Dr. G - Sleep Disorder

What is the recommendation for advanced sleep phase disorder associated with many geriatric people (e.g., asleep by 7pm and wake up at 3am)?

Expose to sunlight to delay release of melatonin and regulate circadian

What is the recommendation for delayed sleep phase disorder associated with many teenagers (e.g., not sleepy until 3 am and sleep till noon)?

REM rebound from d/c of alcohol or BZDs can cause what sleep disturbances?

REM = dreaming

Dreams would be vivid and have nightmares

What is sleep apnea? What is the treatment of choice? Why is it important to avoid CNS depressants (including alcohol) for people with sleep apnea?

Sleep apnea: brain forgets to breathe when sleeping; snoring and gasp for air

DO NOT GIVE HYPNOTIC; CPAP machine has to be given

What stages of sleep are considered restorative sleep (AKA delta sleep)? Explain why patients with sleep apnea are so tired in the daytime despite appearing to sleep for 7-8 hours?

Stage 3: Nonrem sleep; restores cells and repairs damage 

• Usually very tired without CPAP machine because not aware

Which hypnotic classes should be avoided for treatment of insomnia for the elderly?  Why?

Do not take OTC diphenydramine b/c of anticholinergic 

Avoid BZDs b/c accumulation of fat

Lowest dose for ambien 

How does caffeine work to increase wakefulness? What is the half-life of caffeine?

Inhibits adenosine

Half life: 5-7 hours; people sensitive to caffeine, don’t have caffeine too late 

What medications can cause insomnia?

Fluoxetine (Prozaac), Wellbutrin (Bupropion), Trazodone, Oral decongestants

What is narcolepsy and the treatment options?

Narcolepsy: sleeping attacks middle of day during away hours; sleeping episodes throughout the day 

• Power naps, modafanil, movigil  (waking agent)

Which FDA-approved benzodiazepines hypnotics would be a better choice for patients with hepatic impairment?

Temazepan, Restoril

Explain why alcoholic patients need higher doses of benzodiazepines to achieve therapeutic effects?

Cross Tolerance; drink a lot = building tolerance to alcohol and it attaches to the same receptor as BZDs

Why is it important to taper temazepam 30 mg po qhs prn insomnia (used nightly for > 1 year) to zolpidem 10 mg po qhs prn insomnia?

Temazepam → AIMS withdrawal symptoms

Among the 3 Z-hypnotic agents (Ambien – zolpidem, Sonata – zaleplon, Lunesta – eszopiclone), which one is FDA-approved for long-term use?  What is a common side effect of this Z-hypnotic agent?

12 months

SE: BITTER TASTE that doesn’t go away

Name the 2 melatonin receptor agonist hypnotic agents that are FDA-approved for long-term use. Which one is FDA-approved for non-24 hour sleep wake disorder (e.g., blind people)?

Remeltian and Tesmeltion 

Heplios → sleep wake disorder

Which Z-hypnotic can be taken in the middle of the night provided they have 4 hours before time to wake up?

Sunota

Patients taking the Z-hypnotics should not drink grapefruit juice and alcohol/ambien. Explain why?

• Grapefruit juice can inc levels

• Alcohol/ambien = synergistic effects of sedation, respiratory depression

Which class of hypnotics has the most reported CNS ADRs, such as sleep eating, walking, or driving?

Z-hypnotics

Your patient asked if she could take 2 of the 8 mg ramelteon if she cannot stay asleep with this medication. What would you recommend?

The max dose is 8 mg and talk to PCP to consider another medication and not double the dose of ramelteon

Which is the most common hypnotic agent prescribed now that is used to be a sedating antidepressant? What is the most common side effect, other than sedation, associated with this agent?

What is the active ingredient in Unisom? In Advil PM for sleep? What are the common side effects?

Doxylamine

Comment on the dose of this Advil PM product with instructions to take 2 caplets QHS.

What is Silenor? Comment on Silenor’s dosing vs. its use in the past as an antidepressant.

Patient brings in a new Rx for Provigil 200 mg po q6pm. What is the most likely indication in this case?

Taken as a waking agent 

Why do you need to inform patients on Provigil (modanfinil) or Nuvigil (armodafanil) to report rashes?

Might lead to SJS

What are the potential DDIs associated with Provigil (modanfinil) or Nuvigil (armodafanil)?

Oral contraceptives become ineffective

Inducer →

2C9 → warfarin concentration increases