Sleep wake disorders part 2

Define RLS

presents as an urge to move legs in response to uncomfortable or unpleasant sensations

“creepy, crawly” sensations

What time of day does RLS usually worsen?

evening/night

RLS is often associated with what?

periodic limb movements of sleep (leg kicking in sleep)

Risk factors for RLS (not disease states)

• more common in females

• most commonly presents in middle-aged or older individuals

• associated with CV risk

Risk factors for RLS (disease states)

• Parkinson’s disease

• hypothyroidism

• CKD

• iron deficiency

• pregnancy

Untreated RLS is associated with an increased risk for ______

depression

What is the pathophysiology of RLS?

dysfunction of DA-producing cells of the substantia nigra

What is the major NT/factors associated with RLS?

DA and iron

What is iron’s influence with DA?

• necessary for DA synthesis

• regulates DA receptors

• Deficiency impairs DA transport

What are some non-pharm treatments for RLS?

• sleep hygiene

• behavioral modifications

• smoking cessation

• avoid alcohol

• reduce/avoid caffeine

• Evaluate medications that may worsen RLS

1st line agents for RLS?

DA agonists or alpha-2-delta ligand

What are some other agents for RLS?

carbidopa/levodopa

low-dose opioids

What are some DA agonists?

• Pramipexole

• Ropinirole

• Rotigotine

What are some warnings for DA agonists?

hallucinations or psychotic-like behavior

RLS augmentation

impulse control problems

sulfite sensitivity for rotigotine patch

ADR for DA agonist

GI upset

Dizziness

Insomnia

What are the alpha-2-delta ligands?

Gabapentin enacarbil (Horizant)

(pro-drug of Gabapentin that binds to ligand subunit)

ADR of alpha-2-delta ligands

sedation

dizziness

irritability

True or false: RLS is not a chronic condition and may require long-term treatment

false; it is chronic

With RLS, you want to avoid long-term use of _____

opioids

Define narcolepsy

severely debilitating neurologic disorder

For narcolepsy, true or false: REM sleep may occur at any time of day?

true

Onset for narcolepsy is typically around what age

early teens or 20’s

True or false: with narcolepsy, the causes are a combination of genetic and environmental factors

true

What is the 4 may points for narcolepsy?

1. excessive daytime sleepiness (EDS)

2. cataplexy

3. hallucinations

4. sleep paralysis

What is cataplexy?

sudden loss of muscle tone in face or limb

no loss of consciousness

Non-pharm treatment for narcolepsy?

• counsel the patient and family

• scheduled daytime naps

• discourage smoking

• Avoid alcohol or caffeine before bedtime

1st line treatment for EDS

• modafinil

• pitolisant

• solriamfetol

• sodium oxybate

2nd line for EDS

stimulants, armodafinil

1st line for cataplexy

sodium oxybate

pitolisant

2nd line for cataplexy

stimulants

MOA of pitolisant

selective H3 receptor inverse agonist/antagonists that increases synthesis and release of histamine

Pitolisant is contraindicated in

severe hepatic impairment

Warning for pitolisant

QT prolongation

What is the MOA for solriamfetol

DA and NE reuptake inhibitor

Contraindications for solriamfetol

MAOI use within 14 days of starting therapy

Monitoring parameters for solriamfetol

BP and HR

Sodium oxybate is a form of what?

gamma-hydroxybutyrate (GHB)

Effects of sodium oxybate?

• improves nocturnal sleep and improves daytime alertness

• changes sleep architecture to resemble normal sleep

• decreases nighttime awakenings

• improves EDS and decreases episodes of sleep paralysis, cataplexy, and hypnagogic hallucinations

For patients on sodium oxybate, they must be enrolled in what

Xyrem REMS program

Antidepressants are very effective in the treatment for _____

cataplexy

(also help with hypnagogic hallucinations and sleep paralysis)

You should assess every ____ to ___ months for narcolepsy

6-12

Sleep apnea is more common in which gender?

men

True or false: the prevalence for sleep apnea in women decreases after menopause?

false; increases

Sleep apnea is characterized by

• repetitive episodes of cessation of breathing

• blood oxygen desaturation

• brief arousal from sleep to restart breathing

What is sleep apnea associated with what disease states?

CVD, HTN, cerebrovascular events, and increased risk of motor vehicle accidents

How is sleep apnea diagnosed?

polysomnography (PSG)

Define central sleep apnea (CSA)

impaired respiratory drive

Define obstructive sleep apnea (OSA)

partial or complete closure of upper airway

PSG is also used to determine severity by what 2 things?

• number of apnea episodes

• number of hypopnea episodes

Mild apnea-hypopnea is classified as how many episodes/hour

5-14

Moderate apnea-hypopnea is classified as how many episodes/hour

15-29

Severe apnea-hypopnea is classified by how many episodes/hour

30+

Risk factors for OSA

• age >40 years old

• obesity

• large neck circumference

• sleeping on back increases apneic episodes

Non-pharm treatment for OSA

nasal continuous positive airway pressure (CPAP)

weight loss

positional changes

surgical procedures

True or false: there is drug therapy available for treatment of OSA

false

what is FDA approved for EDS secondary to OSA

modafanil/armodafanil

How often do you assess OSA

After 1-3 months of treatment

How long does jet lag usually last?

2-3 days or up to 7-8 days if time zone changes >8 hours