Sleep Disorders - Ott

Insomnia critiera

Difficulties with sleep intitation, sleep maintenace, and/or early morning awakening. Takes place at least 3 times a week and present for at least 3 months

Treatment of Insomnia (be general)

First line is non-pharm so sleep hygiene and behavioral therapy. Z-hypnotics are common but the doses are lower in women and elderly. Use Eszopiclone for long term.

What sleep medication has metallic taste?

Lunesta

All medications FDA approv ed for insomnia have what warning?

Sleep behavior warnings

Ramelteon

1) CI

2) SE

Contraindicated with fluvoxamine. Causes SE of GI upset, next day somnolence, hyperprolactinemia, and prolactinemia

What drug is FDA approved for non-24 sleep-wake disorder in adults

tasimelteon

What is contraindicated in all Orexin receptor antagonists?

Narcolepsy

What is the counseling point on how or when to take an Orexin receptor antagonist?

Take with at least 7 hours to sleep

Doxepin

1) MOA - dosing

2) SE

TCA - low doses. Anticholinergic side effects

Trazodone

Not FDA approved for insomnia but long half life

If a patient is depressed and have difficulty sleeping, what medication could they use?

Mirtazapine

If you are using Mirtazapine and want to improve a patient’s appetite, what must you do?

Make dose greater than 15mg

Quetiapine use in insomnia

Low dose not recmomended

Obstructive Sleep Apnea criteria. List some examples of OSA symptoms

Have evidence of at lest 5 OSAs per hour of sleep confirmed by polysomnography. Symptoms may include excessive daytime sleepiness, snoring, pauses in breathing during sleep, irritability, ED, GERD, and impaired memory

What is the criteria that would constitute Polysomnography testing?

Respiratory issues that are sleep related, history of stroke, chronic opioid use, or severe insomnia

When treating patient with sleep apnea and insomnia, what must be addressed first?

sleep apnea

Treatment of sleep apnea

Weight lose, smoking cessation, avoid CNS depressants and alcohol, and sleeping on the side especially for obese patients. CPAP

What can be used to treat excessive daytime sleepiness in the treatment of sleep apnea?

Modafinil or armodafinil but must assess CPAP adherence first

Diagnostic criteria for Narcolpesy + Symptoms

Recurring episodes of irresistible need for sleep at least 3 times a week for 3 months. Symptoms of EDS, hallucinations, paralysis, cataplexy

What drug is approved for children when treating catapplexy in narcolepsy?

Xywav

What drug is used for adults only and can be used to treat cataplexy that is symptom of narcolepsy?

Lumryz

If you are concerned about sodium levels but need to treat cataplexy in narcolepsy, what drug can you use?

Xywav

Treatment of EDS in narcolepsy

Modafinil/Armodafinil, Sodium oxybate, Pitolisant, and solriamfetol

Pitolisant

1) use

2) CI

3) warnings / avoid

Used for EDS in narcolepsy, CI in severe hepatic impairment, QTc prolongation, avoid use with OTC antihistamines

If a patient comes in and complains about loss of effectiveness of oral contraceptive, what drug would likely be the cause of this?

Pitolisant

Indicated for improvement in wakefulness in adults with excessive daytime sleepiness due to
narcolepsy or obstructive sleep apnea

Solriamfetol

A 45-year-old woman with obstructive sleep apnea (OSA) presents with ongoing excessive daytime sleepiness, despite good adherence to CPAP therapy. She works as a school teacher and reports falling asleep during meetings. Her sleep specialist considers prescribing Sunosi (solriamfetol).

Her past medical history is notable for:

• Psychotic depression, successfully treated 5 years ago with no recurrence

• Type 2 diabetes, well-controlled

• Mild hypertension, currently managed with amlodipine

She is currently stable on sertraline and aripiprazole.

Which of the following is the most appropriate next step in managing this patient?

A. Start Sunosi at the usual dose, as her psychiatric history is not a contraindication
B. Avoid Sunosi due to the risk of serotonin syndrome with sertraline
C. Avoid Sunosi due to her history of hypertension
D. Use Sunosi with caution and monitor for return of psychiatric symptoms
E. Defer treatment until her diabetes is better controlled

Use Sunosi with caution and monitor for return of psychiatric symptoms

Sunosi (Solriamfetol) must be avoided in patients with what

Unstable CV disease and arrhythmias

Sunosi (Solriamfetol) must be cautiously used in what patients?

Patients with history psychosis or bipolar disorder

A patient's occupation requires them to be awake at ungodly hours at night. What can be used to treat wakefulness in shift work disorder, and when should they take it?

Modafinil or armodafinil taken 1 hour before shift

Treatment of Restless Legs Syndrome

Gabapentin is first line. Pramipexole or ropinirole may be used. Iron supplementation may be considered