NAPLEX: Sleep Disorders

chronic insomnia

difficulty falling asleep, reduced duration, poor sleep quality with symptoms at least 3x/week for 3mo despite adequate opportunity for sleep

What is the preferred treatment strategy for insomnia?

CBT w/sleep hygiene

What drugs can contribute to insomnia?

AChE inhibitors (donepezil), alcohol, emtricitabine, INSTIs, aripiprazole, atomoxetine, bupropion, caffeine, decongestants, diuretics, fluoxetine in the evening, steroids, stimulants, varenicline

What natural products can be used for insomnia?

melatonin, valerian, kava (hepatotoxic), chamomile tea

How is melatonin metabolized?

1A2

Sedative-hypnotics are ___ for insomnia.

over-prescribed

What should be used for insomnia when the patient has trouble falling asleep?

eszopiclone, zolpidem, ramelteon, zaleplon

What should be used for insomnia when the patient has trouble staying asleep?

eszopiclone, zolpidem, doxepin, suvorexant

What should be used for insomnia when the patient has trouble falling asleep and staying asleep?

eszopiclone, zolpidem

Which drugs for insomnia are not recommended for long-term use?

diphenhydramine, melatonin, tiagabine, trazodone, valerian

Which drugs for insomnia are on the Beers List?

benzodiazepines, other hypnotics, first gen antihistamines

restless leg syndrome

the urge to move the lower legs, worse at night, relieved with movement

What causes restless leg syndrome?

likely dysfunction of dopamine in the basal ganglia

How is restless leg syndrome treated?

dopamine agonists (pramipexole, ropinorole, rotigotine), gabapentin enacarbil

How are dopamine agonists dosed for RLS?

IR tablet 1-3h before bedtime; rotigotine patch QD

Horizant

gabapentin enacarbil

gabapentin enacarbil

Horizant

gabapentin enacarbil indications

postherpetic neuralgia, RLS

How is gabapentin enacarbil dosed for RLS?

QD at 5pm, swallow whole with food

narcolepsy

excessive daytime sleepiness with cataplexy and sleep paralysis

cataplexy

loss of muscle tone

What causes narcolepsy?

poor control of normal sleep-wake cycles

How is narcolepsy treated?

stimulants, sodium oxybate

Lunesta

eszopiclone

eszopiclone

Lunesta

Edluar

zolpidem SL

zolpidem SL

Edular

zaleplon

Sonata

Sonata

zaleplon

z-drugs MOA

act selectively at benzodiazepine receptors to increase GABA and cause CNS depression

z-drugs BBW

complex sleep behavior

z-drug schedule

CIV

z-drug ADE

risk for additive CNS depression, potential for abuse/dependence, somnolence, dizziness, ataxia, headache, parasomnias

Z-drugs should not be taken with -

fatty food, heavy meal, alcohol, other CNS depressants

How is zolpidem dosed?

female/elderly: 5mg QHS; male: 5-10mg QHS

z-drug contraindications

history of complex sleep behavior

What are the 3 orexin receptor antagonists?

daridorexant, lemoborexant, suvorexant

orexin receptor antagonist contraindications

narcolepsy

orexin receptor antagonist ADE

depression, sleep paralysis, somnolence, headache, dizziness

How are the orexin receptor antagonists dosed?

QHS with at least 7h of sleep remaining

orexin receptor antagonist schedule

CIV

suvorexant

Belsomra

Belsomra

suvorexant

What are the 2 melatonin receptor agonists?

ramelteon, tasimelteon

ramelteon

Rozerem

Rozerem

ramelteon

ramelteon MOA

melatonin receptor agonist to promote sleepiness and regulate circadian rhythm

ramelteon schedule

not controlled

fluvoxamine + ramelteon

contraindicated - increased ramelteon concentrations

Which TCA can be used for insomnia?

doxepin

doxepin BBW

increase in suicidal thoughts in children, teens, and young adults

doxepin ADE

somnolence, serotonin syndrome, anticholinergic ADE

doxepin MOA

TCA - inhibit NE and 5-HT reuptake, block ACh and histamine receptors

Silenor

doxepin

doxepin

Silenor, Sinequan

Restoril

temazepam

temazepam

Restoril

Which benzodiazepines are FDA-approved for insomnia?

temazepam, estazolam, quazepam, flurazepam, triazolam

modafinil

Provigil

Provigil

modafinil

armodafinil

Nuvigil

Nuvigil

armodafinil

modafinil, armodafinil schedule

CIV

modafinil, armodafinil ADE

SJS/TEN, headache, insomnia, anxiety, avoid with cardiac conditions, psychiatric disorders, or Tourette's

Xyrem

sodium oxybate

sodium oxybate

Xyrem

Xywav

calcium, magnesium, potassium, and sodium oxybates

calcium, magnesium, potassium, and sodium oxybates

Xywav

sodium oxybate BBW

strong CNS depressant; active moiety is GHB used for sexual assault - restricted use through REMS program

sodium oxybate schedule

CIII for narcolepsy, CI for illicit use

How is sodium oxybate dosed?

take QHS immediately before bed, and again 2.5-4h later

pitolisant MOA

H3 receptor antagonist/inverse agonist

pitolisant indications

to improve wakefulness in narcolepsy

solriamfetol MOA

dopamine and norepinephrine reuptake inhibitor

solriamfetol indications

to improve wakefulness in narcolepsy and sleep apnea