Sleep-Wake DOs

Question 1

1. Which are Non-Benzo BZRAs?
2. Which are Benzos Hypnotics BZRAs?

• Eszopiclone, Zaleplon, Zolpidem
• Estazolam, Flurazepam, Temazepam, Triazolam, Quazepam

BZRAs = Benzo Receptor Agonists

Answer 1

1. Non-Benzo BZRAs = Eszopiclone, Zaleplon, Zolpidem
2. Benzo BZRAs = Estazolam, Flurazepam, Temazepam, Triazolam, Quazepam

Question 2

1st line Pharm Tx options for Insomnia

Answer 2

Question 3

Which sleeping DO is Doxepin and Ramelton used for?

Answer 3

Insomnia

Question 4

Wake-promoting chemicals

Answer 4

• Orexin
• Catecholamine
• Histamine

Question 5

Sleep-promoting chemicals

Answer 5

• GABA
• Serotonin
• Adenosine
• Melatonin
• Prostaglandin

Question 6

Hypersomnolence Tx

Answer 6

1. Modafinil (Non-amphetamine CNS Stimulant)
2. Armodafinil, Methylphenidate, Amphetamines
3. Oxybate Salts (Xywav) -> DEEP SLEEP (REMS Program d/t date rape)

Question 7

• Mixed Oxybate salts (Xywav) is for _____
• Sodium Oxybate (Xyrem) is ONLY for ______

Narcolepsy or Hypersomnia

Answer 7

Xywav = Hypersomnia
Xyrem = Narcolepsy ONLY

Question 8

What is Cataplexy? What sleeping DO is this commonly seen in?

Answer 8

Sudden muscle weakness
Narcolepsy Type 1

Question 9

In order to be Dx with CHRONIC Insomnia, Hypersomnolence, or Narcolepsy, you must have difficulty ____ nights a week for 3mo+

Answer 9

3

Question 10

Drug class?
* Daridorexant, Lemborexant, Suvorexant

Answer 10

Dual Orexin Receptor Antagonists (DORAs)

Orexin keeps you awake. Antagonize Orexin -> SLEEPY
Used for insomnia

Question 11

Drug Class?
Doxepin

Answer 11

Low-dose Histamine Receptor Antagonist

used for insomnia

Question 12

Drug Class?
Ramelteon

Answer 12

Melatonin Receptor Agonist

used for insomnia

Question 13

Narcolepsy Tx

Answer 13

1. Modafinil, Armodafinil, Pitolisant, Solriamfetol
2. Amphetamines, Methylphenidate

• Severe sleepy & fail 1 med or Severe Cataplexy -> ADD or SWITCH Oxybates
• Residual Cataplexy -> Effexor, Fluoxetine, Duloxetine, TCA
• Milder Insomnia -> Short BZRA
• Peds -> Traditional stimulants or Oxybates

Question 14

Hyperventilation -> _____
Hypoventilation -> _______

CPAP or BIPAP?

Answer 14

Hyperventilation -> CPAP
Hypoventilaiton -> BiPAP

Question 15

OSA Dx
* ____ Apneas/Hr + SS
* _____Apneas/Hr (regardless if SS or not)

Answer 15

• 5 Apneas/Hr + SS
• 15 Apneas/Hr

Question 16

Central Sleep Apnea Dx
_____ Apneas/Hr

Answer 16

5

Question 17

Sleep related hypoventilaiton DO is episodes of _____Respiration with ____PaCO2

High or low?

Answer 17

LOW Respiration
HIGH PaCO2

Question 18

Tx for Sleep related hypoventilation DO

Answer 18

BiPAP

Question 19

Tx for Delayed Sleep Phase Type

A SPECIFIER for any sleeping DO

Answer 19

• Bright light therapy
• Chronotherapy
• Melatonin
• Ramelteon (melatonin receptor agonist)

Question 20

Tx for advanced sleep phase type DO

Answer 20

Bright light therapy
Melatonin

Question 21

Which sleeping DO?
Old person goes to bed early (6-9pm) and wakes up early (2-5am)

Answer 21

Advanced sleep phase type DO

• Delayed sleep phase type = young person on their phone all night
• Advanced sleep phase = seen in ADVANCED ages (old ppl)

Question 22

Which sleeping DO?
Sleep during day and awake at night

Answer 22

Irregular Sleep-wake DO

Question 23

Irregular Sleep-Wake DO Tx?

Answer 23

• Bright light therapy
• Structured physical/social activity
• Melatonin

Question 24

Non-24Hr sleep-wake DO:
SS?
WU?

Answer 24

• Sleep time jumps around
• Sleep Diary

Question 25

Non-24Hr sleep-wake DO Tx: - Blind? - Sighted?

Answer 25

* Blind -> Melatonin, Tasimelteon * Sighted -> Melatonin ## Footnote Tasimelteon (Hetlioz) $$$ Melaotnin Agonist is Melatonin fails or pt doesnt want to try it

Question 26

Shift Work Sleeping DO Tx

Answer 26

* Change work schedule * Sleep schedule * Zolpidem (Ambien) - Non-Benzo BZRA * Triazolam, Temazepam - Benzo BZRA | BZRA = Benzo Receptor Agonist

Question 27

Sleepwalking and nightmare DO are _____ Sleep DOs | NREM or REM?

Answer 27

NREM (Non-rapid eye mvmnt)

Question 28

Tx for SEVERE Sleepwalking - #1 & #2 - Sexual Behaviors? - Eating SS?

Answer 28

* Melatonin * Benzos - Clonezapam (Klonopin) * Sexual -> SSRIs * Eating -> Topiramate (Anticonvulsant)

Question 29

Pharm Tx for Nightmare DO

Answer 29

Prazosin

Question 30

Tx for REM sleep DO

Answer 30

* Melatonin * Clonazepam (Klonopin) * Donepezil (Aricept), Revastigmine (Exelon) - Ach Inhib

Question 31

Restless leg syndrome Dx: ss for ____mo+

Answer 31

3

Question 32

Restless leg syndrome Tx

Answer 32

Question 33

Restless Leg Tx if daytime ss

Answer 33

Carbidopa-Levodopa PRN (benzo)

Question 34

Restless leg Tx if CHRONIC

Answer 34

1. GABA (Pregabalin, Gabapentin) 2. Dopamine Agonist (Pramipexole, Ropinirole, Rotigotine)

Question 35

Restless leg Tx if REFRACTORY

Answer 35

* Combo -> Dopamine agonist, GABA, Benzos * Low-dose Tramadol, Codeine * High-potency Oxycodone, Methadone