RX-413: Sleep Disorders

Therapeutics 1 Exam 4

What are the 3 criteria of having a sleep disorder?

Difficulty initiating sleep (Sleep onset insomnia)

Difficulty maintaining sleep, frequently waking up or returning to sleep after awakenings (Insomnia following middle-of-the-night awakenings)

Early-morning awakening with inability to return to sleep (Sleep maintenance insomnia)

How often does sleep difficulty need to occur for it to be diagnosable as insomnia?

3 nights per week

What are the 3 classifications of insomnia?

Transient: Less than one week; self-limiting

Short term: 1-3 weeks

Long-term (Chronic): Greater than 3 weeks

What are common contributing factors to insomnia?

All the obvious things

medical issues

• Cardiovascular

• Respiratory

• Pain

• Endocrine disorders (Diabetes or hyperthyroidism)
  Pregnant

What medications can lead to insomnia?

Seizure treatments

Diuretics

SSRIs

Corticosteroids

Stimulants (Me when I take meth right before bed)

Decongestants

What OTC medications are used to treat sleep difficulty?

Diphenhydramine (Pop a benny)

Doxylamine

Melatonin

Valerian

Chamomile

What non-OTC medications are used to treat insomnia?

Benzodiazepines (Bind to GABA complex resulting in a sedative hypnotic effect)

What are the 2 long-acting benzodiazepines used to treat both sleep onset insomnia and sleep maintenance insomnia?

Flurazepam and quazepam

What are the 2 intermediate-acting benzodiazepines used to treat both sleep onset insomnia and sleep maintenance insomnia?

Temazepam and estazolam

What is the short-acting benzodiazepine used to treat sleep onset insomnia?

Triazolam

What adverse effects can be expected when taking a benzodiazepine?

CNS depression

Sleep-related behaviors (Sleep walking, eating, driving)

Increased risk of falls (Hip fractures in elderly caution)

Long term use can cause withdrawals and disturbed sleep

What are the non-benzodiazepine - benzodiazepine receptor agonists, and which types of insomnia do they treat?

Z drugs. They all start with Z.

• Zolpidem is short acting and helps with sleep onset and sleep maintenance.

• Zaleplon is short acting and is used for sleep onset and insomnia following middle-of-the-night awakenings

which of the z drugs are approved for short term use only, which are not limited to short-term use?

Zaleplon and zolpidem IR are used short-term. Zolpidem CR can be used long term.

What is Eszopiclone (Lunesta)?

Nonbenzodiazepine drug used for sleep onset and sleep maintenance that can be used long-term.

What melatonin receptor agonist is used to treat insomnia? What type of insomnia?

Ramelteon, sleep onset.

What is the MOA of Dual Orexin-Receptor Antagonists?

Block the binding of orexin to the orexin receptor which promotes wakefulness when active.

What are the 3 orexin-receptor antagonists? What type of insomnia do they treat?

The rexants

• Suvorexant

• Lemborexant

• Daridorexant

they all treat sleep onset and sleep maintenance.

What antidepressants are approved for insomnia, which type of insomnia?

Low-dose doxepin

Trazodone

Mirtazapine

They treat sleep maintenance insomnia.

What are the 4 characteristics of narcolepsy?

EDS (Excessive daytime sleepiness)

Cataplexy: Sudden bilateral loss of muscle tone without loss of consciousness

Hallucinations

Sleep paralysis: An episodic loss of muscle tone, conscious but can’t speak or move.

What are the 2 types of narcolepsy?

Type 1: Narcolepsy with cataplexy (Sudden loss of consciousness)

Type 2: Narcolepsy without cataplexy

What are the two non-pharmacologic treatments for narcolepsy

At least 2 scheduled 15 minute naps a day

Good sleep hygiene.

What are the 3 stimulants used in narcolepsy?

Methylphenidate and dextroamphetamine (Schedule 2)

Dextroamphetamine/Amphetamine salts (Adderall) and Lisdexamphetamine (Vyvanse)

• Neither are FDA Approved

• Lisdex doesn’t treat cataplexy

• Has potential tolerance

Modafinil and Armodafinil

• Not affective in cataplexy

What are the 3 nonstimulants used to treat narcolepsy?

Solriamfetol

• Not useful for cataplexy

Pitolisant

• Improves EDS and cataplexy

Sodium oxybate

• EDS and Cataplexy

• DONT GIVE IN ALCOHOL USE DISORDER OR SLEEP APNEA)

What is Restless legs syndrome?

Restlessness that has ongoing relief from moving.

What is RLS associated with

CKD

Iron deficiency

Pregnant

Caffeine, stress, alcohol, fatigue.

What are the pharmacologic treatments for RLS?

Magnesium supplementation

Dopamine agonists

• Ropinirole, Rotigotin, Pramipexole

GABA Analogues

True or false: When used for the treatment of narcolepsy, modafinil is best dosed at bedtime.

False

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.

Ramelteon

Flurazepam

Zolpidem IR

Zolpidem CR

Suvorexant

Suvorexant

True or false: 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?

Unpleasant taste

Heart failure

Priapism

Drug-induced diabetes mellitus

Angioedema

Priapism (Tragic bone)

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

Temazepam

Zolpidem IR

Triazolam

Eszopiclone

Daridorexant

Triazolam