Meds
Name the med:
8mg @ HS
FDA approved for tx of insomnia
MT1/MT2 receptor agonist (10 x's more effective then supplement melatonin
SE: sedation, dizziness, fatigue, H/A, respiratory depression
Ramelteon/Rozerem
Name the FDA med used for excessive sleepiness d/t OSA or Narcolepsy (2)
Armodafinil/Nuvigil
Modafinil/Provigil
Name the med:
1-16 mg /day divided doses. start at 1 mg
Alpha 1 adrenergic receptor to decrease hyperarousal (FDA approved for b/p)
SE: ortho B/P's/dizziness, lightheadedness, fatigue, nausea, H/A syncope
Prazosin/Minipress
**** recommended by VA for tx of nightmares in PTSD pts.
The PMHNP knows the following classes of medications can be used for sleep wake disorders:
DORAs
Antidepressant (including TCAs-2)
Antipsychotics (low doses-2)
Antihistamines
Anticonvulsants
The PMHNP knows the pharmacological approach to enhancing sleep drive means:
using + allosteric modulators (pams) of GABA receptors (GABA A receptors BZD sensitive)
-Activation of the GABA in the hypothalamic sleep ctr
- BZDs & Z drugs
Name the med:
schedule IV
10-20mg Q HS for 7-10 days
nonbenzo
GABA A agonist and benzo receptor
short term use only
Long term use can cause rebound anxiety
SE: sedation, dizziness, ataxia, amnesia, hallucinations, CNS depression, anxiety, impaired driving
Zaleplon/Sonata
Name this med:
schedule IV
200-800mg/day dosed in the am
MOA not understood Stops DAT and stimulates alpha adrenergic
SE: h/a anxiety, insomnia, dry mouth, HTN, palpitations, EKG changes, psychosis/mania, SJS
Modafinil/Provigil
Delayed onset of sleep?
1. take med earlier
2. take on empty stomach
3. raise dose
Black Box Warning for BZDs?
1. Risk for combined opioid use d/t sedation, respiratory depression, coma, & death
2. Addiction, Abuse, and Misuse: can lead to OD and death when combine with other meds, ETOH, or illicit drugs
3. Dependence Withdrawal Rxn: physical dependence, significant withdrawal with longer use and higher dly use which requires gradual reduction to minimize life threatening risks including seizures
The PMHNP knows reducing arousal through pharmacological means prescribing:
-DORAS (Dual Orexin Receptor Antagonist ) block orexin
-H1 antagonist block histamine ex. benadryl is an
antihistamine
-5HT antagonist block serotonin
-Alpha 1 antagonist block NE
Name the med:
schedule IV
women 5mg or CR 6.25mg
men10mg or CR 12.5 mg
nonbenzo hypnotic
GABA A agonist receptor
short term 7-10 days
SE: make sure adequate sleep time, education, dizziness, amnesia, anxiety, hallucinations, nightmares behaviors, impaired driving
Zolpidem/Ambien
Ambien CR-slow releasing form
(Middle of the night dose-intermezzo women 1.75, men 3.5mg-if 4 hours left of sleep)
Name the med:
schedule IV
150-250 mg/ day
May cause release of hypocretin
SE: h/a anxiety, insomnia, dry mouth, HTN, palpitations, EKG changes, psychosis/mania, SJS
Armodafinil/Nuvigil
Too drowsy in the morning?
1. take earlier in the evening
2. lower the dose
3. switch to an agent with a shorter 1/2 life
BBW for Z Drugs?
Complex Sleep Behaviors (CSB)
Benzos used for insomnia and why?
Alprazolam/Xanax 6-12
Lorazepam/Ativan 10-20 hrs
d/t shorter 1/2 life
Name the med:
schedule IV
safest profile for long tern use
2-3 mg @ HS
nonbenzo hypnotic
GABA A agonist receptor
SE: driving impairment, amnesia, sedation, ataxia, dizziness, nervousness, unpleasant taste
Eszopiclone/Lunesta
Name the med
Schedule III
6-9 mg/night in 2 divided doses given 2-5-4 hirs apart
needs to be diluted in water
SE: CNS depression, H/A, dizziness, sedation, N/V, enuresis, psychosis, depression, confusion, agitation, wandering, ****fatality in OD
Sodium/Oxybate/Xyrem
What is special about Doxepin/Sinequan dosages?
3-6 mg highly selective for H1 without anticholinergic properties (can use with elderly)
Doses 10-150 have anticholinergic properties
The PMHNP when prescribing BZDs to:
1. use BZDs with caution when pt has sleep apnea
2. avoid ETOH,OPIOIDS, and other RESPIRATORY Depressants
3. use with caution when a pt has a HX OF EPILEPSY as withdrawal can result in seizure activity
4. Can experience rebound insomnia worse than original presentation
Name the dug class of meds used for sleep
sedatives taht bund to GABA A receptors
Varying 1/2 lives
Schedule iV abuse potential
tolerance and dependence likely
impairs driving
disinhibiting( bipolar rare)
Benzodiazepines
Name the med:
not FDA approved
75-100 mg@ HS
TCA= blocks 5HT & NE reuptake, INCREASES DA transmission in the prefrontal cortex
anticholinergic properties
SE: Sedation, bl vision, constipation, fatigue, QTc prolongation, ileus, ortho b/p's, hypotension, increased intraocular pressure
Imipramine/Tofranil
FDA approved medication for Non: 24 Sleep wake disorder?
MOA?
When can the med be found?
Tasimelteon/Hetlioz
Binds to Melatonin 1 &2 receptors(melatonin receptor agonist
20mg capsules
special pharmacy
What are the 2 pharmacological approaches to interventions to the sleep wake cycle?
Enhancing sleep drive or
Reducing Arousal