Offending drugs

• Stimulants (ADHD meds, decongestants, appetite suppressants, weight loss drugs, caffeine), alcohol, MAO-B inhibitor, bupropion (avoid taking at bedtime, tends to be more activating), Fluoxetine (longest half-life of all SSRI), steroids, drugs causing urinary retention or nocturia (diuretics), too much levothyroxine.

 

The Zs

• Drugs: zolpidem, zaleplon (Sonata), eszopiclone (Lunesta), C-IV controlled substance.

• MOA: enhances activity of GABA (an inhibitor neurotransmitter that causes sedation), similar side effects to benzos, maybe that’s why they are both C-IV.
• Risk of fall in elderly, non-drug intervention that promotes sleep hygiene is still the preferred treatment for insomnia.
• Do not take with alcohol, may cause parasomnias, "pins and needle" on skin.
• Zolpidem: sleep walking, new lower dosing guideline for women, Lunesta: long half-life keeps you asleep, but it increases the risk of morning residual sedation, many patients notice a bitter taste the morning after, Sonata: short half-life, good for early night awakening

 

Others

• Ramelteon (Rozerem): Melatonin receptor agonist; Do not take w/ fatty food
• Doxepin (Silenor): Tricyclic, used for difficulty staying asleep.
• Belsomra (Suvorexant),C-IV: An orexin receptor antagonist used to treat insomnia

 

Sleep apnea

• 50% of patients with heart failure may also have sleep apnea, either obstructive or central. 
• Continuous positive airway pressure (CPAP) is beneficial in patients with CV disease and obstructive sleep apnea. In patients with obstructive sleep apnea, CPAP has been shown to reduce apnea, improve sleep quality, and improve oxygenation. 
• In patients with heart failure, NYHA class II through IV and central sleep apnea, adaptive sero-ventilation has been shown to cause harm.
• Encourage patients with daytime sleepiness or signs of sleep apnea (e.g., snoring, episodes of not breathing while sleeping) to have this evaluated.

 

 

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