross-tolerance from chronic alcohol use affects GABA receptors

Why taper temazepam when switching to zolpidem after long-term use

To prevent withdrawal symptoms from abrupt benzodiazepine discontinuation

Which Z-hypnotic is FDA-approved for long-term use and what is a common side effect

Eszopiclone (Lunesta) with bitter taste

Name the 2 FDA-approved melatonin receptor agonists for long-term use and which is for non-24 hour sleep-wake disorder

Ramelteon (Rozerem) and tasimelteon (Hetlioz) with tasimelteon for non-24 hour sleep-wake disorder

Which Z-hypnotic can be taken in the middle of the night if 4 hours remain before waking

Zaleplon (Sonata)

What should patients avoid when taking Z-hypnotics and why

Avoid alcohol (increases sedation/impairment) and meals (delays onset)

Which hypnotic class has the most reported CNS ADRs like sleep eating or driving

Z-hypnotics (e.g.

What to recommend if a patient cannot stay asleep with 8 mg ramelteon

Ramelteon is for sleep onset so suggest a different medication for sleep maintenance

What is the most common off-label hypnotic originally an antidepressant and its common side effect

Trazodone with orthostasis

What are the active ingredients in Unisom and Advil PM for sleep and their common side effects

Unisom: doxylamine and Advil PM: diphenhydramine with anticholinergic side effects (dry mouth constipation urinary retention) and grogginess

What is the concern with taking 2 caplets of Advil PM (38 mg diphenhydramine each) at bedtime

76 mg diphenhydramine exceeds typical 25-50 mg dose increasing grogginess and anticholinergic effects

What is Silenor and how does its insomnia dosing compare to its antidepressant use

Silenor is doxepin used at 3-6 mg for insomnia much lower than 100-300 mg for depression

What is the likely indication for Provigil (modafinil) 200 mg daily

Excessive daytime sleepiness from narcolepsy shift work sleep disorder or sleep apnea

Why should patients on modafinil or armodafinil report rashes

Risk of serious skin reactions like Stevens-Johnson syndrome

What are potential drug interactions with modafinil or armodafinil

CYP3A4 inducers decrease levels of CYP3A4 substrates (e.g.

Why is Tylenol PM problematic for Alzheimer’s patients

Contains diphenhydramine an anticholinergic that can worsen cognitive impairment

What is the mechanism of action of suvorexant and lemborexant and their interaction with grapefruit juice

Orexin receptor antagonists with CYP3A4 metabolism meaning grapefruit juice increases levels

What is the max dose of suvorexant (Belsomra) and why was it lowered

20 mg lowered from 40 mg due to safety concerns

What are non-pharmacologic options for insomnia

Cognitive behavioral therapy meditation relaxation techniques sleep hygiene education

Name 3 psychiatric drugs used off-label for insomnia

Trazodone mirtazapine quetiapine

What are the pros and cons of benzodiazepines for insomnia

Pros: Effective for sleep onset and maintenance Cons: Risk of dependence tolerance withdrawal sedation cognitive impairment

What are the pros and cons of Z-hypnotics for insomnia

Pros: Effective for sleep onset or maintenance lower dependence risk than benzodiazepines Cons: Complex sleep behaviors potential abuse

What are the pros and cons of melatonin receptor agonists for insomnia

Pros: Aid sleep onset low dependence risk Cons: Ineffective for sleep maintenance possible hormonal effects

What are the pros and cons of orexin receptor antagonists for insomnia

Pros: Help sleep onset and maintenance novel mechanism Cons: Next-day somnolence CYP3A4 interactions

What adverse drug reactions (ADRs) should be monitored with hypnotics

Daytime sedation cognitive impairment falls complex sleep behaviors dependence withdrawal

How do you choose the most appropriate hypnotic for a patient

Consider insomnia type (onset vs. maintenance) patient age comorbidities (e.g.