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General Considerations
This lecture will cover medications commonly taken by sleep lab patients that are known to have effects on sleep
The purpose of this lecture is not to memorize the generic and trade name of every medication our patients may ever take!
General Considerations Medication classes that will be covered:
Sedatives and hypnoticsStimulantsPsychiatric medicationsPain medicationsAntiepilepticsRLS/PLMD medicationsCardiovascular medicationsRespiratory medicationsCold medications and antihistaminesRecreational drugs
General Considerations 3.1 billion prescriptions were written in
2002 in the US alone Nearly half of all Americans are currently
prescribed at least one medication Most patients seen at the sleep lab are
under the influence of prescribed medicationsIt’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
General Considerations
584 prescription and OTC drugs list sleepiness as a side effect
Of the 20 most commonly prescribed medications in the US, at least half are known to affect sleep
20 most commonly prescribed brand-name medications
20 most commonly prescribed generic medications
General Considerations The effects many medications have on
sleep are largely unknownEven highly controlled studies have
produced differing results
Several factors limit the understanding of how different medications affect sleep and wakefulness:Limited researchInconsistent findingsPopulation differencesAcute vs. chronic effects
General Considerations The more medications a patient is on,
the higher the chance of clinically significant interactions
Physicians should always be aware of a patient’s medications and instruct the patient and tech as to their use before and during the PSGAny changes to a patient’s regular
medication routine should be clearly indicated on the study order or history
General Considerations Abbreviations:
SOL – sleep onset latency○ Some charts will use “SL” instead
ROL – REM onset latency○ Some charts will use “RL” instead
TST – total sleep timeSWS – slow-wave sleepWASO – wake after sleep onsetEDS – excessive daytime sleepiness
I will try to give both generic and trade namesTrade names will always be capitalized
Sedatives and Hypnotics
Sedatives are prescribed to treat anxiety, and hypnotics are prescribed to treat insomniaNearly identical in how they function and are
often used interchangeably
Have a history of limited efficacy, serious side effects, addiction, and lethal toxicity in overdoseLong-term use can lead to tolerance and
actually cause insomnia
Sedatives and Hypnotics All classes bind to GABA receptors in
the brain, inhibiting internal and external influences from disrupting sleepBasically “protect” sleep from things such as
worries, noise, and painTreating OSA-induced EDS with sedatives
can decrease respiratory drive and increase prevalence of OSA, actually worsening sleep
Beware that the effects of multiple sedatives may be more than additive
Sedatives and Hypnotics
3 main categories of hypnotics:BarbituratesBenzodiazepinesNon-benzodiazepines
Barbiturates Widely used until the 1960s, but were often
abused and had a high danger of overdose Examples:
Trade name Generic name
Luminal phenobarbital
Nembutal pentobarbital
Quaalude, Sopor methaqualone
Doriden glutethimide
Placidyl ethchlorvynol
Nodudor methyprylon
Barbiturates Biggest effect seen on sleep is that they’re
very sedating Increase TST, decrease REM, increase
spindle frequency and density, increase SWSPhenobarbital (Luminal) may actually suppress
SWS
Can decrease respiratory drive and increase prevalence of OSA
May exacerbate respiratory failure in patients with COPD, CSA, or restrictive lung disease
Benzodiazepines Became available in the 1970s, and have less
overdose and abuse potential than barbiturates
Bind to a broad range of GABA receptors and have a widespread sedating effect
Examples:
Trade name Generic name
Ativan lorazepam
Klonopin clonazepam
Dalmare flurazepam
Valium diazepam
Xanax alprazolam
Halcion triazolam
Tranzene clorazepate
Benzodiazepines Tend to lose efficacy with prolonged use Decrease WASO, increase TST,
increase stages N1 and N2, increase spindle frequency/density, decrease SWS, decrease REMClonazepam (Klonopin) may actually
increase SWS
Are also sometimes used to treat PLMD Clonazepam (Klonopin) is also used to
treat REM behavior disorder
Benzodiazepines Have similar respiratory effects as
barbiturates:Can cause respiratory depression, causing or
worsening OSACan exacerbate respiratory failure in patients with
COPD, CSA, or restrictive lung disease
Withdrawal can cause REM rebound Flurazepam (Dalmare), diazepam (Valium),
and clorazepate (Tranzene) have almost 11 day half-livesEffects may be seen long after being discontinued
Non-benzodiazepines Bind preferentially to GABAA receptors
and have a less widespread effect than benzodiazepines
Examples:Trade name Generic name
Ambien zolpidem
Benadryl diphenhydramine (also an antihistamine)
Sonata zaleplon
Lunesta eszopiclone
Rozerem ramelteon
BuSpar buspirone
Non-benzodiazepines Have a relatively short half-life, and have the
fewest side effects of all hypnoticsBuspirone (BuSpar) in particular has been studied and
found to have no effects on sleep architecture or daytime alertness
Zolpidem (Ambien) and eszopiclone (Lunesta) have greatest sleep-inducing efficacy, but zaleplon (Sonata) has fewest side effects
Zaleplon (Sonata) may increase ROL and SWS Conflicting studies have shown that zolpidem
(Ambien) can either suppress or increase SWS No REM rebound occurs after discontinuing
Stimulants
Increase CNS activation to promote alertness
Used to treat narcolepsy, hypersomnia, ADHD, obesity, and even the common cold
Many of the same medications are used to treat both narcolepsy and ADHD
Stimulants
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
Example narcolepsy/hypersomnia/ADHD medications: Example appetite suppressants:
Stimulants Most have high potential for abuse and
can cause personality changes, tremor, hypertension, headaches, and GERD
Newer stimulants modafinil (Provigil) and armodafinil (Nuvigil) are distinct from the amphetamines and have a much lower abuse potentialNow usually the first route of treatment for
narcolepsy
Stimulants
Any medications that increase alertness have the risk of causing insomnia
Increase SOL, ROL, WASO, arousals, and stages N1 and N2
Decrease SWS, REM, and TST
Stimulants Common dose-dependent side effects
may also interfere with sleep:AnxietyHeadacheIrritabilityHeart palpitationsTremors
Sudden withdrawal from any stimulant substance may cause profound sleepinessBeware of how stimulant withdrawal may
affect MSLTs
Antidepressants
Four main classes:SSRIs and SNRIsTricyclicsMAOIsAtypical antidepressants
Each class affects neurotransmitters in different ways
Each has its own set of side effects, which range from stimulating to sedating
Antidepressants Most antidepressants affect the
neurotransmitters norepinephrine, serotonin, acetylcholine, and dopamineAll are known to play an important role in the
sleep-wake cycle
15% of those who take antidepressants report disrupted sleep or daytime fatigue
Many are sedating, but stopping them prior to a PSG is not always practical or safe
Almost all classes have been known to exacerbate PLMD
SSRIs and SNRIs Selective serotonin reuptake inhibitors
affect the neurotransmitter serotoninSNRIs affect both serotonin and
norepinephrine, and have similar sleep effects to SSRIs
Trade name Generic name
Prozac fluoxetine
Zoloft sertraline
Celexa citalopram
Lexapro escitalopram
Paxil paroxetine
Luvox fluvoxamine
Trade name Generic name
Cymbalta duloxetine
Effexor venlafaxine
Example SSRIs: Example SNRIs:
SSRIs and SNRIs Generally have the mildest side effects of
all antidepressants SSRIs tend to be stimulating, and can
cause mild-moderate insomniaFluoxetine (Prozac) is the most sleep-disruptive
Can also cause drowsiness in some individualsMostly seen with paroxetine (Paxil) and
fluvoxamine (Luvox)
Decrease TST, increase WASO, decrease REM, and increase PLMDFluoxetine (Prozac) can also decrease SWS
SSRIs and SNRIs Tend to be respiratory stimulants and
can improve OSA Can cause SEMs to occur during most
of the night, even long after cessation of drug useMost prevalent with fluoxetine (Prozac),
paroxetine (Paxil), and sertraline (Zoloft)Less prevalent with citalopram (Celexa) and
escitalopram (Lexapro)“Prozac eyes” are often so rapid that they
can easily be mistaken for REMs.
SSRIs and SNRIs MSLT of a patient taking 20mg
fluoxetine daily (30 seconds)
SSRIs and SNRIs Same patient and epoch (120 seconds)
SSRIs and SNRIs Most increase ROL and decrease REM by
about 30%Knowing this is important for correct interpretation
REM suppression was once believed to be an important part of treatment
Because of their stimulating effects, SSRIs and SNRIs can worsen REM behavior disorder
Despite the sleep disruption caused by these drugs, patients report sleeping better subjectively
Tricyclics Have a broader effect on neurotransmitters
Alter norepinephrine, histamine, and acetylcholine activity
Examples:
Trade name Generic name
Elavil amitriptyline
Norpramin desipramine
Pamelor nortriptyline
Sinequan doxepin
Tofranil imipramine
Vivactil protriptyline
Tricyclics
Mildly-moderately sedating Improve sleep but cause EDS
Protriptyline (Vivactil) less sedating than others
Increase TST, decrease WASO, increase SWS, decrease REM, and increase PLMD
MAOIs
Monoamine oxidase inhibitors are the oldest antidepressants, and have greatest effects on sleep
Examples:
Trade name Generic name
Marplan isocarboxazid
Nardil phenelzine
Parnate tranylcypromine
MAOIs
Tend to be sedating, but can also cause insomnia
Suppress REM, but effect is more sustained than with SSRIs
Cause increased WASO, decreased TST, and markedly reduced REM
Atypical Antidepressants
Work through a variety of mechanisms and affect multiple neurotransmitters, so effects on sleep are less known
Examples:
Trade name Generic name
Desyrel trazodone
Serzone nefazodone
Remeron mirtazapine
Wellbutrin bupropion
Atypical Antidepressants Trazodone (Desyrel) and nefazodone
(Serzone) are considered serotonin antagonist and reuptake inhibitorsCan cause EDS, but may improve sleepIncrease TST and SWSConflicting results on REM effects
Mirtazapine (Remeron) is a norepinephrine and specific serotonin antagonistAlso causes sedation and EDS but enhances
sleepIncreases TST, decreases SOL
Atypical Antidepressants Bupropion (Wellbutrin), as well as the
tricyclic protryiptiline (Vivactil), are norepinephrine and dopamine reuptake inhibitorsMost alerting of antidepressants, and can
cause insomniaActually increase REM and don’t exacerbate
PLMD
St. John’s Wort is an herb taken by some for depressionHas been shown to increase SWS
Antidepressants
Antipsychotics Lithium has traditionally been the drug of
choice for treating bipolar disorderTrade names include Cibalith, Eskalith,
Lithane, and LithobidThe seizure medication divalproex
(Depakote) is also prescribed to treat the manic phase of bipolar disorder
Tends to be sedating, causing EDS but improving sleep
Reduces REM, increases SWS and the prevalence of arousal disorders such as night terrors and somnambulism
Antipsychotics Common antipsychotics which are prescribed
for schizophrenia, other psychoses, and occasionally bipolar disorder:
Characterized mainly by their sedative effectChlorpromazine (Thorazine) can cause an increase in
SWS; diffuse, slower activity in the EEG; and a decrease in spindle activity
Trade name Generic name
Thorazine chlorpromazine
Haldol haloperidol
Mellaril thioridazine
Risperdal risperidone
Seroquel quetiapine
Zyprexa olanzapine
Chantix
Smoking cessation aid that works by blocking nicotine receptors in the brainMakes smoking have less of a pleasurable
effect
Known to cause insomnia and vivid, unusual dreams
Watch for symptoms of stimulant withdrawal
Pain Medications Many prescription pain medications are
either narcotics or barbiturates Are often VERY sedating Examples:
Trade name Generic name
Vicodin, Lortab hydrocodone
Darvocet propoxyphrene
Demerol meperidine
Methadone methadone
Percocet oxycodone
Norgesic orphenadrine
--- morphine
--- codeine
Pain Medications
Decrease SOL and WASO, increase TST, may decrease SWS and REM
May decrease alpha, and can cause slower, diffuse EEG
Can depress respiratory system and increase severity of OSA
Have been known to cause confusion in elderly patients
Aspirin (ASA or acetylsalicylic acid) in an NSAID taken for pain or to prevent heart attackMain effect on sleep is a decrease in SWS
Antiepileptic and Neuromuscular Medications
Prescribed to treat epileptic seizures as well as muscle pain caused by injury
Include both muscle relaxants and anticonvulsants
Example muscle relaxants:
Trade name Generic name
Flexeril cyclobenzaprine
Soma carisoprodol
Antiepileptic and Neuromuscular Medications Example anticonvulsants:
Topiramate (Topamax) is also prescribed to treat migraine headaches
Divalproex (Depakote) is also prescribed for bipolar disorder
Trade name Generic name
Depakote divalproex
Dilantin phenytoin
Neurontin gabapentin
Tegretol carbamazepine
Topamax topiramate
Keppra levetiracetam
Antiepileptic and Neuromuscular Medications
Tend to be very sedating Phenytoin (Dilantin) may increase
SWS, decrease alpha, and cause diffuse, slower EEG activity
Anticonvulsants also tend to reduce REM
RLS/PLMD Medications Restless leg syndrome and periodic limb
movement disorder occur in up to 15% of the populationOften occur comorbidly
Frequency of RLS/PLMD increases with age
Historically treated with benzodiazepines, particularly clonazepam (Klonopin)
Newer drugs affect mainly dopamine receptors
RLS/PLMD Medications Examples:
Carbidopa and levodopa (Sinemet) have been reported to induce vivid dreams or nightmares, hallucinations, vocalizations, and somnambulism
○ Rarely used due to the potential for tachyphylaxis and augmentation of symptoms
Trade name Generic name
Sinemet carbidopa/levodopa
Permax pergolide
Mirapex pramipexole
Requip repinirole
Eldepryl selegiline
RLS/PLMD Medications Tend to reduce SWS and REM
Conflicting studies have shown levodopa either increases or decreases REM
Common side effects are nausea and headache, which may also interfere with sleep
Usually improve sleep quality and decrease arousals
Pramipexole (Mirapex) was originally developed to treat Parkinson’s DiseaseMay cause sudden attacks of uncontrollable
sleepiness in some individuals
Antihypertensives Different classes have
different methods of action, but the desired effect is to lower blood pressureClasses include
diuretics, beta-blockers, alpha-beta-blockers, ACE inhibitors, calcium channel blockers, and vasodilators
Examples:
Trade name Generic name
Inderal propranolol
Tenormin atenolol
Lopressor metoprolol
--- pindolol
--- reserpine
Catapres clonidine
Coreg carvedilol
Cozaar losartan
Privinil, Zestril lisinopril
Antihypertensives
May suppress REM and increase SWS Have been reported to cause insomnia,
nightmares, vivid dreams, hallucinations, vocalizations, somnambulism, and EDSMost sleep effects seen with clonidine
(Catapres)Fewest sleep effects seen with atenolol
(Tenormin)
Diuretics
Work by stimulating the kidneys to excrete more sodium into the urineThis draws excess fluid out of cells so it can
be eliminated from the body
Although mainly prescribed to treat high blood pressure, are also commonly used to treat edema caused by heart failure, kidney disease, or liver cirrhosis
Diuretics Examples:
The main effect on sleep is excessive urination, which can cause frequent nocturnal awakenings
A possible side effect is potassium deficiency, which can cause nocturnal cramping of the calf muscles
Trade name Generic name
Bumex bumetanide
Zaroxolyn metolazone
Aquazide, Microzide hydrochlorothiazide (HCTZ)
Lasix furosemide
Hypolipidemics
Work to lower cholesterol by blocking its production by or absorption into the body
Along with antihypertensives, are some of the most common drugs taken by sleep lab patients
Hypolipidemics Examples:
No consistent findings on sleep and wakefulness Insomnia reported rarely with atorvastatin (Lipitor) and
lovastatin (Mevacor, Altoprev)
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
Antiarrhythmatics Work by slowing down the heart rate to
treat fast arrhythmias such as atrial fibrillation, atrial flutter, ventricular fibrillation, and ventricular tachycardia
Includes a vast array of medications that work through a variety of mechanisms
How they affect sleep has been largely inconclusive
Atrialfibrillation
Antiarrhythmatics
Examples:
Trade name Generic name
--- quinidine
Tambocor flecainide
Rythmol propafenone
Ethmozine moricizine
Calan verapamil
Cardizem diltiazem
Procardia nifedipine
Lanoxin digoxin
Coumadin warfarin
Antiarrhythmatics
Most common complaint is daytime fatigue
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!
Respiratory Medications The most common respiratory conditions
that require long-term medication are asthma and COPD
Examples:
Theophylline (Aerolate) is chemically related to caffeine, and doses are usually high enough to disrupt sleep
Trade name Generic name
Proventil, Ventolin albuterol
Maxair pirbuterol
Aerolate theophylline
--- aminophylline
Atrovent ipratropium
Respiratory Medications Work by stimulating the central nervous
system, which can cause insomnia, especially if taken shortly before bedtime
Corticosteroids like prednisone are prescribed for asthma as well as for joint pain and inflammationCan cause jitters and insomniaIncrease appetite and can cause fluid
retention○ Any weight gain can increase the risk of OSA
Decongestants Work by reducing blood flow to the mucus
membranes so that less mucus is produced
Examples include oxymetazoline (Afrin), phenylphrine (Contac-D, Sudafed PE), and phenylpropanolamine (Phenyldrine), but most common decongestant is pseudoephedrine
Pseudoephedrine can be found in:Actifed, Advil Cold & Sinus, Aleve Cold & Sinus,
DayQuil, NyQuil, Dimetapp, Robitussin, Sudafed, Triaminic, Tylenol Cold, and most drugs that end in “-D”
Decongestants
Most cause some degree of CNS stimulation, which may result in insomniaParticularly true w/ drugs containing
pseudoephedrine
Pseudoephedrine has been reported to induce hallucinations, vocalizations, and somnambulismEphedrine in brain = adrenaline in body
Antihistamines Work by blocking histamine, a
neurotransmitter that’s responsible for allergy symptoms but that also promotes wakefulness
Examples:Trade name Generic name
Zyrtec cetirizine
Astelin azelastine
Benadryl diphenhydramine
Allegra fexofenadine
Claritin, Alavert loratadine
Clarinex desloratadine
Dramamine dimenhydrinate
Antihistamines Tend to be sedating, and can cause
drowsinessDiphenhydramine (Benadryl) also used as a
sleep aid
Shorten SOL, decrease REM, decrease arousals, and increase TSTNewer antihistamines such as cetirizine
(Zyrtec) have fewer side effects
Taking antihistamines before bed can result in a dry mouth and drowsiness upon awakening
Cold Medications and Antihistamines 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
Most cold medications
are available OTC, so
they’re readily
accessible to patients
Alcohol
Affects GABA receptors in the brain Consumed close to bedtime, can
initially be very sedatingAt least 25% of insomniacs report
using alcohol as a sleep aidThose with greater trouble sleeping
are more likely to have diagnosable alcoholism
Alcohol In the first half of the night, NREM is
increased and REM is reduced In the second half of the night,
withdrawal symptoms occur, particularly in heavy drinkersShallow, disrupted sleep; late-night REM
rebound; nightmares; sympathetic nervous system arousal; tachycardia; sweating
Decreases SOL and REM, increased WASO (especially in second half of the night)
Alcohol Relaxes muscles of the upper
airwayThis can cause or worsen snoring and
OSA Alcoholics often report insomnia,
hypersomnia, circadian rhythm disturbances, and parasomniasRecovering alcoholics may have
abnormal sleep patterns for years after becoming sober
Caffeine Binds to adenosine receptors
in the brain, blocking the
sleep-inducing neurotransmitter
adenosine from having an effect Consumption of large amounts may lead
to restlessness, nervousness, excitement, insomnia, flushed face, and GI problems1000mg can produce insomnia, dyspnea,
delirium, and arrhythmiasDoses above 5000mg can be fatal
Caffeine Because it’s so prevalent,
it’s easy to ingest large amounts unintentionally.
Caffeine Chronic daily use leads to tolerance and
dependence Half-life is 3-7 hours, so even caffeine
consumed in the afternoon can disrupt sleep at nightEffect more pronounced in children, pregnant
women, the elderly, and people with hypothyroidism
Increases arousals, decreases TST and SWS Beware that caffeine is present in many
headache medications (e.g., Excedrin Migraine)
Nicotine Approximately 23% of adults in the US use
nicotine products Conflicting reports on how it affects sleep
May be sedating in lower doses but altering in higher doses
Also conflicting reports on how it affects REMSome reports have shown an increase while
others have shown a decrease
Nicotine patches deliver small doses of nicotine into the bloodstream around the clockCan cause insomnia and disturbing dreams
Other Recreational Drugs Marijuana (tetrahydracannibinol)
Effects on sleep very similar to alcoholMay induce sleepiness
OpiatesMay induce sleepiness but cause
REM suppressionCan increase SWS and prevalence of
night terrors and somnambulism
Other Recreational Drugs Amphetamines
Can be useful as prescription stimulants, but some forms (particularly methamphetamine) have a high abuse potential when used as recreational drugs
Effects tend to be dose-dependent, so recreational users may have even more disturbed sleep than those who take prescription amphetamines as prescribed
Helpful Hints Drugs that can cause nightmares or
vivid dreams:Antihistamines, benzodiazepines, beta-
blockers, dopaminergics, isotretinoin, ofloxacin, naproxen, thiothixene, verapamil, varenicline
Drugs that can cause excessive daytime sleepiness:Antihistamines, antihypertensives, anti-
nausea agents, dopamine agonists, antiepileptics
Helpful Hints
Drugs that can cause insomnia:Amphetamines,
antiretrovirals, anti-influenza drugs, cholesterol-lowering drugs, corticosteroids
Helpful Hints Following are some tips for
recognizing the class of unfamiliar drugs
Some precautions:These only work on generic names, as
trademarked drugs are often named arbitrarily and for marketing purposes
These tips aren’t applicable in all cases – they’re a general trend, not a hard and fast rule
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" Cholesterol-lowering statins
End in “-buterol” or “-phylline” Respiratory medications
Conclusion The vast array of substances available
to our patients will continually challenge our ability to interpret PSGs
As technologists, we must remain aware of the latest trends in the use and abuse of various drugs
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
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 protected].
Thank You.
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