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Medication Review Presentation
Medication Review Presentation
Medication Review Presentation
Medication Review Presentation
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Medication Review Presentation
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Medication Review Presentation

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  • 1.  
  • 2. General Considerations <ul><li>This lecture will cover medications commonly taken by sleep lab patients that are known to have effects on sleep </li></ul><ul><li>The purpose of this lecture is not to memorize the generic and trade name of every medication our patients may ever take! </li></ul>
  • 3. General Considerations <ul><li>Medication classes that will be covered: </li></ul><ul><ul><li>Sedatives and hypnotics </li></ul></ul><ul><ul><li>Stimulants </li></ul></ul><ul><ul><li>Psychiatric medications </li></ul></ul><ul><ul><li>Pain medications </li></ul></ul><ul><ul><li>Antiepileptics </li></ul></ul><ul><ul><li>RLS/PLMD medications </li></ul></ul><ul><ul><li>Cardiovascular medications </li></ul></ul><ul><ul><li>Respiratory medications </li></ul></ul><ul><ul><li>Cold medications and antihistamines </li></ul></ul><ul><ul><li>Recreational drugs </li></ul></ul>
  • 4. General Considerations <ul><li>3.1 billion prescriptions were written in 2002 in the US alone </li></ul><ul><li>Nearly half of all Americans are currently prescribed at least one medication </li></ul><ul><li>Most patients seen at the sleep lab are under the influence of prescribed medications </li></ul><ul><ul><li>It’s important to know and understand patients’ medication lists (even OTC drugs) to correctly read and score studies, and also for the sake of safety </li></ul></ul>
  • 5. General Considerations <ul><li>584 prescription and OTC drugs list sleepiness as a side effect </li></ul><ul><li>Of the 20 most commonly prescribed medications in the US, at least half are known to affect sleep </li></ul>
  • 6. 20 most commonly prescribed brand-name medications 20 most commonly prescribed generic medications
  • 7. General Considerations <ul><li>The effects many medications have on sleep are largely unknown </li></ul><ul><ul><li>Even highly controlled studies have produced differing results </li></ul></ul><ul><li>Several factors limit the understanding of how different medications affect sleep and wakefulness: </li></ul><ul><ul><li>Limited research </li></ul></ul><ul><ul><li>Inconsistent findings </li></ul></ul><ul><ul><li>Population differences </li></ul></ul><ul><ul><li>Acute vs. chronic effects </li></ul></ul>
  • 8. General Considerations <ul><li>The more medications a patient is on, the higher the chance of clinically significant interactions </li></ul><ul><li>Physicians should always be aware of a patient’s medications and instruct the patient and tech as to their use before and during the PSG </li></ul><ul><ul><li>Any changes to a patient’s regular medication routine should be clearly indicated on the study order or history </li></ul></ul>
  • 9. General Considerations <ul><li>Abbreviations: </li></ul><ul><ul><li>SOL – sleep onset latency </li></ul></ul><ul><ul><ul><li>Some charts will use “SL” instead </li></ul></ul></ul><ul><ul><li>ROL – REM onset latency </li></ul></ul><ul><ul><ul><li>Some charts will use “RL” instead </li></ul></ul></ul><ul><ul><li>TST – total sleep time </li></ul></ul><ul><ul><li>SWS – slow-wave sleep </li></ul></ul><ul><ul><li>WASO – wake after sleep onset </li></ul></ul><ul><ul><li>EDS – excessive daytime sleepiness </li></ul></ul><ul><li>I will try to give both generic and trade names </li></ul><ul><ul><li>Trade names will always be capitalized </li></ul></ul>
  • 10. Sedatives and Hypnotics <ul><li>Sedatives are prescribed to treat anxiety, and hypnotics are prescribed to treat insomnia </li></ul><ul><ul><li>Nearly identical in how they function and are often used interchangeably </li></ul></ul><ul><li>Have a history of limited efficacy, serious side effects, addiction, and lethal toxicity in overdose </li></ul><ul><ul><li>Long-term use can lead to tolerance and actually cause insomnia </li></ul></ul>
  • 11. Sedatives and Hypnotics <ul><li>All classes bind to GABA receptors in the brain, inhibiting internal and external influences from disrupting sleep </li></ul><ul><ul><li>Basically “protect” sleep from things such as worries, noise, and pain </li></ul></ul><ul><ul><li>Treating OSA-induced EDS with sedatives can decrease respiratory drive and increase prevalence of OSA, actually worsening sleep </li></ul></ul><ul><li>Beware that the effects of multiple sedatives may be more than additive </li></ul>
  • 12. Sedatives and Hypnotics <ul><li>3 main categories of hypnotics: </li></ul><ul><ul><li>Barbiturates </li></ul></ul><ul><ul><li>Benzodiazepines </li></ul></ul><ul><ul><li>Non-benzodiazepines </li></ul></ul>
  • 13. Barbiturates <ul><li>Widely used until the 1960s, but were often abused and had a high danger of overdose </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Luminal phenobarbital Nembutal pentobarbital Quaalude, Sopor methaqualone Doriden glutethimide Placidyl ethchlorvynol Nodudor methyprylon
  • 14. Barbiturates <ul><li>Biggest effect seen on sleep is that they’re very sedating </li></ul><ul><li>Increase TST, decrease REM, increase spindle frequency and density, increase SWS </li></ul><ul><ul><li>Phenobarbital (Luminal) may actually suppress SWS </li></ul></ul><ul><li>Can decrease respiratory drive and increase prevalence of OSA </li></ul><ul><li>May exacerbate respiratory failure in patients with COPD, CSA, or restrictive lung disease </li></ul>
  • 15. Benzodiazepines <ul><li>Became available in the 1970s, and have less overdose and abuse potential than barbiturates </li></ul><ul><li>Bind to a broad range of GABA receptors and have a widespread sedating effect </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Ativan lorazepam Klonopin clonazepam Dalmare flurazepam Valium diazepam Xanax alprazolam Halcion triazolam Tranzene clorazepate
  • 16. Benzodiazepines <ul><li>Tend to lose efficacy with prolonged use </li></ul><ul><li>Decrease WASO, increase TST, increase stages N1 and N2, increase spindle frequency/density, decrease SWS, decrease REM </li></ul><ul><ul><li>Clonazepam (Klonopin) may actually increase SWS </li></ul></ul><ul><li>Are also sometimes used to treat PLMD </li></ul><ul><li>Clonazepam (Klonopin) is also used to treat REM behavior disorder </li></ul>
  • 17. Benzodiazepines <ul><li>Have similar respiratory effects as barbiturates: </li></ul><ul><ul><li>Can cause respiratory depression, causing or worsening OSA </li></ul></ul><ul><ul><li>Can exacerbate respiratory failure in patients with COPD, CSA, or restrictive lung disease </li></ul></ul><ul><li>Withdrawal can cause REM rebound </li></ul><ul><li>Flurazepam (Dalmare), diazepam (Valium), and clorazepate (Tranzene) have almost 11 day half-lives </li></ul><ul><ul><li>Effects may be seen long after being discontinued </li></ul></ul>
  • 18. Non-benzodiazepines <ul><li>Bind preferentially to GABA A receptors and have a less widespread effect than benzodiazepines </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Ambien zolpidem Benadryl diphenhydramine (also an antihistamine) Sonata zaleplon Lunesta eszopiclone Rozerem ramelteon BuSpar buspirone
  • 19. Non-benzodiazepines <ul><li>Have a relatively short half-life, and have the fewest side effects of all hypnotics </li></ul><ul><ul><li>Buspirone (BuSpar) in particular has been studied and found to have no effects on sleep architecture or daytime alertness </li></ul></ul><ul><li>Zolpidem (Ambien) and eszopiclone (Lunesta) have greatest sleep-inducing efficacy, but zaleplon (Sonata) has fewest side effects </li></ul><ul><li>Zaleplon (Sonata) may increase ROL and SWS </li></ul><ul><li>Conflicting studies have shown that zolpidem (Ambien) can either suppress or increase SWS </li></ul><ul><li>No REM rebound occurs after discontinuing </li></ul>
  • 20. &nbsp;
  • 21. Stimulants <ul><li>Increase CNS activation to promote alertness </li></ul><ul><li>Used to treat narcolepsy, hypersomnia, ADHD, obesity, and even the common cold </li></ul><ul><li>Many of the same medications are used to treat both narcolepsy and ADHD </li></ul>
  • 22. Stimulants Example narcolepsy/hypersomnia/ ADHD medications: Example appetite suppressants: Trade name Generic name Provigil Modafinil Nuvigil Armodafinil Strattera atomexetine Adderall amphetamine Dexedrine dextroamphetamine Desoxyn methamphetamine Concerta, Ritalin methylphenidate Trade name Generic name Didrex benzphetamine Desoxyn methamphetamine Adipex phentermine Meridia sibutramine
  • 23. Stimulants <ul><li>Most have high potential for abuse and can cause personality changes, tremor, hypertension, headaches, and GERD </li></ul><ul><li>Newer stimulants modafinil (Provigil) and armodafinil (Nuvigil) are distinct from the amphetamines and have a much lower abuse potential </li></ul><ul><ul><li>Now usually the first route of treatment for narcolepsy </li></ul></ul>
  • 24. Stimulants <ul><li>Any medications that increase alertness have the risk of causing insomnia </li></ul><ul><li>Increase SOL, ROL, WASO, arousals, and stages N1 and N2 </li></ul><ul><li>Decrease SWS, REM, and TST </li></ul>
  • 25. Stimulants <ul><li>Common dose-dependent side effects may also interfere with sleep: </li></ul><ul><ul><li>Anxiety </li></ul></ul><ul><ul><li>Headache </li></ul></ul><ul><ul><li>Irritability </li></ul></ul><ul><ul><li>Heart palpitations </li></ul></ul><ul><ul><li>Tremors </li></ul></ul><ul><li>Sudden withdrawal from any stimulant substance may cause profound sleepiness </li></ul><ul><ul><li>Beware of how stimulant withdrawal may affect MSLTs </li></ul></ul>
  • 26. Antidepressants <ul><li>Four main classes: </li></ul><ul><ul><li>SSRIs and SNRIs </li></ul></ul><ul><ul><li>Tricyclics </li></ul></ul><ul><ul><li>MAOIs </li></ul></ul><ul><ul><li>Atypical antidepressants </li></ul></ul><ul><li>Each class affects neurotransmitters in different ways </li></ul><ul><li>Each has its own set of side effects, which range from stimulating to sedating </li></ul>
  • 27. Antidepressants <ul><li>Most antidepressants affect the neurotransmitters norepinephrine, serotonin, acetylcholine, and dopamine </li></ul><ul><ul><li>All are known to play an important role in the sleep-wake cycle </li></ul></ul><ul><li>15% of those who take antidepressants report disrupted sleep or daytime fatigue </li></ul><ul><li>Many are sedating, but stopping them prior to a PSG is not always practical or safe </li></ul><ul><li>Almost all classes have been known to exacerbate PLMD </li></ul>
  • 28. SSRIs and SNRIs <ul><li>Selective serotonin reuptake inhibitors affect the neurotransmitter serotonin </li></ul><ul><ul><li>SNRIs affect both serotonin and norepinephrine, and have similar sleep effects to SSRIs </li></ul></ul>Example SSRIs: Example SNRIs: Trade name Generic name Prozac fluoxetine Zoloft sertraline Celexa citalopram Lexapro escitalopram Paxil paroxetine Luvox fluvoxamine Trade name Generic name Cymbalta duloxetine Effexor venlafaxine
  • 29. SSRIs and SNRIs <ul><li>Generally have the mildest side effects of all antidepressants </li></ul><ul><li>SSRIs tend to be stimulating, and can cause mild-moderate insomnia </li></ul><ul><ul><li>Fluoxetine (Prozac) is the most sleep-disruptive </li></ul></ul><ul><li>Can also cause drowsiness in some individuals </li></ul><ul><ul><li>Mostly seen with paroxetine (Paxil) and fluvoxamine (Luvox) </li></ul></ul><ul><li>Decrease TST, increase WASO, decrease REM, and increase PLMD </li></ul><ul><ul><li>Fluoxetine (Prozac) can also decrease SWS </li></ul></ul>
  • 30. SSRIs and SNRIs <ul><li>Tend to be respiratory stimulants and can improve OSA </li></ul><ul><li>Can cause SEMs to occur during most of the night, even long after cessation of drug use </li></ul><ul><ul><li>Most prevalent with fluoxetine (Prozac), paroxetine (Paxil), and sertraline (Zoloft) </li></ul></ul><ul><ul><li>Less prevalent with citalopram (Celexa) and escitalopram (Lexapro) </li></ul></ul><ul><ul><li>“ Prozac eyes” are often so rapid that they can easily be mistaken for REMs. </li></ul></ul>
  • 31. SSRIs and SNRIs <ul><li>MSLT of a patient taking 20mg fluoxetine daily (30 seconds) </li></ul>
  • 32. SSRIs and SNRIs <ul><li>Same patient and epoch (120 seconds) </li></ul>
  • 33. SSRIs and SNRIs <ul><li>Most increase ROL and decrease REM by about 30% </li></ul><ul><ul><li>Knowing this is important for correct interpretation </li></ul></ul><ul><li>REM suppression was once believed to be an important part of treatment </li></ul><ul><li>Because of their stimulating effects, SSRIs and SNRIs can worsen REM behavior disorder </li></ul><ul><li>Despite the sleep disruption caused by these drugs, patients report sleeping better subjectively </li></ul>
  • 34. Tricyclics <ul><li>Have a broader effect on neurotransmitters </li></ul><ul><ul><li>Alter norepinephrine, histamine, and acetylcholine activity </li></ul></ul><ul><li>Examples: </li></ul>Trade name Generic name Elavil amitriptyline Norpramin desipramine Pamelor nortriptyline Sinequan doxepin Tofranil imipramine Vivactil protriptyline
  • 35. Tricyclics <ul><li>Mildly-moderately sedating </li></ul><ul><li>Improve sleep but cause EDS </li></ul><ul><ul><li>Protriptyline (Vivactil) less sedating than others </li></ul></ul><ul><li>Increase TST, decrease WASO, increase SWS, decrease REM, and increase PLMD </li></ul>
  • 36. MAOIs <ul><li>Monoamine oxidase inhibitors are the oldest antidepressants, and have greatest effects on sleep </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Marplan isocarboxazid Nardil phenelzine Parnate tranylcypromine
  • 37. MAOIs <ul><li>Tend to be sedating, but can also cause insomnia </li></ul><ul><li>Suppress REM, but effect is more sustained than with SSRIs </li></ul><ul><li>Cause increased WASO, decreased TST, and markedly reduced REM </li></ul>
  • 38. Atypical Antidepressants <ul><li>Work through a variety of mechanisms and affect multiple neurotransmitters, so effects on sleep are less known </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Desyrel trazodone Serzone nefazodone Remeron mirtazapine Wellbutrin bupropion
  • 39. Atypical Antidepressants <ul><li>Trazodone (Desyrel) and nefazodone (Serzone) are considered serotonin antagonist and reuptake inhibitors </li></ul><ul><ul><li>Can cause EDS, but may improve sleep </li></ul></ul><ul><ul><li>Increase TST and SWS </li></ul></ul><ul><ul><li>Conflicting results on REM effects </li></ul></ul><ul><li>Mirtazapine (Remeron) is a norepinephrine and specific serotonin antagonist </li></ul><ul><ul><li>Also causes sedation and EDS but enhances sleep </li></ul></ul><ul><ul><li>Increases TST, decreases SOL </li></ul></ul>
  • 40. Atypical Antidepressants <ul><li>Bupropion (Wellbutrin), as well as the tricyclic protryiptiline (Vivactil), are norepinephrine and dopamine reuptake inhibitors </li></ul><ul><ul><li>Most alerting of antidepressants, and can cause insomnia </li></ul></ul><ul><ul><li>Actually increase REM and don’t exacerbate PLMD </li></ul></ul><ul><li>St. John’s Wort is an herb taken by some for depression </li></ul><ul><ul><li>Has been shown to increase SWS </li></ul></ul>
  • 41. Antidepressants
  • 42. Antipsychotics <ul><li>Lithium has traditionally been the drug of choice for treating bipolar disorder </li></ul><ul><ul><li>Trade names include Cibalith, Eskalith, Lithane, and Lithobid </li></ul></ul><ul><ul><li>The seizure medication divalproex (Depakote) is also prescribed to treat the manic phase of bipolar disorder </li></ul></ul><ul><ul><li>Tends to be sedating, causing EDS but improving sleep </li></ul></ul><ul><ul><li>Reduces REM, increases SWS and the prevalence of arousal disorders such as night terrors and somnambulism </li></ul></ul>
  • 43. Antipsychotics <ul><li>Common antipsychotics which are prescribed for schizophrenia, other psychoses, and occasionally bipolar disorder: </li></ul><ul><ul><li>Characterized mainly by their sedative effect </li></ul></ul><ul><ul><li>Chlorpromazine (Thorazine) can cause an increase in SWS; diffuse, slower activity in the EEG; and a decrease in spindle activity </li></ul></ul>Trade name Generic name Thorazine chlorpromazine Haldol haloperidol Mellaril thioridazine Risperdal risperidone Seroquel quetiapine Zyprexa olanzapine
  • 44. Chantix <ul><li>Smoking cessation aid that works by blocking nicotine receptors in the brain </li></ul><ul><ul><li>Makes smoking have less of a pleasurable effect </li></ul></ul><ul><li>Known to cause insomnia and vivid, unusual dreams </li></ul><ul><li>Watch for symptoms of stimulant withdrawal </li></ul>
  • 45. Pain Medications <ul><li>Many prescription pain medications are either narcotics or barbiturates </li></ul><ul><li>Are often VERY sedating </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Vicodin, Lortab hydrocodone Darvocet propoxyphrene Demerol meperidine Methadone methadone Percocet oxycodone Norgesic orphenadrine --- morphine --- codeine
  • 46. Pain Medications <ul><li>Decrease SOL and WASO, increase TST, may decrease SWS and REM </li></ul><ul><li>May decrease alpha, and can cause slower, diffuse EEG </li></ul><ul><li>Can depress respiratory system and increase severity of OSA </li></ul><ul><li>Have been known to cause confusion in elderly patients </li></ul><ul><li>Aspirin (ASA or acetylsalicylic acid) in an NSAID taken for pain or to prevent heart attack </li></ul><ul><ul><li>Main effect on sleep is a decrease in SWS </li></ul></ul>
  • 47. Antiepileptic and Neuromuscular Medications <ul><li>Prescribed to treat epileptic seizures as well as muscle pain caused by injury </li></ul><ul><li>Include both muscle relaxants and anticonvulsants </li></ul><ul><li>Example muscle relaxants: </li></ul>Trade name Generic name Flexeril cyclobenzaprine Soma carisoprodol
  • 48. Antiepileptic and Neuromuscular Medications <ul><li>Example anticonvulsants: </li></ul><ul><ul><li>Topiramate (Topamax) is also prescribed to treat migraine headaches </li></ul></ul><ul><ul><li>Divalproex (Depakote) is also prescribed for bipolar disorder </li></ul></ul>Trade name Generic name Depakote divalproex Dilantin phenytoin Neurontin gabapentin Tegretol carbamazepine Topamax topiramate Keppra levetiracetam
  • 49. Antiepileptic and Neuromuscular Medications <ul><li>Tend to be very sedating </li></ul><ul><li>Phenytoin (Dilantin) may increase SWS, decrease alpha, and cause diffuse, slower EEG activity </li></ul><ul><li>Anticonvulsants also tend to reduce REM </li></ul>
  • 50. RLS/PLMD Medications <ul><li>Restless leg syndrome and periodic limb movement disorder occur in up to 15% of the population </li></ul><ul><ul><li>Often occur comorbidly </li></ul></ul><ul><li>Frequency of RLS/PLMD increases with age </li></ul><ul><li>Historically treated with benzodiazepines, particularly clonazepam (Klonopin) </li></ul><ul><li>Newer drugs affect mainly dopamine receptors </li></ul>
  • 51. RLS/PLMD Medications <ul><li>Examples: </li></ul><ul><ul><li>Carbidopa and levodopa (Sinemet) have been reported to induce vivid dreams or nightmares, hallucinations, vocalizations, and somnambulism </li></ul></ul><ul><ul><ul><li>Rarely used due to the potential for tachyphylaxis and augmentation of symptoms </li></ul></ul></ul>Trade name Generic name Sinemet carbidopa/levodopa Permax pergolide Mirapex pramipexole Requip repinirole Eldepryl selegiline
  • 52. RLS/PLMD Medications <ul><li>Tend to reduce SWS and REM </li></ul><ul><ul><li>Conflicting studies have shown levodopa either increases or decreases REM </li></ul></ul><ul><li>Common side effects are nausea and headache, which may also interfere with sleep </li></ul><ul><li>Usually improve sleep quality and decrease arousals </li></ul><ul><li>Pramipexole (Mirapex) was originally developed to treat Parkinson’s Disease </li></ul><ul><ul><li>May cause sudden attacks of uncontrollable sleepiness in some individuals </li></ul></ul>
  • 53. Antihypertensives <ul><li>Different classes have different methods of action, but the desired effect is to lower blood pressure </li></ul><ul><ul><li>Classes include diuretics, beta-blockers, alpha-beta-blockers, ACE inhibitors, calcium channel blockers, and vasodilators </li></ul></ul><ul><li>Examples: </li></ul>Trade name Generic name Inderal propranolol Tenormin atenolol Lopressor metoprolol --- pindolol --- reserpine Catapres clonidine Coreg carvedilol Cozaar losartan Privinil, Zestril lisinopril
  • 54. Antihypertensives <ul><li>May suppress REM and increase SWS </li></ul><ul><li>Have been reported to cause insomnia, nightmares, vivid dreams, hallucinations, vocalizations, somnambulism, and EDS </li></ul><ul><ul><li>Most sleep effects seen with clonidine (Catapres) </li></ul></ul><ul><ul><li>Fewest sleep effects seen with atenolol (Tenormin) </li></ul></ul>
  • 55. Diuretics <ul><li>Work by stimulating the kidneys to excrete more sodium into the urine </li></ul><ul><ul><li>This draws excess fluid out of cells so it can be eliminated from the body </li></ul></ul><ul><li>Although mainly prescribed to treat high blood pressure, are also commonly used to treat edema caused by heart failure, kidney disease, or liver cirrhosis </li></ul>
  • 56. Diuretics <ul><li>Examples: </li></ul><ul><li>The main effect on sleep is excessive urination, which can cause frequent nocturnal awakenings </li></ul><ul><li>A possible side effect is potassium deficiency, which can cause nocturnal cramping of the calf muscles </li></ul>Trade name Generic name Bumex bumetanide Zaroxolyn metolazone Aquazide, Microzide hydrochlorothiazide (HCTZ) Lasix furosemide
  • 57. Hypolipidemics <ul><li>Work to lower cholesterol by blocking its production by or absorption into the body </li></ul><ul><li>Along with antihypertensives, are some of the most common drugs taken by sleep lab patients </li></ul>
  • 58. Hypolipidemics <ul><li>Examples: </li></ul><ul><li>No consistent findings on sleep and wakefulness </li></ul><ul><ul><li>Insomnia reported rarely with atorvastatin (Lipitor) and lovastatin (Mevacor, Altoprev) </li></ul></ul>Trade name Generic name Caduet amlodipine/atorvastatin Vytorin ezetimibe/simvastatin Zetia ezetimibe Tricor fenofibrate Lipitor atorvastatin Mevacor, Altoprev lovastatin Pravachol pravastatin Crestor rosuvastatin Zocor simvastatin
  • 59. Antiarrhythmatics <ul><li>Work by slowing down the heart rate to treat fast arrhythmias such as atrial fibrillation, atrial flutter, ventricular fibrillation, and ventricular tachycardia </li></ul><ul><li>Includes a vast array of medications that work through a variety of mechanisms </li></ul><ul><li>How they affect sleep has been largely inconclusive </li></ul>Atrial fibrillation
  • 60. Antiarrhythmatics <ul><li>Examples: </li></ul>Trade name Generic name --- quinidine Tambocor flecainide Rythmol propafenone Ethmozine moricizine Calan verapamil Cardizem diltiazem Procardia nifedipine Lanoxin digoxin Coumadin warfarin
  • 61. Antiarrhythmatics <ul><li>Most common complaint is daytime fatigue </li></ul><ul><li>Most important thing to be aware of with these drugs is that they indicate the patient has a documented history of cardiac arrhythmias, so be very vigilant! </li></ul>
  • 62. Respiratory Medications <ul><li>The most common respiratory conditions that require long-term medication are asthma and COPD </li></ul><ul><li>Examples: </li></ul><ul><ul><li>Theophylline (Aerolate) is chemically related to caffeine, and doses are usually high enough to disrupt sleep </li></ul></ul>Trade name Generic name Proventil, Ventolin albuterol Maxair pirbuterol Aerolate theophylline --- aminophylline Atrovent ipratropium
  • 63. Respiratory Medications <ul><li>Work by stimulating the central nervous system, which can cause insomnia, especially if taken shortly before bedtime </li></ul><ul><li>Corticosteroids like prednisone are prescribed for asthma as well as for joint pain and inflammation </li></ul><ul><ul><li>Can cause jitters and insomnia </li></ul></ul><ul><ul><li>Increase appetite and can cause fluid retention </li></ul></ul><ul><ul><ul><li>Any weight gain can increase the risk of OSA </li></ul></ul></ul>
  • 64. Decongestants <ul><li>Work by reducing blood flow to the mucus membranes so that less mucus is produced </li></ul><ul><li>Examples include oxymetazoline (Afrin), phenylphrine (Contac-D, Sudafed PE), and phenylpropanolamine (Phenyldrine), but most common decongestant is pseudoephedrine </li></ul><ul><li>Pseudoephedrine can be found in: </li></ul><ul><ul><li>Actifed, Advil Cold &amp; Sinus, Aleve Cold &amp; Sinus, DayQuil, NyQuil, Dimetapp, Robitussin, Sudafed, Triaminic, Tylenol Cold, and most drugs that end in “-D” </li></ul></ul>
  • 65. Decongestants <ul><li>Most cause some degree of CNS stimulation, which may result in insomnia </li></ul><ul><ul><li>Particularly true w/ drugs containing pseudoephedrine </li></ul></ul><ul><li>Pseudoephedrine has been reported to induce hallucinations, vocalizations, and somnambulism </li></ul><ul><ul><li>Ephedrine in brain = adrenaline in body </li></ul></ul>
  • 66. Antihistamines <ul><li>Work by blocking histamine, a neurotransmitter that’s responsible for allergy symptoms but that also promotes wakefulness </li></ul><ul><li>Examples: </li></ul>Trade name Generic name Zyrtec cetirizine Astelin azelastine Benadryl diphenhydramine Allegra fexofenadine Claritin, Alavert loratadine Clarinex desloratadine Dramamine dimenhydrinate
  • 67. Antihistamines <ul><li>Tend to be sedating, and can cause drowsiness </li></ul><ul><ul><li>Diphenhydramine (Benadryl) also used as a sleep aid </li></ul></ul><ul><li>Shorten SOL, decrease REM, decrease arousals, and increase TST </li></ul><ul><ul><li>Newer antihistamines such as cetirizine (Zyrtec) have fewer side effects </li></ul></ul><ul><li>Taking antihistamines before bed can result in a dry mouth and drowsiness upon awakening </li></ul>
  • 68. Cold Medications and Antihistamines <ul><li>Many cold medications contain an antihistamine as well as a decongestant, so side effects may be unpredictable and can vary greatly from one patient to the next </li></ul><ul><li>Most cold medications </li></ul><ul><li>are available OTC, so </li></ul><ul><li>they’re readily </li></ul><ul><li>accessible to patients </li></ul>
  • 69. Alcohol <ul><li>Affects GABA receptors in the brain </li></ul><ul><li>Consumed close to bedtime, can initially be very sedating </li></ul><ul><ul><li>At least 25% of insomniacs report using alcohol as a sleep aid </li></ul></ul><ul><ul><li>Those with greater trouble sleeping are more likely to have diagnosable alcoholism </li></ul></ul>
  • 70. Alcohol <ul><li>In the first half of the night, NREM is increased and REM is reduced </li></ul><ul><li>In the second half of the night, withdrawal symptoms occur, particularly in heavy drinkers </li></ul><ul><ul><li>Shallow, disrupted sleep; late-night REM rebound; nightmares; sympathetic nervous system arousal; tachycardia; sweating </li></ul></ul><ul><li>Decreases SOL and REM, increased WASO (especially in second half of the night) </li></ul>
  • 71. Alcohol <ul><li>Relaxes muscles of the upper airway </li></ul><ul><ul><li>This can cause or worsen snoring and OSA </li></ul></ul><ul><li>Alcoholics often report insomnia, hypersomnia, circadian rhythm disturbances, and parasomnias </li></ul><ul><ul><li>Recovering alcoholics may have abnormal sleep patterns for years after becoming sober </li></ul></ul>
  • 72. Caffeine <ul><li>Binds to adenosine receptors </li></ul><ul><li>in the brain, blocking the </li></ul><ul><li>sleep-inducing neurotransmitter </li></ul><ul><li>adenosine from having an effect </li></ul><ul><li>Consumption of large amounts may lead to restlessness, nervousness, excitement, insomnia, flushed face, and GI problems </li></ul><ul><ul><li>1000mg can produce insomnia, dyspnea, delirium, and arrhythmias </li></ul></ul><ul><ul><li>Doses above 5000mg can be fatal </li></ul></ul>
  • 73. Caffeine <ul><li>Because it’s so prevalent, it’s easy to ingest large amounts unintentionally. </li></ul>
  • 74. Caffeine <ul><li>Chronic daily use leads to tolerance and dependence </li></ul><ul><li>Half-life is 3-7 hours, so even caffeine consumed in the afternoon can disrupt sleep at night </li></ul><ul><ul><li>Effect more pronounced in children, pregnant women, the elderly, and people with hypothyroidism </li></ul></ul><ul><li>Increases arousals, decreases TST and SWS </li></ul><ul><li>Beware that caffeine is present in many headache medications (e.g., Excedrin Migraine) </li></ul>
  • 75. Nicotine <ul><li>Approximately 23% of adults in the US use nicotine products </li></ul><ul><li>Conflicting reports on how it affects sleep </li></ul><ul><ul><li>May be sedating in lower doses but altering in higher doses </li></ul></ul><ul><li>Also conflicting reports on how it affects REM </li></ul><ul><ul><li>Some reports have shown an increase while others have shown a decrease </li></ul></ul><ul><li>Nicotine patches deliver small doses of nicotine into the bloodstream around the clock </li></ul><ul><ul><li>Can cause insomnia and disturbing dreams </li></ul></ul>
  • 76. Other Recreational Drugs <ul><li>Marijuana (tetrahydracannibinol) </li></ul><ul><ul><li>Effects on sleep very similar to alcohol </li></ul></ul><ul><ul><li>May induce sleepiness </li></ul></ul><ul><li>Opiates </li></ul><ul><ul><li>May induce sleepiness but cause REM suppression </li></ul></ul><ul><ul><li>Can increase SWS and prevalence of night terrors and somnambulism </li></ul></ul>
  • 77. Other Recreational Drugs <ul><li>Amphetamines </li></ul><ul><ul><li>Can be useful as prescription stimulants, but some forms (particularly methamphetamine) have a high abuse potential when used as recreational drugs </li></ul></ul><ul><ul><li>Effects tend to be dose-dependent, so recreational users may have even more disturbed sleep than those who take prescription amphetamines as prescribed </li></ul></ul>
  • 78. Helpful Hints <ul><li>Drugs that can cause nightmares or vivid dreams: </li></ul><ul><ul><li>Antihistamines, benzodiazepines, beta-blockers, dopaminergics, isotretinoin, ofloxacin, naproxen, thiothixene, verapamil, varenicline </li></ul></ul><ul><li>Drugs that can cause excessive daytime sleepiness: </li></ul><ul><ul><li>Antihistamines, antihypertensives, anti-nausea agents, dopamine agonists, antiepileptics </li></ul></ul>
  • 79. Helpful Hints <ul><li>Drugs that can cause insomnia: </li></ul><ul><ul><li>Amphetamines, antiretrovirals, anti-influenza drugs, cholesterol-lowering drugs, corticosteroids </li></ul></ul>
  • 80. Helpful Hints <ul><li>Following are some tips for recognizing the class of unfamiliar drugs </li></ul><ul><li>Some precautions: </li></ul><ul><ul><li>These only work on generic names, as trademarked drugs are often named arbitrarily and for marketing purposes </li></ul></ul><ul><ul><li>These tips aren’t applicable in all cases – they’re a general trend, not a hard and fast rule </li></ul></ul>
  • 81. Helpful Hints Generic drug names that: Are usually: Contain “barb” Barbiturates End in “-pam” or “-lam” Benzodiazepines Contain “amphetamine” Amphetamines End in “-oxetine” or “-pram” SSRI antidepressants End in “-triptyline” Tricyclic antidepressants Start or end with “lith” Lithium preparations End in “-dopa” Dopaminergic Parkinson’s drugs End in “-lol’ Beta-blockers Contain “statin&amp;quot; Cholesterol-lowering statins End in “-buterol” or “-phylline” Respiratory medications
  • 82. Conclusion <ul><li>The vast array of substances available to our patients will continually challenge our ability to interpret PSGs </li></ul><ul><li>As technologists, we must remain aware of the latest trends in the use and abuse of various drugs </li></ul><ul><li>We must know if and how each PSG might be affected by a patient’s medications, including those NOT taken the night of the study </li></ul>
  • 83. Questions,Concerns,Feedback Should you have any questions or feedback regarding this presentation please feel free to contact our program director, Jennifer Brickner-York, at [email_address] . Thank You.
  • 84. References <ul><li>Boehringer Ingelheim Pharmaceuticals, Inc. (2005). PDR pharmacopoeia: Pocket dosing guide 2006 . Deerfield, IL: Astellas Pharma US. </li></ul><ul><li>Butkov, N., &amp; Lee-Chiong, T. (Eds.). (2007). Fundamentals of sleep technology . Philadelphia, PA: Lippincott Williams &amp; Wilkins. </li></ul><ul><li>Lenik, S.H. (2009). Handbook for sleep medicine technologists . Denver, CO: Outskirts Press. </li></ul><ul><li>Neubauer, D.N. (2008). Medication effects on sleep. (2008). ACCP Sleep Medicine Review Board syllabus book, ed. C.W. Atwood . </li></ul><ul><li>Pandi-Perumal, S.R., Ruoti, R.R., &amp; Kramer, M. (Eds.). (2007). Sleep and psychosomatic medicine . Boca Raton, FL: Informa Healthcare. </li></ul><ul><li>Silverman, H.M. (1998). The pill book . New York, NY: Bantam. </li></ul>

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