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Sleep Medications in Primary Care Disclosure • No Real Or Potential Sleep Medications in Primary Care Disclosure Sleep Medications in Primary Care • No real or potential conflict of Margaret A. Fitzgerald, interest to disclose. DNP, FNP-BC, NP-C, FAANP, CSP, FAAN, DCC, FNAP President, • No off-label, experimental or Fitzgerald Health Education Associates, North Andover, MA investigational use of drugs or Family Nurse Practitioner, Greater Lawrence (MA) Family Health Center devices will be presented. Editorial Board Member The Nurse Practitioner Journal, The Prescriber’s Letter, American Nurse Today Member, Pharmacy and Therapeutics Committee Neighborhood Health Plan, Boston, MA Fitzgerald Health Education Associates 2 Objectives Objectives (continued) • Upon completion of the learning • Upon completion of the learning activity the participant will be able to: activity the participant will be able – Describe the process of naturally- to: (cont.) occurring sleep. – Recognize the anticipated sleep – Identify the pharmacokinetics and outcomes with select medications pharmacodynamics of medications and commonly prescribed or used to herbal products to enhance sleep. enhance sleep as well as the risks associated with these products. Fitzgerald Health Education Associates 3 Fitzgerald Health Education Associates 4 Sleep Defined Insomnia: The Cost of the Problem (Or Best Defined in its Absence?) • Difficult to define and characterized • Costs the average American worker by observable changes in behavior – 11.3 days per year, $2,280 in lost and responsiveness productivity each year – Decreased activity • Presenteeism vs. absenteeism – Recognizable posture •Entire USA – Brain is less attentive to external stimuli – $63.2 billion in lost productivity – Source: http://healthland.time.com/2011/09/01/the-high-cost- – Altered consciousness yet easily aroused of-bad-sleep-63-billion-per-year/ –Source: http://healthysleep.med.harvard.edu/healthy/science/what/characteristics Fitzgerald Health Education Associates 5 Fitzgerald Health Education Associates 6 Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. 1 Prior permission required for use of questions or course content. Sleep Medications in Primary Care Insomnia: The Cost of the Problem The focus of this program is medications (continued) used to induce/maintain sleep. • In primary care • Not addressed in program – Up to 1/3 of all patients have a complaint of – Sleep apnea, central disordered sleep or obstructive – One in 6 patients – Restless leg syndrome describing problem – Parasomnias, sleepwalking, as “serious or severe” sleep terrors – One in 12 patients –Narcolepsy describing problem –Others as “chronic” – Source: http://www.medscape.org/viewarticle/478849 Fitzgerald Health Education Associates 7 Fitzgerald Health Education Associates 8 Insomnia Disorders (continued) Insomnia Disorders • Defined – Complaint of difficulty in falling asleep, Source: maintaining sleep (awakening frequently http://www.dsm5.org/File%20Library/Psychiatrists/Pract during the night), or an inability to easily ice/DSM/APA_DSM-5-Sleep-Wake-Disorders.pdf fall back asleep – Dissatisfaction with sleep – Significant negative impact on daytime functioning Fitzgerald Health Education Associates 10 Insomnia Disorders Insomnia Disorders (continued) (continued) • Dissatisfaction with sleep defined • Significant negative impact on daytime functioning defined – Difficulty initiating and/or maintaining sleep – Significant fatigue – Non-restorative sleep – Sleepiness – ≥3 nights per week for ≥3 months, – Poor concentration despite adequate opportunity to sleep – Low mood – Impaired ability to perform social, occupational or caregiving responsibilities • Not explained by other health issues Fitzgerald Health Education Associates 11 Fitzgerald Health Education Associates 12 Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. 2 Prior permission required for use of questions or course content. Sleep Medications in Primary Care Cognitive Behavioral The focus of this program is medications Therapy (CBT) for Insomnia used to induce/maintain sleep. Consider medications as an aid to gap while working with patient on CTB. Assumed that the NP has Resources: appropriately assessed the patient http://www.mentalhealth.va.gov/coe/cih- and that a sleep medication is a visn2/Documents/Provider_Education_Handouts/CBT_for_Inso prudent clinical action with risks mnia_Information_Sheet_for_BHPs_Version_3.pdf and benefits shared with patient http://www.sleepeducation.org/treatment-therapy/cognitive- behavioral-therapy Caffeine’s Pharmacokinetics One Culprit of Modern-day Life Clinical Significance? Caffeine • MW=194.19 • Lipophilic •T½ range=1.5−9 h •Cmax=~15−100 mins • Minimum first-pass effect • CYP 450 substrate 1A2 Source image: https://en.wikipedia.org/wiki/Caffeine – Source: http://books.nap.edu/openbook.php?isbn=0309082587 16 Fitzgerald Health Education Associates 16 True or false? Caffeine PK • When compared with a healthy • Common 1A2 inhibitors? 40-year-old adult, CYP 450 isoenzyme – Remember the “Cs” levels can drop by up to 30% in elders •Ciprofloxacin after age 70 years. • Cimetidine • Common 1A2 inducer? • CYP 450 1A2’s activity is influenced by – Nicotine the presence or absence of estrogen in women. – And remember to advise when cutting down… 17 Fitzgerald Health Education Associates 17 Fitzgerald Health Education Associates 20 Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. 3 Prior permission required for use of questions or course content. Sleep Medications in Primary Care Sleep Architecture Non-REM: Stages 1 and 2 Naturally-occurring Sleep’s 2 Stages •Stage 1 1. Non-rapid eye movement (NREM) – Easily awakened –Stage 1 − Transitional “muscle jump” –Stage 2 − Light sleep (hypnic myoclonia) –Stage 3 − Deep sleep •Stage 2 –Stage 4 − Deepest sleep – Heart rate slows, body 2. Rapid eye movement (REM) temperature drops – 50% of total sleep time Fitzgerald Health Education Associates 21 Fitzgerald Health Education Associates 22 Non-REM: Stage 3 Stage 4: “Deep Sleep” •Stage 3 •Stage 4 –Delta waves –Delta waves exclusively, (slow waves) difficult to arouse, –Moving to no eye movement or deeper sleep muscle activities –When interrupted, “groggy and disoriented” –Stage of bedwetting, night terrors or sleepwalking occur during deep sleep Fitzgerald Health Education Associates 23 Fitzgerald Health Education Associates 24 REM Sleep Sleep Stages 20% of Adult Sleep Movement Through 5 Stages • Rapid, irregular and • Adults actively shallow breathing move through the • Rapid eye jerks in sleep process from various directions NREM stages 1−4 • Temporary paralysis to REM of limb muscles – Complete cycle • Increased HR, BP typically 90−100 minutes • Penile erections – Complete 4−5 • Most vivid dreams cycles per night Fitzgerald Health Education Associates 25 Fitzgerald Health Education Associates 26 Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. 4 Prior permission required for use of questions or course content. Sleep Medications in Primary Care Sleep Stages Circadian Rhythm Movement Through 5 Stages (continued) • Biologic “internal clock” •Length of REM –Housed in sleep becomes suprachiasmatic nucleus progressively in anterior hypothalamus longer and time – Fully developed by age in deep sleep 25 years –Source: decreases http://www.howsleepworks.com/ho throughout w_circadian.html the night Fitzgerald Health Education Associates 27 Fitzgerald Health Education Associates 28 Sleep-Wake Homeostasis Potential Influence of Sleep Aids • The pressure to sleep on Sleep Architecture: – Also known as sleep drive Potential Increase in Stage 1, Stage 2 Sleep • Unable to overcome Potential Reduction in Stage 3, Stage 4, – With use of stimulants, can only mask REM Sleep need to sleep Consider as short-term therapy! – With medications, can mildly promote or enhance sleep drive Source: http://www.medscape.com/viewarticle/723907_2 Fitzgerald Health Education Associates 30 Pharmacology of Insomnia Treatment Pharmacology of Insomnia Treatment Therapeutic Approaches Therapeutic Approaches (continued) • Stimulate/activate sleep-promoting system • Suppress the wake-promoting systems –GABA –Histamine • Inhibitory neurotransmitter (NT) – Cholinergic • Main hypothalamic NT, projects to several sleep-regulating centers of the brain – Serotonin – Increase in GABA inhibits (“blocks”) the wake- –Orexin promoting chemicals –Melatonin Fitzgerald Health Education Associates 31 Fitzgerald Health Education Associates 32 Fitzgerald Health Education Associates. All rights reserved. Reproduction is prohibited. 5 Prior permission required for use of questions or course content. Sleep Medications in Primary Care In particular, for sleep medications T that induce sedation, what is the ½ medication’s half-life (T )? ½ • Time required for the amount of drug How much of the medication will be in the body to be reduced or eliminated on board upon AM awakening? by ½ Onset of action? • Also known as elimination or biological T½ Peak of action? –3−5 T½ needed to reach steady state –3−5 drug-free T needed to eliminate Reference: ½ PL Detail-Document, Comparison of Insomnia Treatments. drug from body Pharmacist’s Letter/Prescriber’s Letter. May 2012. Fitzgerald Health Education Associates 34 What % is left of original drug dose? True or false? •1 T½ •The T½ of a medication is a predictable – 50% left number regardless of the patient’s age, •2 T½ – 50% of 50%=25% left gender, and overall state of health.
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