701 > Sleep > Flashcards

Sleep Flashcards

(52 cards)

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1
Q

What part of the brain controls the biological clock?

A

Suprachiasmatic nucleus

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2
Q

What are sleep cycles?

A
  • 4-6 each night
  • Back and forth between NREM and REM sleep
  • Last about 70-120 minutes
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3
Q

What are the 4 stages of sleep

A
  1. NREM stage 1: 5-10 minutes of falling asleep
  2. NREM stage 2: HR, temp drops, sleep spindles produced
  3. NREM stage 3: muscles relax, BP + RR drop (deepest sleep)
  4. REM sleep: brain active, dreaming, eye movement, muscles paralyzed
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4
Q

Sleep spindles

A

Allow us to sleep through loud noises and disturbances (stage 2)

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5
Q

K-complexes

A

Allow for sleep-based memory consolidation (stage 2)

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6
Q

Delta waves

A

Slow wave sleep, difficult to awaken from (stage 3 deep sleep)

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7
Q

What chemicals modulate wakefulness?

A
  • NE
  • ACh
  • Histamine
  • Serotonin
  • Dopamine
  • Orexin/hypocretin
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8
Q

What chemicals modulate sleepiness?

A
  • Adenosine
  • GABA
  • Melatonin
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9
Q

What chemicals modulate NREM sleep?

A
  • GABA
  • Adenosine
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10
Q

What chemical modulates REM sleep?

A

ACh

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11
Q

S/S of sleep disorders

A
  • EDS
  • Impaired daytime functioning
  • Irregular breathing
  • Increased movement during sleep
  • Irregular sleep/wake cycle
  • Difficulty falling asleep
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12
Q

Insomnia

A

Persistent sleep difficulty, adequate sleep opportunity, and associated daytime function
- Most common
- Difficulty falling asleep, staying asleep, or feeling restored from sleep
- Women 2x likely than men

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13
Q

Insomnia categories

A

Several days: transient insomnia
<3 months: short-term insomnia
At least 3 nights per week for >3 months: chronic insomnia

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14
Q

Common insomnia-worsening drugs

A
  • Alcohol, caffeine, nicotine
  • Anticholinergics
  • SSRIs/SNRIs*** (could be short term)
  • BBs, alpha blockers
  • ACEi/ARBs
  • Cholinesterase inhibitors
  • Bronchodilators
  • CNS stimulants
  • Steroids
  • Decongestants
  • Diuretics
  • H2RAs
  • Statins
  • Opioids***
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15
Q

Treatment for transient/short term insomnia?

A

Correct underlying problem, avoid medication ADEs
- Sleep diary?
- Good sleep hygiene
- Avoid napping, regular schedule
- Short term use of medication

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16
Q

First line therapy for long-term insomnia?

A

Cognitive behavioral therapy (+/- medications)
- Initial CBT-I + medication taper if quick improvement is necessary

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17
Q

What are reasons to avoid first-line BZRAs?

A
  • Older age
  • Cognitive dysfunction
  • Opioid use
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18
Q

BZRAs

A
  • Most common insomnia treatment
  • Agonist of GABA
  • Always take before bedtime
  • Caution in the elderly (drowsiness, confusion, risk of falls)
  • Avoid with alcohol, opioids
  • Withdrawal upon discontinuation (tremors, muscle cramps, seizures)
  • All Z drugs are FDA approved for sleep, but not all benzos
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19
Q

Benzodiazepines

A
  • Reduce sleep latency
  • Increase stage 2, decrease delta
  • Dose-dependent side effects
  • Caution in sleep-apnea/substance abuse
  • Anxiolytic
  • Beer’s list strong recommendation
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20
Q

Nonbenzodiazepine GABA agonists (Z drugs)

A
  • More selective
  • Increase total sleep time
  • Less disruptive of sleep stages
  • Less withdrawal/tolerance/rebound
  • Parasomnic episodes with amnesia (sleep walking, driving, etc)***
  • Beer’s list strong recommendation
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21
Q

Benzo BBWs

Study These Flashcards
A
  • Use with opioids
  • Abuse potential
  • Physical dependence
22
Q

Z-drugs BBW

Study These Flashcards
A

Sleep behaviors (parasomnic episodes) -> DISCONTINUE IMMEDIATELY

23
Q

Which BZRAs have quick onset?

Study These Flashcards
A
  • Flurazepam
  • Zolpidem
  • Zaleplon
  • Eszopiclone
24
Q

Which BZRAs have long half lives?

Study These Flashcards
A
  • Quazepam
  • Temazepam
  • Estazolam
25
Eszopiclone
- CIV - Rapid absorption -> approved for sleep-onset (delayed with food) - Good for sleep maintenance or early morning awakenings (approved for maintenance) - Duration 6-9 hours - Major CYP3A4
26
Zaleplon
- CIV - Ultra-short acting rapid onset (delayed with high fat meal) - Approved for short-term insomnia (max 30 days) - Duration 3-4 hours - Major CYP3A4
27
Zolpidem
- CIV - Rapid onset, short half-life - Many formulations with different dosing/indications - take immediately HS and plan 7-8 sleep except for intermezzo SL tablet
28
Zolpidem formulations
- Intermezzo SL tab: middle-of-night awakening - Ambien CR (ER) tab: sleep onset or maintenance - Edluar SL tab: sleep onset (off label sleep maintenance) - Ambien (IR) tab: sleep onset (off label sleep maintenance) - Generic IR cap: sleep onset (off label sleep maintenance) -> use 7.5mg if 5mg of another product is ineffective
29
DORAs
- CIV - suvorexant, lemborexant, daridorexant - turns off wake signaling, approved sleep onset or maintenance - Take HS plan 7h - CYP3A4 - CI in narcolepsy
30
Suvorexant (Belsomra)
- Onset <30 min - Long half life 12h - CYP3A4 - ADE sleep paralysis, abnormal dreams***
31
Lemborexant (DayVigo)
- Onset <30 min - Long half life 17-19 hours - CYP3A4 - Next day drowsiness, increased falling risk (effects persist) - ADE complex sleep behaviors, abnormal dreams
32
Daridorexant (Quviviq)
- Onset 30 min - Fair half life 8h - CYP3A4 - Onset delayed with food - ADE complex sleep behaviors, hallucinations, sleep paralysis
33
Ramelteon (Rozeram)
Melatonin receptor agonist - M1 induces sleep, M2 regulates circadian rhythm - Onset 30 min - Short half life 1-2.6h - Approved for sleep onset + long term use - Not as effective for patients who took BZRAs - Noncontrol! - Ci with fluvoxamine (CYP1A2) - Less rebound and abuse potential
34
Doxepin
- TCA - Low dose for sleep maintenance - Do not take within 3 hours of a meal - BBW for suicidality but it's a low dose
35
Melatonin
- Beneficial effects on sleep-onset latency, shift workers, jet lag - Avoid in autoimmune conditions - Not recommended in Alzheimer's
36
First-generation antihistamines
- Diphenhydramine, doxylamine - OTC - Avoid in older adults (Beer's list) - Quick tolerance to sedation - Anticholinergic ADEs
37
Trazodone
- OFF LABEL for sleep continuity - May be useful in patients with substance abuse hx or depression (non-control) - ADE of carryover sedation and alpha adrenergic blockade (orthostasis for elderly) - Taper off 2-4 weeks when discontinuing
38
Best meds for elderly insomnia
- Ramelteon* (sleep onset) - Low-dose doxepin* (sleep maintenance)
39
Pregnancy
- Diphenhydramine - Doxylamine - Low-dose doxepin
40
Sleep apnea treatment
- Behavior modification (weight loss, alter position, avoid alcohol/sedatives) - Positive airway pressure (PAP) is standard of care* - Medication for EDS
41
Modafinil and armodafinil
- CIV - Approved for EDS in OSA and narcolepsy - Administer in morning - Avoid in pregnancy - CYP3A4 (reduce contraceptives) - Caution in CV disease - ADE headache, SJS, TEN, CV events, mania, psychosis
42
Solriamfetol (Sunosi)
- CIV - Approved for EDS in OSA and narcolepsy - Dopamine and NE reuptake inhibitor - Administer QM, avoid <9h before bedtime - CI with MAOi - Avoid in unstable CV disease
43
Pitolisant (Wakix)
- Noncontrol - OFF LABEL for EDS in OSA but approved in narcolepsy - Antagonist/inverse agonist at H3 receptors - May prolong QT (avoid in arrhythmia) - ADE headaches
44
Narcolepsy treatment
- Good sleep hygiene, daytime naps*** - Avoid sedatives - Treat symptoms (EDS, cataplexy, REM abnormalities) No disease-modifying therapies
45
EDS medications in narcolepsy
- Modafinil, armodafinil - Solriamfetol - Pitolisant - Amphetamines - Methylphenidate - Sodium oxybate - Oxybate salts
46
Sodium oxybate (Xyrem)
- CIII - REMS program*** - Approved for cataplexy or EDS in adult narcolepsy - BBWs: CNS depression, abuse, restricted access - Take on empty stomach - Administer in bed, then lie down - 2nd dose after 2.5-4 hours - Can't do anything for 6 hours after taking MOA: CNS depression via GABA
47
Lumyrz
ER sodium oxybate - Given same as Xyrem but 1 DOSE
48
Oxybate salts
Xywav - Contains more than sodium (Ca, Mg, K) - Otherwise similar to Xyrem
49
Cataplexy medications in narcolepsy (CAN ALSO TREAT EDS)
REM suppressing drugs: Venlafaxine, Fluoxetine, Duloxetine, Clomipramine - Pitolisant - Sodium oxybate CAN ALSO TREAT EDS
50
Restless leg syndrome
- Fix nutrition first (iron, vitamin B, or folate deficiency) - Reduce caffeine/alcohol - Weight loss
51
Medication withdrawal causing RLS
- Central antihistamines - Antidepressants - Antipsychotics - Anti-nausea drugs that block dopamine
52
RLS treatment
- Carbidopa/levodopa - BZDRA (clonazepam*) - Pregablin, gabapentin - Dopamine agonists (ropinerole, rotigotine)
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