Sleep Disorders

For how long must insomnia symptoms be present to qualify for an insomnia disorder?

3 months

Sleep onset insomnia

Difficulty initiating sleep

Insomnia following middle-of-the-night awakenings

Difficulty maintaining sleep, characterized by frequent awakenings or problems returning to sleep after awakenings

Sleep-maintenance insomnia

Early-morning awakening with inability to return to sleep

What are the DSM-5 criteria for insomnia disorder?

- Predominant complaint of dissatisfaction with sleep quality

- Sleep difficulty occurring at least 3 nights per week

- Sleep difficulty despire adequate opportunity

- Not attributable to other medications or conditions

Insomnia lasting less than one week, self-limiting

Transient insomnia

Insomnia lasting 1 to 3 weeks

Short-term insomnia

Insomnia lasting greater than 3 weeks

Long-term (chronic) insomnia

What medication classes can cause insomnia?

- Anticonvulsants

- Diuretics

- SSRIs

- Stimulants

- Corticosteroids

- Decongestants

What over-the-counter medications and supplements can be used for insomnia?

- Diphenhydramine

- Doxylamine

- Melatonin

- Valerian

- Chamomile

How do benzodiazepines work for insomnia?

Binds to GABA complex in neuron membranes

What are the key points of flurazepam (Dalmane) for insomnia?

- 60-120 minute onset

- Half-life > 100 hours

- Long-acting benzodiazepine

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

What are the key points of quazepam (Doral) for insomnia?

- 60-120 minute onset

- Half-life 39-73 hours

- Long-acting benzodiazepine

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

What are the key points of temazepam (Restoril) for insomnia?

- 60-120 minute onset

- Half-life 3.5-18.4 hours

- Intermediate-acting benzodiazepine

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

What are the key points of estazolam (ProSom) for insomnia?

- 60-120 minute onset

- Half-life 10-24 hours

- Intermediate-acting benzodiazepine

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

What are the key points of triazolam (Halcion) for insomnia?

- 15-30 minute onset

- Half-life 1.5-5.5 hours

- Short-acting benzodiazepine

- Treats sleep onset insomnia

What are the adverse effects of benzodiazepines for insomnia?

- Hangover effect

- Complex sleep-related behaviors

- Anterograde amnesia

- Increased risk of falls and hip fractures

- Withdrawal

What are the benzodiazepines used for insomnia?

- Flurazepam (Dalmane)

- Quazepam (Doral)

- Temazepam (Restoril)

- Estazolam (ProSom)

- Triazolam (Halcion)

What are the benzodiazepine receptor agonists used for insomnia?

- Zolpidem (Ambien)

- Zaleplon (Sonata)

What types of insomnia does zolpidem treat?

- Sleep onset insomnia

- Sleep maintenance insomnia

What types of insomnia does zaleplon (Sonata) treat?

- Sleep onset insomnia

- Insomnia following middle-of-the-night awakenings

For how long can zolpidem (Ambien) be used?

Optimally not exceed 4 weeks

What are the adverse effects of zolpidem (Ambien)?

- Drowsiness

- Dizziness

- Headache

- Amnesia

- GI upset

- Complex sleep-related behaviors

What are the key points of zolpidem CR (Ambien CR)?

- Not limited to short-term use

- Bi-phasic, dual layer delivery

- 60% released for immediate sleep onset

- 40% released for sleep maintenance

For what is zompidem sublingual (Edluar) approved?

Short-term insomnia, to improve sleep onset

What are the key points of zaleplon (Sonata)?

- Approved for short-term use

- Rapid onset, short half-life

- Effective for decreasing time to sleep onset but not for increasing total sleep time

- Has no effect on next-day psychomotor performance

- Can be used 4-5 hours before arising

What are the adverse effects of zaleplon (Sonata)?

- Dizziness

- Headache

What are the key points of eszopiclone (Lunesta)?

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

- Can be used long-term

- Minimal hangover effect

What are the adverse effects of eszopiclone (Lunesta)?

- Unpleasant taste

- Headache

- Dry mouth

What are the key points for ramelteon (Rozerem)?

- Treats sleep onset insomnia

- Selective MT1 and MT2 agonist

- No potential for abuse

- May increase prolactin and decrease testosterone

What are the side effects of ramelteon (Rozerem)?

- Somnolence

- Dizziness

- Nausea

- Fatigue

- Headache

- Rebound insomnia

What are the dual orexin-receptor antagonists used for insomnia?

- Suvorexant (Belsomra)

- Lemborexant (Dayvigo)

- Daridorexant (Quviviq)

What are the key points of dual orexin-receptor antagonists?

- Treats sleep onset insomnia

- Treats sleep maintenance insomnia

- Blocks OX1R and OX2R binding to suppress the wake drive

What are the adverse effects of dual orexin-receptor antagonists?

- Somnolence

- Fatigue

- Headache

- Abnormal dreams

- Impaired next-day driving

- Complex sleep-related behaviors

What are the antidepressants used for insomnia?

- Low-dose doxepin (Silenor)

- Trazodone (Desyrel)

- Mirtazapine (Remeron)

What are the key points of low-dose doxepin (Silenor) for insomnia?

- Tricyclic antidepressant

- Strong H1 receptor affinity

- Treats sleep maintenance insomnia

- Less anticholinergic side effects than other TCAs

- Can cause residual next-day somnolence

What are the key points of trazodone (Desyrel) for insomnia?

- Not FDA approved for insomnia

- Treats insomnia in patients prone to substance abuse

- Lower dose than for depression

What are the side effects of trazodone (Desyrel) for insomnia?

- Priapism

- QT prolongation

- Next-day sedation

- Alpha1 adrenergic blockade

What are the key points of mirtazapine (Remeron) for insomnia?

- H1-receptor-blocking properties

- No anticholinergic properties

- Can cause weight gain

- Often used in elderly patients

What are the characterizations of narcolepsy?

- Excessive daytime sleepiness

- Cataplexy

- Hallucinations

- Sleep paralysis

Cataplexy

A sudden bilateral loss of muscle tone varying in severity and duration without the loss of consciousness

Narcolepsy with cataplexy

Narcolepsy type 1

Narcolepsy without cataplexy

Narcolepsy type 2

What are the early symptoms of narcolepsy?

- Excessive daytime sedation

- Poor sleep quality

How should naps be taken for narcolepsy?

2 or more scheduled naps lasting at least 15 minutes per day

What stimulants are FDA-approved for narcolepsy?

- Methylphenidate (Ritalin)

- Dextroamphetamine (Dexedrine)

What stimulants are not FDA-approved for narcolepsy but are used for its treatment?

- Dextroamphetamine/amphetamine (Adderall)

- Lisdexamfetamine (Vyvanse)

- Not completely effective at treating cataplexy

What are the adverse effects of stimulants for narcolepsy?

- Insomnia

- Hypertension

- Palpitations

- Irritability

- Tolerance

- High abuse potential

What are the non-stimulant treatments for narcolepsy?

- Modafinil (Provigil)

- Armodafinil (Nuvigil)

- Solriamfetol (Sunosi)

- Pitolisant (Wakix)

- Sodium oxybate (Xyrem, Lymryz)

What are the key points of modafinil (Provigil) and armodafinil (Nuvigil) for narcolepsy?

- FDA-approved for narcolepsy

- Schedule IV controlled substance

- Not effective at treating cataplexy

What are the adverse effects of modafinil and armodafinil for narcolepsy?

- Headache

- Nausea

- Nervousness

- Anxiety

- Insomnia

What are the key points of solriamfetol (Sunosi) for narcolepsy?

- Norepinephrine and dopamine reuptake inhibitor

- FDA-approved for narcolepsy

- Schedule IV controlled substance

- Not effective at treating cataplexy

What are the adverse effects of solriamfetol (Sunosi) for narcolepsy?

- Headache

- Tachycardia

- Increased blood pressure

What are the key points of pitolisant (Wakix) for narcolepsy?

- H3 antagonist/inverse agonist

- FDA-approved for narcolepsy with cataplexy

- Can be used in combination with other treatments

What are the adverse effects of pitolisant (Wakix)?

- Headache

- Insomnia

- Anxiety

- Musculoskeletal pain

What are the key points of sodium oxybate (Xyrem, Lumryz) for narcolepsy?

- FDA-approved for narcolepsy with cataplexy

- CNS depressant, taken at bedtime

- Decreased sleep paralysis, cataplexy, and hallucinations

- Can be administered safely with stimulants

- Should not be given to those with sleep apnea or alcohol/substance use disorder

- Significant abuse potential

What methods are employed due to the significant abuse potential of sodium oxybate?

- Xyrem Success Program (REMS)

- Restricted distribution

What are the adverse effects of sodium oxybate (Xyrem, Lumryz) for narcolepsy?

- Nausea

- Somnolence

- Confusion

- Dizziness

- Incontinence

What other medication classes may be used to reduce cataplexy in patients with narcolepsy?

Antidepressants (TCAs, SNRIs, SSRIs)

What may restless leg syndrome be associated with?

- Chronic kidney disease

- Iron deficiency anemia

- Pregnancy

What should patients with restless leg syndrome avoid?

Alcohol, caffeine, and nicotine

What are the nonpharmacologic treatments for restless leg syndrome?

- Exercise

- Baths

- Massage

- Compression stockings

What are the pharmacoligic treatment options for restless leg syndrome?

- Magnesium

- Dopamine agonists

- GABA analogues

What are the dopamine agonists used for restless leg syndrome?

- Ropinirole

- Rotigotine

- Pramipexole

What are the GABA analogues used for restless leg syndrome?

- Gabapentin

- Pregabalin

What are the side effects of dopamine agonists for restless leg syndrome?

- Compulsive behaviors

- Symptom augmentation over time

When used for the treatment of narcolepsy, modafinil is best dosed at bedtime.

False

Which of the following medications is only useful for sleep onset insomnia?

Triazolam

Weight gain is a clinically significant adverse drug reaction associated with pregabalin.

True

Which of the following is a rare but clinically significant adverse reaction associated with the use of trazodone?

Priapism

Which of the following types of insomnia is associated with "difficulty falling asleep"?

Sleep onset insomnia

Which of the following medications is useful for "insomnia following middle-of-the-night awakenings"?

Zaleplon

Unpleasant taste is a side effect associated with which of the following medications?

Eszopiclone

Which of the following insomnia medications has the least potential for abuse?

Ramelteon

Common side effects associated with solriamfetolinclude tachycardia and increased blood pressure.

True

A 52-year-old patient with chronic muscle spasticity and pain present to your ambulatory clinic for a recommendation for mixed sleep onset and sleep-maintenance insomnia. His current scheduled medications are diazepam 10 mg PO BID and baclofen 10 mg PO TID. Which of the following choices is the best recommendation for his insomnia type? Keep in mind that some choices may cause detrimental drug interactions with his current medication regimen.

Suvorexant