sleep, RLS, narcolepsy (NAPLEX)

Chronic insomnia is when patient has symptoms at least __ times per week for at least ___ months

3, 3

What is the preferred TX for chronic insomnia?

CBT

Meds worsening insomnia (14)

• ADHD meds

• ACHease inhibitors (Donepezil)

• Aripirazole

• Buproprion

• Fluoxetine (if taken late in day)

• NRT

• Varenicline

• Caffeine

• Decongestants

• Phentermine

• Alcohol

• Steroids

• Diuretics (due to nocturia)

• INSTI

Sleep hygeine

• Keep bedroom dark, comfortable, and quiet

• Keep a regular sleep schedule

• Avoid daytime naps, limit to 30 min

• Resverse bedroom for sleep

• Turn face of clock to side

• If unable to sleep, get up and do something to get mind of it

• Establish a pre-bedtime ritual

• Avoid exercising right before bed

• Do not eat heavy meals right before bed

• Do not have caffeine in the afternoon

HELP FALLING ASLEEP (4)

• Eszopiclone

• Zolpidem

• Ramelteon

• Zaleplon

HELP STAYING ASLEEP (4)

• Eszopiclone

• Zolpidem

• Doxepin

• Suvorexant

Patients may self treat insomnia with OTC first gen antihistamines such as _______ or _______ but these should not be used long term

diphenhydramine, doxylamine (Unisom sleep tabs)

Eszopiclone brand

Lunesta

Zolpidem formulations

• Ambien IR and ER tablets

• Edluar: SL tablets

Zolpidem (Ambien and Edluar) dosing

• Females/older adults: 5 mg PO/SL QHS

• Male: 5-10 mg PO/SL QHS

Is ramelteon a controlled substance?

No

Hypnotics options (3)

• Eszopiclone

• Zolpidem

• Zaleplon

Melatonin agonist options (2)

• Ramelteon

• Tasimelteon

TCA option (1)

• Doxepin

Preferred benzo for sleep and schedule

Temazepam (Restoril), IV

Orexin antagonist options (3)

• Daridorexant

• Lemborexant

• Suvorexant

Doxylamine brand

Unisom sleep tabs

Antihistamines should be avoided in (2)

• BPH

• Glaucoma

Restless leg syndrome (3)

• Iron supplementation if needed

• Gabapentin enacarbil, pregabalin

• DA agonist (pramiprexole, ropinirole, rotigotine) but not for long term TX

Narcolepsy TX

• Stimulants: Modafinil, Armodafinil

• Sodium oxybate

Modafanil warning *

SJS

Sodium oxybate is derived from ______

GABA

What narcolepsy med has a REMS?

Sodium oxybate for using as a sexual assualt med

Sodium oxybate is a schedule

CIII

EZ tip for excellent ZZ sleep

Eszopiclone

Zolpidem

Are BZDs or non-BZDs preferred for insomnia

non-BZDs

If BZDs required which ones are approved for pts 65 yrs or older

L-O-T

Lorazepam

Oxazepam

Temazepam

Are natural substances valerien and kava recommended

no due to heptatoxicity

Non bzd hypnotics MOA

act selectively at BZD receptors to increase GABA

non bzd hypnotics schedule

IV

Boxed warnings and contraindication of hypnotics

Complex sleep behavior

Warnings of hypnotics

Increase risk of CNS depression

Potential for abuse

Side effects of hypnotics

Somnolence

dizziness

ataxia

HA

Melatonin receptor agonist MOA

agonists at MT1 and MT2 melatonin receptors

Temazepan BW

avoid use with opioids

Temazepan warnings

pregnancy

Temazepan side effects

drowsiness

dizziness

increased fall risk

cognitive impairment

TCA MOA

inhibit norepinephrine and serotonin reuptake

Doxepin CI

MAOI use within 2 wks, glaucoma, severe urinary retention

Doxepin side effects

Seizures

Anticholinergic effects

orexin receptor antagonists MOA

block orexin neuropeptide signaling system

orexin receptor antagonists CI

narcolepsy

orexin receptor antagonists warnings

worsening depression/suicidal ideations

orexin receptor antagonists side effects

somnolence

orexin receptor antagonists schedule

IV

first gen antihistamines MOA

block H1 histamine receptors

when to take modafinil and armodafinil

QAM

When should Sodium oxybate be given

at bedtime

Sodium oxybate contraindications

use with sedative-hypnotics or alcohol