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85 Cards in this Set
- Front
- Back
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Treatment principles: transient insomnia
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a)sleep hygiene
b)careful use of S-H |
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short-term insomnia
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a)sleep hygiene
b)intermittent use of S-H (skip 1-2 nights of meds after 1-2 nights of good sleep) |
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chronic insomnia
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a)reassessment of other etiologies
b)reinforce sleep hygiene c)limit use of S-H to 1 out of 3 nights to prevent tolerance and dependence |
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these agents are useful in mild, transient insomnia, but less effective than BZDs
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1st gen antihistamines (doxylamine, diphenhydramine)
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this antihistamine is typically used for peri-operative sedation, but is occasionally used for insomnia
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hydroxyzine (Vistaril or Atarax)
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1st gen antihistamines adverse effects (3)
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1)hangover effect
2)anticholinergic effects 3)paradoxical CNS stimulation in young children/elderly |
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regular use of antihistamines should be avoided because tolerance develops after how many days of continuous use?
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4
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diphenydramine dose
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50mg HS
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doxylamine dose
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25mg HS
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possible advantage of doxylamine over diphenhydramine
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doxylamines shorter t1/2 may cause less hangover effect
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BZDs MOA
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binds to BZD-1 (a1-GABA-A) and BZD-2 (a2-GABA-A) receptors in brain and periphery, enhancing GABA neurotransmission
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BZD adverse effects (4)
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1)hangover effect
2)anterograde amnesia 3)respiratory depression 4)reduce stage 3,4 sleep and REM sleep |
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these long-acting BZDs are more likely to exert a hangover effect due to accumulation of active metabolites (2)
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flurazepam, quazepam
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If a patient presents w/ hangover sxs (daytime sedation/falls) what should you do?
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a)switch to a BZD w/ shorter duration of action
b)switch to another class of S-H |
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Type of BZD preferred if a patient has concomitant anxiety
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long-acting BZD to maintain duration throught the next day
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anterograde amnesia is especially seen w/ this BZD due to its rapid onset and short t1/2
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triazolam
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Time to development of tolerance with short-acting BZDs and longer-acting BZDs
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-1-2wks of ocntinued use
-1-3months |
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pregnancy category of BZDs
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D or X; avoid in breastfeeding women
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If a patient presents w/ hangover sxs (daytime sedation/falls) what should you do?
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a)switch to a BZD w/ shorter duration of action
b)switch to another class of S-H |
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Type of BZD preferred if a patient has concomitant anxiety
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long-acting BZD to maintain duration throught the next day
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anterograde amnesia is especially seen w/ this BZD due to its rapid onset and short t1/2
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triazolam
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If a patient presents w/ hangover sxs (daytime sedation/falls) what should you do?
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a)switch to a BZD w/ shorter duration of action
b)switch to another class of S-H |
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Type of BZD preferred if a patient has concomitant anxiety
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long-acting BZD to maintain duration throught the next day
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anterograde amnesia is especially seen w/ this BZD due to its rapid onset and short t1/2
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triazolam
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Time to development of tolerance with short-acting BZDs and longer-acting BZDs
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-1-2wks of ocntinued use
-1-3months |
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Time to development of tolerance with short-acting BZDs and longer-acting BZDs
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-1-2wks of ocntinued use
-1-3months |
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pregnancy category of BZDs
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D or X; avoid in breastfeeding women
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pregnancy category of BZDs
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D or X; avoid in breastfeeding women
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If a patient presents w/ hangover sxs (daytime sedation/falls) what should you do?
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a)switch to a BZD w/ shorter duration of action
b)switch to another class of S-H |
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Type of BZD preferred if a patient has concomitant anxiety
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long-acting BZD to maintain duration throught the next day
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anterograde amnesia is especially seen w/ this BZD due to its rapid onset and short t1/2
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triazolam
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Time to development of tolerance with short-acting BZDs and longer-acting BZDs
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-1-2wks of ocntinued use
-1-3months |
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pregnancy category of BZDs
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D or X; avoid in breastfeeding women
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These BZDs are better options for the elderly, those w/ hepatic dysfunction, and for patents w/ CYP-450 altering medications
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BZDs that are conjugated (via glucoronidation)= oxazepam, temazepam, lorazepam
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possible tapering option for BZDs
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reduce dose 10-25% q1-2wks
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if withdrawal symptoms are experienced when tapering, what should you do?
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temporarily increase dose and start a less aggressive taper
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BZDs indicaton
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transient and short-term insomnia
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Types of BZDs for sleep onset problems and sleep maintenance problems
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-shorter acting agents
-longer acting agents |
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flurazepam dose
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15-30mg
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temazepam dose
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15-30mg
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triazolam dose
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0.125-0.25mg
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BZD-1 selective agents (3)
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-zolpidem
-zaleplon (Sonata) -eszopiclone (Lunesta) |
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BZD-1 selective agents MOA
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selectively acts on a1-GABA-A receptors w/ little anxiolytic, anticonvulsant, or muscle relaxant activity
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zolpidem/zolipdem CR adverse effects
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1)min tolerance/rebound effects compared to BZDs (case reports)
2)drowsiness, amnesia, HA, GI complaints |
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zolpidem effectiveness
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-comparable to BZDs for reducing sleep latency
-increases both total sleep time and efficiency -does not disturb sleep architecture |
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zaleplon adverse effects
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1)no significant reports of tolerance, withdrawal, or hangover (short t1/2)
2)dizziness, HA, somnolence |
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zaleplon effectiveness
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-useful in reducing sleep latency, but not for reducing nocturnal awakenings or increasing total sleep time (due to short t1/2 and fast onset)
-does not distur sleep architecture |
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eszopliclone adverse effects
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1)no significant reports of tolerance, withdrawal, or hangover
2)HA, somnolence, unpleasant taste |
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eszoplicone effectiveness
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-reduces sleep latency and improves sleep maintenance
-does not disturb sleep architecture |
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this agent may be used when a person wakes up in the middle of the night and 4hrs of sleep may be achieved
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zaleplon
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zolpidem dose
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5-10mg HS
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zolpidem CR dose
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6.25-12.5mg HS
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zaleplon dose
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5-20mg HS
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eszopiclone dose
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1-3mg HS
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ramelteon MOA
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agonist at both MT1 and MT2 receptors and is thought to be useful for sleep initiation
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ramelteon C/I
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-severe hepatic insufficiency
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ramelteon adverse effects
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1)no evidence for w/drawal or tolerance
2)dizziness |
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remaleteon drug interaction
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fluvoxamine can increase serum concentrations dramatically (Cmax inc 70fold)
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ramelteon effectiveness
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a)useful for pts w/ prolonged sleep latencies
b)long-term and is not controlled c)substance abusers w/ insomnia |
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this agents use is limited to transient insomnia and it may cause hyperbilirubinemia
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chloral hydrate
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these agents have a higher risk of CNS and respiratory depression as compared to BZDs w/o offering significant advantages
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barbiturates
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these agents are not recommended unless patient has insomnia and cannot take a BZD
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antidepressants
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these agents may be useful in patients w/ depression or neuropathic pain as co-morbidities
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tricyclic antidepressants
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TCA MOA
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inhibit reuptake of NE and 5-HT
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TCA adverse effects (4)
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1)hangover
2)falls in elderly 3)anticholinergic 4)cardiac conduction abnormalities (dangerous in pts w/ hx of suicide attempts) |
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this agent has been shown to increase total sleep in pts w/ depression and it has a very low propensity for drug abuse
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trazodone
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trazodone MOA
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SSRI w/ mixed agonist/antagonist effects at serotonergic receptors
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trazodone adverse effects (3)
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1)serotonin syndrome
2)orthostatic effects from alpha adrenergic blockade 3)priapism |
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a sedating SSRI
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paroxetine (sertraline, fluoxetine, etc can cause insomnia)
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agent that may decrease sleep latency, but results in fragmented, unfruitful sleep
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ethanol
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herbal melatonin should be used cautiously in what kind of patients (3)
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1)vascular d/o (can cause vasoconstriction)
2)immunosuppressive therapy (enhance immune function) 3)pregnant/lactating females |
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herbal melatonin is most commonly used for?
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children or jet lag
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valerian root adverse effects (4)
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1)HA
2)cardiac disturbances 3)uterine contractions (no to pregnant pts) 4)hepatotoxicity |
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pharmacological therapy for patients with circadian rhythm sleep d/o
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a)zaleplon, zolpidem (preferred to to lack of hangover effects)
b)short-acting BZDs c)ramelteon d)melatonin (herbal) |
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pharmacological therapy for patients with breathing-related sleep d/o and its general indication
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modafinil (Provigil) (indicated for use in pts w/ daytime sleepiness despite treatment w/ CPAP)
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modafinil MOA
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CNS stimulant which lacks many adverse effects of traditional stimulants (tachycardia, HTN)
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modafinil adverse effects (3)
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1)HA
2)nausea 3)nervousness |
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treatment of breathing-related sleep d/o with these agents may be lethal
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CNS depressants (BZD, opiods, etc)
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standard pharmacological treatment in pts w/ narcolepsy who have excessive daytime sleepiness (EDS)
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modafanil
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pharmacological treatment in pts w/ narcolepsy who have cataplexy (sudden loss of muscle tone)(3)
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-TCAs
-fluoxetine -sodium oxybate (GHB) |
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this agent for cateplexy is considered 2nd line eventhough it appears to be more effective in treating cataplexy than other agents
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sodium oxybate
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sodium oxybate MOA
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binds to GABA-B receptors and sodium oxybate specific receptors and has mamy effects on other neurotransmitters
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sodium oxybate effectiveness
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-improves sleep architecture while reducing EDS, sleep paralysis, cataplexy, and hypnagogic hallucinations
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pharmacological therapy for patients w/ restless leg syndrome (RLS)
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a)mild=BZD may be 1st line
b)opiates (concerns w/ tolerance) c)dopamine agonists (ropinirole, pramipexole, pergolide)=titrate slow to avoid nausea d)gabapentin |
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Use of these agents in RLS may exacerbate insomnia
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dopamine agonists
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