KIDAPAWAN’S DOCTOR COLLEGE, INC.

DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH

MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

INTRODUCTION TO ADVERSE DRUG REACTION

➢ A response to a drug that is noxious and

PHARMACOTHERAPY unintended: occurs at doses normally used in
humans the result of the drug’s intrinsic
PHARMACOTHERAPY properties and CANNOT be prevented.

➢ the use of medications to treat diseases and PHARMACOVIGILANCE

disorders
➢ can be pharmacologic or non-pharmacologic ➢ Continuous monitoring of unwanted effects
and other safety related aspects of the marketed
drugs.

PHARMACOEPIDEMIOLOGY

➢ Use and effects of drugs in large number of

people.

1. Introduction/Background
2. Epidemiology
3. Etiology
4. Pathophysiology
5. Clinical Presentation/ Manifestation
6. Evaluation
7. Treatment/ Management
8. Desired Outcomes
9. Therapeutic Considerations
10. Evaluation of therapeutic outcomes AMS Program aims to:
11. Conclusions
12. Prognosis 1. Promote rational and optimal antimicrobial therapy;
2. Improve patient outcomes and decrease healthcare costs by
Therapeutic Guidelines reducing unnecessary antimicrobial use, adverse drug
events, and mortality and morbidity from infections (including
➢ Clear, concise, independent and evidence- secondary infections by resistant pathogens);
3. Foster awareness on the global and country situation on the
based recommendations about patient
threat of AMR and the compelling need to address it;
management that have been developed 4. Effect positive behavior and/or institutional changes through
➢ Reduces chance of error by establishing educational and persuasive interventions towards improving
standard protocol for how care is carried out. the use of antimicrobials by the prescribers, dispensers, other
healthcare professionals, and patients;
Clinical Pharmacist’s Interventions 5. Establish multi-disciplinary leadership and commitment,
clinical governance and accountability in antimicrobial
management to ensure that interventions are sustainable and
• CORE
well-supported with necessary technical and financial
• FARM resources;
• SOAP 6. Create an environment where healthcare professionals are
supported with monitoring tools and systems to implement
Medication Errors antimicrobial management;
7. Conduct research aiming to analyze the progress and
➢ Any preventable event that may lead to challenges on implementing hospital AMS Program; and,
8. Prevent the spread or slow down the emergence of AMR.
inappropriate medication use or cause harm
to the patient while the medication is in control Regulated/ Restricted Antibiotics:
of health care professional, patient or consumer.
➢ Causes extended hospital stays, additional Last resort drugs – use is limited to serious infections
treatment and malpractice litigation. to prevent resistance.
1. Unauthorized Drug Error
2. Omission Error
3. Extra Dose Error
4. Wrong Dose Error
5. Wrong Dosage Form
6. Wrong Route
7. Wrong Time

ADVERSE DRUG EVENT

➢ An injury resulting from medical intervention

related to a drug includes ADRs but also
includes preventable reactions, including
those caused by human error.
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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

you (as a clinical pharmacist) going to

assume responsibility for?
3. Therapeutic assessment
a) Determine which problems are active or
require maintenance therapy
b) Using appropriate laboratory results, physical
findings, and subjective patient reports,
assess drug efficacy of current regimen.
c) Assess potential contributing causes (e.g.
non-compliance, change in renal status,
change in dietary habits, disease
- PHARMACISTS’ WORKUP progression, etc)
d) Determine presence of risk factors which
DRUG THERAPY (PWDT) may place a patient at increased risk for
adverse drug effects or poor therapeutic
Pharmacists’ Workup of Drug Therapy (PWDT) response (e.g., increased ulcerogenic effects
of NSAID’s in elderly women, ulcer relapse
➢ The PWDT is a thought process which is meant rate in smokers)
to serve as a systemic guideline for the 4. Rank all drug-related
documentation of clinical pharmacy activities a) Rank most serious or immediate problem
and is NOT intended as a form to be completed highest.
on each patient seen by the pharmacist. 5. Desired therapeutic outcomes
a) Define measurable outcomes for the use of
STEPS: each drug or drug combination (e.g., blood
1. Collect data and identify issues with the pressure < 140/90, Blood Glucose <
patient’s drug therapy 140mg/dl).
a) Age, sex, race, Ht, Wt, 6. Therapeutic alternatives
b) CC: Chief complaint a) List acceptable drug therapies for each
c) HPI: History of present illness problem.
d) PMH: Past medical history b) Consider the following factors during drug
e) Problem List: Current Diagnostic list selection:
f) Med Hx: Current medication list, past I) altered physiologic
medications, OTC drug use, and/or prn drug parameters (e.g., renal, liver
use disease)
g) Allergies: Drug allergies/sensitivities (include II) altered pharmacokinetic
description) parameters (e.g., Vd,
h) Social Hx: Smoking/alcohol/recreational drug clearance)
use history III) presence of adverse drug
i) Compliance: Assessment of compliance - is reaction risk factors (e.g.
problem related to improper use? age, influence of
j) Review of Systems: hypokalemia on digoxin
1. GEN: general appearance and health status toxicity)
2. VS: blood pressure, heart rate, temperature, IV) concurrent illnesses (e.g.,
respiration rate concurrent CHF, diabetes,
3. HEENT: head, ears, eyes, nose, throat asthma, etc)
4. CV/RESP: cardiopulmonary exam V) concurrent drug therapies
5. ABD: abdomen (i.e., potential drug-drug
6. EXT: extremities interactions)
7. NEURO: neurological exam c) Anticipate problems and list alternative drug
8. PSYCH: mental status exam therapy solutions
7. Pharmacist’s drug recommendation and
2. Organize patient specific-data and create individualization
drug-related problem list a) For each problem, list the drug of choice and
a) Attempt to cluster signs and symptoms into an individualized patient-specific drug
recognisable patterns. administration regimen
b) Review side effects of each medication to 8. Therapeutic drug monitoring
determine iatrogenic potential. a) Determine what information is needed to
c) Determine if onset of chief complaint is ensure that the recommended drug therapy
temporally related to start of new drug. is producing the desired effect.
d) Determine which problems are you going to 9. Patient education and follow-up
solve for this patient? Which problems are a) Determine frequency and duration of drug
monitoring.
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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

b) Document important aspects of the patient o Involves the basal forebrain, brain stem,
counseling session. thalamus, and hypothalamus.
o Key neurotransmitters: GABA,
adenosine.
• REM Sleep Control:
Pharmacotherapy of Central Nervous o Activated by cholinergic cells in various
System Disorders: brain regions.
o Suppressed by the dorsal raphe nucleus
SLEEP DISORDERS and locus coeruleus (noradrenergic
systems).
• Wakefulness Neurochemistry:
Introduction o Dopamine, norepinephrine,
acetylcholine, histamine, and
• Approximately 70 million Americans suffer with a
neuropeptides play a role.
sleep-related problem, and as many as 60% of
those experience a chronic disorder. POLYSOMNOGRAPHY (PSG)
• In a study by the National Institute on Aging, of
9,000 patients aged 65 years and older, more • Definition: Primary diagnostic tool for sleep
than 80% report a sleep-related disturbance. disorders.
• Sleep Cycle, showed from its survey that Filipino • What it Measures:
adults only get an average of six hours and 30 o Brain waves, eye movements, muscle
minutes per day of sleep. activity, heart rate, and breathing.
• According to a survey previously, Filipinos have • Home Sleep Monitoring: Increasingly used for
one of the highest rates of sleep deprivation in diagnosing conditions like sleep apnea.
Asia; 46% of Filipinos do not get enough sleep.
Classification of Sleep Disorders (DSM-5)
SLEEP CYCLES
• Insomnia Disorder
• Non-Rapid Eye Movement (NREM) Sleep: • Hypersomnolence Disorder
o Three stages: Progresses from light to • Narcolepsy
deep sleep. • Breathing-Related Sleep Disorders
▪ Stage 1: Transition between • Circadian Rhythm Sleep Disorders
wakefulness and sleep. • Non-REM Sleep Arousal Disorders
▪ Stage 2: Light sleep; deeper • Nightmare Disorder
relaxation. • REM Sleep Behavior Disorder
▪ Stage 3: Deep sleep (Delta • Restless Legs Syndrome
sleep); slow-wave activity.
• Substance- or Medication-Induced Sleep
• Rapid Eye Movement (REM) Sleep:
Disorder
o Brain becomes highly active.
o REM occurs in bursts with increased INSOMNIA
cerebral blood flow and dreaming.
o REM cycles lengthen later in the sleep ➢ Difficulty initiating or maintaining sleep with
period. daytime consequences.
➢ the most common complaint in general medical
practice as it frequently causes distress, due to
CIRCADIAN RHYTHM the fear or a feeling of not being able to fall asleep
at bedtime, leading to impaired work-related
• Development Over Time: productivity because of daytime fatigue or
o Newborns sleep up to 20 hours daily. drowsiness
o By age 3, the sleep-wake cycle becomes o Chronic insomnia: Duration of 3
circadian. months or more, occurring at least 3
• Changes Across Lifespan: times per week.
o Delta sleep declines from childhood to
Epidemiology:
adolescence.
o Sleep becomes more fragmented with ➢ Primary insomnia usually begins in early or
age, leading to lighter sleep in the elderly. middle adulthood and is rare in childhood or
• Suprachiasmatic Nucleus: Controls the body's adolescence
internal clock. ➢ Affects 33-50% of adults short-term, with chronic
insomnia seen in 9-12%.
NEUROCHEMISTRY OF SLEEP
➢ Women report insomnia twice as often as men.
• NREM Sleep Control: ➢ Forty percent of individuals with insomnia also
have a concurrent psychiatric disorder (anxiety,
depression, or substance abuse) and a significant
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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

percentage of those with insomnia use restless legs syndrome (RLS), periodic limb
nonprescription drugs or alcohol to self-treat movement disorder, and sleep apnea.

Etiology: Desired Outcomes

➢ The goals of treatment of insomnia are to correct

the underlying sleep complaint, consolidate
sleep, improve daytime functioning and
sleepiness, and avoid adverse effects from
selected therapies.
➢ Drug therapy should be used in the lowest
possible dose, for the shortest possible time
period.

General Approach to Treatment

➢ Therapeutic management of insomnia is initially

based on whether the individual has
experienced a short-term or chronic sleep
disturbance.
➢ Clinical history should assess the onset, duration,
and frequency of the symptoms; effect on
daytime functioning; sleep hygiene habits; and
history of previous symptoms or treatment.
➢ Management of all patients with insomnia should
include identifying the cause, patient education
on sleep hygiene, and stress management.
➢ Any unnecessary pharmacotherapy that may
worsen insomnia should be eliminated.

Short-Term Insomnia Treatment

• Cause: Usually triggered by acute stressors.

• Approach:
o Focus on good sleep hygiene.
o Careful use of sedative-hypnotics if
Diagnosis of chronic insomnia disorder include the necessary.
following three conditions: • Outcome: Expected to resolve quickly.
1. difficulty in sleep initiation or maintenance Chronic Insomnia Treatment
2. adequate opportunity to sleep
3. presence of daytime consequences due to • Detailed Assessment:
difficulty sleeping o Investigate underlying medical causes.
• Treatment:
Differential Diagnosis o Nonpharmacologic therapies preferred.
o Consider sedative-hypnotics with caution
➢ Insomnia is considered to be an endogenous
if necessary.
disorder caused by either a neurochemical or a
• Goal: Long-term management with minimal
structural disorder affecting the sleep–wake
medication reliance.
cycle.
➢ Individuals with primary insomnia can be light Nonpharmacologic Therapy for Insomnia
sleepers who are easily aroused by noise,
temperature, or anxiety • Education:
➢ Primary insomnia is a “hyperarousal state,” in that o Teach patients about normal sleep
insomnia patients have increased metabolic rates patterns.
compared with controls and thus take longer to o Emphasize habits for maintaining good
fall asleep. sleep hygiene.
➢ A complete diagnostic examination should be • Cognitive Behavioral Therapy (CBT):
completed in these individuals and should include o Proven effective for managing insomnia,
routine laboratory tests, physical and mental especially in older adults.
status examinations, as well as ruling out any o Techniques include stimulus control,
medication- or substance-related causes. sleep restriction, and relaxation therapy
➢ Other sleep disorders that can have a similar • Cognitive Behavioral Therapy (CBT)
presentation should be ruled out, including Techniques
o Stimulus Control Therapy:
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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

▪ Strengthen the association o Trazodone: Common for insomnia with

between bed and sleep. substance abuse risk; side effects
o Sleep Restriction: include sedation and orthostasis
▪ Limit time in bed to improve
sleep efficiency. SUVOREXANT
o Relaxation Therapy:
• Mechanism: Dual orexin receptor antagonist
▪ Focus on techniques that reduce
(turns off wake signaling)
mental and physical tension.
• Dose: 10-20 mg at bedtime
o Cognitive Therapy:
• Side Effects: Somnolence, sleep paralysis,
▪ Address negative thoughts
narcolepsy-like symptoms
about sleep.
o Paradoxical Intention & Biofeedback: • Caution: Can worsen depression and trigger
▪ Encourage reverse psychology suicidal thoughts
to reduce anxiety about sleep. RAMELTEON
▪ Use biofeedback to improve
relaxation. • Mechanism: Melatonin receptor (MT1, MT2)
agonist
• Indication: Sleep-onset insomnia
• Dose: 8 mg at bedtime
• Side Effects: Headache, dizziness, somnolence
• Advantages: Not a controlled substance;
effective for sleep-onset issues in COPD and
sleep apnea

VALERIAN

• Mechanism: May increase GABA concentration

• Dose: 300-600 mg or 2-3 g dried valerian root in
tea
• Indication: Herbal remedy for insomnia

BENZODIAZEPINE RECEPTOR AGONISTS (BZDRAS)

• Types: Nonbenzodiazepine GABA agonists and

traditional benzodiazepines
• Mechanism: Bind to GABAA receptors,
enhancing GABAergic transmission
• Properties:
Pharmacologic Therapy
o Traditional Benzodiazepines:
ANTIHISTAMINES Sedative, anxiolytic, muscle relaxant,
anticonvulsant
• Agents: Diphenhydramine, Doxylamine, o Nonbenzodiazepines: Primarily
Pyrilamine sedative
• Indications: Mild insomnia
• Limitations: Watch out for:
o Tolerance to sedative effects develops o Anaphylaxis
quickly o Facial angioedema
o Anticholinergic side effects (especially in o Complex sleep behaviors (e.g., sleep
the elderly) driving, phone calls, sleep eating)
o Less effective than benzodiazepines

ANTIDEPRESSANTS

• For Nonrestorative Sleep: Particularly useful for

patients with depression, pain, or substance
abuse risk
• Agents:
o Doxepin (low dose): FDA-approved for
sleep maintenance insomnia
o Amitriptyline, Doxepin, Nortriptyline:
Effective but with significant side effects
o Mirtazapine: Sedating, but causes
daytime sedation and weight gain

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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

BENZODIAZEPINE HYPNOTICS Other Considerations

• Mechanism: Reduce sleep latency, increase • Advantages of Nonbenzodiazepines: Less

total sleep time by increasing stage 2 sleep, withdrawal, tolerance, and rebound insomnia
decreasing delta sleep • No Active Metabolites: Minimal drug
• Contraindications: Pregnancy, untreated sleep accumulation with prolonged use
apnea, history of substance abuse
• Patient Instructions: Avoid alcohol and other SLEEP APNEA
CNS depressants Types of Sleep Apnea:
Adverse Effects of Benzodiazepines: • Central Sleep Apnea (CSA): Impaired
• Dose-Dependent Side Effects: respiratory drive
o Daytime sedation • Obstructive Sleep Apnea (OSA): Upper airway
o Psychomotor incoordination collapse
o Cognitive deficits • Mixed Sleep Apnea: Combination of CSA and
• Tolerance and Anterograde Amnesia: OSA
Reported with short-acting agents Diagnosis
• Rebound Insomnia: Can occur with abrupt
discontinuation • Polysomnography (PSG): Used to diagnose
• Older Patients: Prolonged half-lives, increased and quantify sleep apnea
risk of falls, cognitive impairment • Respiratory Disturbance Index (RDI):
o Mild: 5-15 episodes/hour
NONBENZODIAZEPINE GABAA AGONISTS
o Moderate: 15-30 episodes/hour
• Agents: Zolpidem, Zaleplon, Eszopiclone o Severe: More than 30 episodes/hour
• Mechanism: Selectively bind to GABAA OBSTRUCTIVE SLEEP APNEA (OSA)
receptors, inducing sleep
• Advantages: Less disruptive to sleep stages, • Causes: Neck obesity, narrow airway, polyps,
fewer side effects compared to benzodiazepines enlarged tonsils
1. Zolpidem • Symptoms: Witnessed apneas, gasping,
• Duration: 6-8 hours snoring, daytime sleepiness, hypertension
• Effects: Reduces sleep latency, • Complications: Linked to cardiovascular and
nocturnal awakenings, increases total cerebrovascular morbidity and mortality.
sleep time
• Formulations: Sustained-release, Treatment Goals
sublingual, reduced-strength for middle- • Primary Goals: Alleviation of sleep-disordered
of-the-night dosing breathing, prevention of complications
• Side Effects: Drowsiness, amnesia, • Approach: Nonpharmacologic therapies
dizziness, headache, GI issues, sleep preferred; avoid medications that worsen sleep
eating.
2. Zaleplon Nonpharmacologic Therapy
• Onset: Rapid, with a 1-hour half-life
• Positive Airway Pressure (PAP):
• Effects: Decreases time to sleep onset,
o CPAP: Continuous positive airway
no effect on nighttime awakenings or
pressure
total sleep time
o AutoPAP: Auto-titrating positive airway
• Advantages: No next-day psychomotor
pressure
effects, useful for middle-of-the-night
o Improves blood pressure control
awakenings
• Weight Reduction: Recommended for
• Dose: 10 mg (adults), 5 mg (elderly)
overweight/obese patients
3. Eszopiclone
• Surgery: Uvulopalatopharyngoplasty,
• Effects: Reduces time to sleep onset,
tracheostomy (in severe cases)
increases total sleep time and sleep
quality Other Therapies
• Duration: 6 hours
• Common Side Effects: Somnolence, • Positional Therapy: Effective for positional OSA
unpleasant taste, headache, dry mouth • Oral Appliances: Advance lower jaw and keep
• Use: Approved for long-term use (up to 6 tongue forward to open airway
months) • Barriers to PAP Adherence: Ill-fitted mask,
nasal dryness

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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

Pharmacologic Considerations o Cataplexy: Sudden loss of muscle tone,

triggered by emotion
• No Drug Therapy for OSA o Hallucinations: Hypnagogic (falling
• Avoid CNS Depressants: Alcohol, hypnotics, asleep) or hypnopompic (awakening)
and drugs that promote weight gain worsen OSA o Sleep paralysis: Conscious but unable
• Wake-Promoting Medications: Modafinil and to move
Armodafinil for residual daytime sleepiness
(EDS) Mechanism and Causes

Evaluation of Outcomes • Cause: Loss of hypocretin-orexin

neurotransmitter function in the brain
• Reevaluation: After 1-3 months of treatment for • Role of Autoimmunity: Hypocretin-producing
improvement in alertness and daytime symptoms cells destroyed in 75% of cases
• PAP Adherence: Monitor with compliance meter • Genetic Component: 3% of patients have a first-
• Repeat PSG: If symptoms persist despite degree relative with narcolepsy
treatment • Environmental Factors: May play a role, onset
in adolescence or adulthood
CENTRAL SLEEP APNEA (CSA)
Nonpharmacologic Treatment
• Characteristics: Absence of airflow with no
activation of inspiratory muscles • Patient Counseling: Education to alleviate
• Causes: Autonomic nervous system lesions, high misconceptions
altitudes, opioid abuse, heart failure • Good Sleep Hygiene: Encouraged for all
• Treatment: Acetazolamide, Theophylline patients
(limited efficacy) • Scheduled Naps: Two or more 15-minute naps
o Induces a metabolic acidosis that can refresh individuals
stimulates respiratory drive
Pharmacologic Treatment Goals
NARCOLEPSY
• Objective: Reduce symptoms that impair quality
Overview of life
• Treatment Focus:
• Prevalence: Affects 0.03%-0.06% of adult o Excessive daytime sleepiness (EDS)
Americans o REM sleep abnormalities
• Gender Distribution: Equal or slightly higher in
men
• Common Onset: Second decade of life, worsens
in third and fourth decades

Clinical Presentation

• Symptoms:
o Excessive daytime sleepiness (EDS)
o Disrupted nighttime sleep
o REM sleep abnormalities: sleep
paralysis, cataplexy, hallucinations

Diagnostic Tests

• HLA Haplotypes: High incidence of human

leukocyte antigen (HLA-DR2 and HLA-
DQ6/DQB1)
• CSF Hypocretin-1: Less than 110 pg/mL
confirms narcolepsy
• Multiple Sleep Latency Test: Quick sleep onset,
REM sleep in naps
CIRCADIAN RHYTHM D/O
Narcolepsy Types
Overview
• Narcolepsy Type 1: With cataplexy
• Narcolepsy Type 2: Without cataplexy • Sleep-Wake Cycle: Controlled by circadian
oscillators
NARCOLEPSY TETRAD • Disruption: Misalignment between internal
biologic clock and external demands
➢ Four Characteristic Symptoms:
o Excessive daytime sleepiness (EDS) • Common Symptoms: Insomnia or hypersomnia

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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

JET LAG o Low doses, caution for compulsive

behaviors and sudden sleepiness
• Cause: Traveling across time zones, o Risk of augmentation with levodopa
misalignment of circadian clock • Alternative Medications: Gabapentin,
• Duration: 2-3 days; up to 7-10 days if time zone pregabalin, iron supplementation (if ferritin <50-
change exceeds 8 hours 75 mcg/L)
• Effects: Decreased alertness, performance, and
gastrointestinal disturbances Non-Pharmacologic Management

Treatment • Lifestyle Modifications:

o Reduce caffeine, alcohol, stress, and
• Nonpharmacologic Approaches: Adjust sleep fatigue
schedule 1-2 hours before travel • Iron Deficiency: Iron supplementation improves
• Pharmacologic Approaches: symptoms in deficient patients
o Short-acting BZDRAs
o Ramelteon PERIODIC LIMB MOVEMENT DISORDER (PLMS)
o Melatonin (0.5-5 mg)
• Definition: Repetitive, stereotypic leg
SHIFT WORK SLEEP DISORDER (SWSD) movements during sleep every 20-40 seconds
• Duration: Can last from 10 minutes to several
• Prevalence: Affects ~20% of the workforce hours
• Symptoms: Insomnia, excessive sleepiness due •
to circadian misalignment • Involvement: Big toe, ankle, knee, and hip
• Risks: Higher rates of injury, divorce, substance flexions; may end with violent body movements
use, peptic ulcers, depression, breast cancer,
sleepiness-related accidents PLMS Symptoms

Treatment • Awareness: Patients often unaware of

movements; bed partners may notice
• Nonpharmacologic Approaches: • Other Signs: Insufficient sleep, morning leg
o Optimize sleep hygiene cramps
o Daytime naps
• Diagnosis: Diagnosed in sleep labs with
o Switch to day shift
electromyogram recordings
• Pharmacologic Approaches:
o Short-acting BZDRAs, ramelteon, PLMS Causes & Treatment
melatonin
o Modafinil, armodafinil (for EDS) • Causes: Can co-occur with RLS or be caused by
o Bright light exposure at night, darkness systemic diseases (e.g., renal failure) or
during da medications (TCAs, SSRIs, alcohol, caffeine,
nicotine)
RESTLESS LEGS SYNDROME (RLS) • Treatment:
o Dopaminergic medications for limb
• Symptoms: movement suppression
o Paresthesias, urge to move limbs o Sedative-hypnotics to reduce
o Symptoms worsen during rest and at awakenings and consolidate sleep
night
o Temporary relief with movement PARASOMNIAS
• Associated Conditions: Chronic kidney
disease, iron deficiency, pregnancy Overview

Diagnosis • Definition: Abnormal behaviors or physiological

events during sleep
• Criteria: • Types:
o Urge to move limbs with unpleasant o Disorders of Arousal: Sleepwalking,
sensations sleep terrors
o Symptoms worsen during rest o Sleep-Wake Transition Disorders: Sleep-
o Exclusively worse at night talking
o Temporary relief with movement o REM Parasomnias: REM behavior
• Effect on Sleep: Leads to insomnia, daytime disorder, nightmares
sleepiness o Miscellaneous: Enuresis, bruxism

RLS Pharmacologic Therapy Disorders of Arousal (NREM Parasomnias)

• Dopamine Agonists: • Sleepwalking & Sleep Terrors:

o Ropinirole, pramipexole, rotigotine o Common in children, usually resolves by
adolescence
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 KIDAPAWAN’S DOCTOR COLLEGE, INC.
DEPARTMENT OF PHARMACY | CI: KARL JASPER CABAGNOT, RPH, CPH
MIDTERMS | TRANSCRIBED BY: FATIMAH ANDANG

o Can occur in adults, not linked to

psychological issues
• Characteristics:
o Occurs in the first third of the night during
NREM sleep
o Sleepwalking: Difficult to awaken,
amnestic of the event
o Sleep Terrors: Intense fear, difficult to
console, amnestic of the event

REM Parasomnias & Nightmares

• REM Behavior Disorder: Acting out violent

dreams, risk of injury
• Nightmares: Anxiety-provoking, vivid recall;
often due to stress, anxiety, or sleep deprivation
• Treatment:
o Clonazepam for REM behavior disorder
o Melatonin (3-12 mg) and pramipexole
can also be effective

Treatment of Parasomnias

• Sleepwalking & Sleep Terrors:

o Safety measures: Lock doors, remove
hazards, cover glass doors
o Medications: Benzodiazepines, SSRIs,
or TCAs for adults
o Benzodiazepines can help with sleep
terrors
• Nightmares: Manage stress, anxiety, and sleep
deprivation; benzodiazepines in extreme cases

Treatment Algorithm

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