4: Pharmacology

Section 4 Pharmacology



Questions



Psychotropic Drugs



A Case of Waking Up Four Times at Night




A 48-year-old woman presents to your clinic with a 10-year history of insomnia. Many years ago she was treated with barbiturates but was concerned about addiction. She has no difficulty going to sleep but wakes frequently at night and has trouble reinitiating sleep. Her overall health is good, although she has been told she snores if she has a glass of wine about an hour before bedtime. Answer the following series of questions.


1 You think about prescribing a hypnotic. Which of the following treatments is least likely to be useful in her case?
A Eszopiclone

B Zolpidem

C Ramelteon

D Zaleplon

2 Barbiturates affect sleep architecture by:
A Increasing REM sleep

B Decreasing N3 sleep

C Increasing N3 sleep

D Decreasing REM

3 She undergoes a PSG in your sleep lab and is found to have only 3% N3 sleep. Which is the most likely explanation for this finding?
A The patient is taking a barbiturate.

B The patient is taking a benzodiazepine.

C The patient is taking a monoamine oxidase inhibitor.

D The patient is taking an SSRI.

4 Alternatively she is found to have 0% REM on the PSG. You find out that she neglected to tell you she is taking an antidepressant. Which of the following drug classes is the most powerful REM suppressor?
A Tricyclics

B Monoamine oxidase inhibitors

C Selective serotonin reuptake inhibitors

D Serotonin antagonists


Nonrefreshed



5 A 45-year-old woman is referred to the sleep clinic with nonrefreshing sleep. Her PCP has diagnosed chronic fatigue syndrome and prescribed fluoxetine 20 mg. hs. What is the effect of this medication on sleep architecture?
A It increases TST.

B It decreases TST by 25% to 30%.

C It decreases N1.

D It reduces sleep continuity.


Jumpy Legs and Depression




A 62-year-old man with a history of mild RLS is referred to you owing to a recent intensification in symptoms. The leg symptoms begin about 6 PM and can be so uncomfortable that he soaks in a hot tub for about an hour before bedtime. He recently started taking an antidepressant to help him cope with the death of a close relative.


6 Which of these antidepressants is least problematic with regard to increasing RLS symptoms and periodic limb movements?
A Bupropion

B Mirtazapine

C Trazodone

D Imipramine

7 His PCP originally started him on a hypnotic agent but it was not effective for managing symptoms once he initiated sleep. Which of the following is true about zolpidem for the treatment of insomnia?
A Half-life is about 6 hours.

B The drug has relative affinity for type 2 GABAA receptors.

C There is no food effect.

D Peak plasma is at about 1.5 hours.


Call from a Psychiatrist




You receive a call from a psychiatrist colleague who is planning treatment for a 22-year-old patient with schizophrenia. The psychiatrist wants to start the patient on an antipsychotic that will help the patient get more deep sleep.


8 The following antipsychotic drugs increase N3 sleep except for:
A Olanzapine

B Haloperidol

C Ziprasidone

D Quetiapine

9 The psychiatrist also plans to prescribe an anxiolytic but has concerns about the effect it will have on daytime alertness. Which of the following drugs are not known to induce sleepiness?
A Diazepam

B Alprazolam

C Buspirone

D Mirtazapine


Medications That May Be Hypnotics



10 You decide to develop a new drug for treating insomnia. Considering the following pharmacologic actions, which one would you select?
A GABAA receptor antagonist

B 5-HT2A receptor agonist

C 5-HT2A receptor antagonist

D Orexin receptor agonist


Still Sleepy on Cpap




Moderate OSA has been diagnosed in a 54-year-old man in your sleep laboratory. He has a BMI of 37 and a neck circumference of 18.5 inches. A second night in the lab reveals an optimal CPAP pressure of 14 cm H2O. He returns 90 days later and the download measuring compliance indicates he is using CPAP an average of 6 hours per night, 5 nights per week. He tells you that his sleepiness has improved since he began CPAP but that on some days he is still severely sleepy even when he has used CPAP the night before. To objectively measure his sleepiness you have him undergo an MSLT, which results in a mean sleep latency of 6.5 minutes. His Epworth score is 15/24. You prescribe 200 mg of modafinil.


11 Modafinil for treating residual sleepiness associated with OSA has been found to:
A Increase MSLT scores by 5-10 minutes compared to baseline

B Increase Epworth scores on average by 5 points

C Decrease Epworth scores on average by 5 points

D Increase MSLT scores about 1 minute compared to baseline

12 He returns to see you 2 weeks later and his sleepiness is resolved; however, he complains of side effects from taking the drug. Which one of the following adverse events associated with modafinil and armodafinil is least likely?
A Headache

B Chest pain

C Rash

D Severe depression

13 Modafinil in healthy adults has a half-life of:
A 3 to 7 hours

B 14 to 18 hours

C 9 to 14 hours

D 2 to 3 hours


Cataplexy Resistant to Treatment




A patient with previously diagnosed narcolepsy continues to have severe bouts of cataplexy. Treatment with an SSRI was marginally effective. You prescribe Xyrem (sodium oxybate), which is very effective for reducing or eliminating cataplexy.


14 The effects of sodium oxybate are not mediated by interaction with:
A Adenosine receptors

B GABAB receptors

C GHB receptors

D Dopamine receptors

15 Sodium oxybate given to healthy subjects has what impact on sleep architecture?
A Increases N3

B Decreases N3

C Increases REM

D Lengthens REM latency


Potpourri



16 A friend of yours likes to drink red wine up to 30 minutes before bed about 5 nights a week. He tells you that the wine does indeed have an effect of his sleep. Which of the following is an expected impact on sleep when adults drink alcoholic beverages near bedtime?
A Bizarre dreams

B Increased REM sleep

C Reduced WASO

D Decreased limb movements

17 A waitress drinks 3 pots of coffee to stay alert and energized on her shift. The reason caffeine helps her remain alert is:
A Caffeine is an adenosine agonist.

B Caffeine is an adenosine antagonist.

C Caffeine is a norepinephrine agonist.

D Caffeine blocks reuptake of dopamine.

18 Caffeine has an approximate half-life of:
A 3 to 5 hours

B 15 to 30 minutes

C 6 to 8 hours

D 1 to 2 hours

19 You are at a social gathering. One of the partygoers hears you are a sleep medicine specialist. He brags to you that he can drink four espresso drinks before bed without an effect on subsequent sleep. What should you tell him?
A Caffeine has no effect on some persons.

B Caffeine consumption will eventually cause insomnia.

C Caffeine reduces REM sleep.

D Caffeine reduces N3 sleep.


Too Sleepy




A 31-year-old narcoleptic patient has been taking 250 mg of armodafinil, resulting in moderate success in reducing daytime sleepiness. The sleepiness is so severe upon awakening she has to delay her drive to work until the armodafinil kicks in. You prescribe 10 mg of dextroamphetamine to be taken immediately upon awakening.


20 The mechanism of action of amphetamines is to directly:
A Increase activity in histamine neurons

B Increase activity in dopamine system

C Increase activity in orexin system

D Increase activity in VLPO neurons

21 The patient’s previous sleep specialist prescribed clomipramine for treatment of cataplexy. Tricyclic antidepressants interact with all of the following except:
A Dopamine receptors

B Serotonin receptors

C Acetylcholine receptors

D Histamine receptors


Insomnia Through the Ages



22 An 82-year-old patient with a 5-year history of insomnia involving onset and maintenance problems tells you he is taking Tylenol PM (acetaminaphen and diphenyhydramine) at bedtime, which has not improved his condition. The most likely reason for this is:
A Diphenhydramine has little effect on reducing sleep-onset latency.

B Diphenhydramine can reduce objective total sleep time.

C Diphenhydramine makes most people feel groggy for up to 30 minutes after sleep offset.

D Diphenhydramine does not reduce objective nighttime awakenings.

23 A pediatrician sees an 8-year-old boy who has a long history of sleep-onset insomnia. Efforts with behavioral intervention were unsuccessful. The parents are upset and the child is having problems with performance and behavior at school. The pediatrician decides to try a low dose of chloral hydrate to treat the insomnia. Chloral hydrate can affect sleep architecture by:
A Increasing REM latency

B Reducing N3 sleep

C Increasing N3 sleep

D Chloral hydrate has no impact on N3 or REM sleep.


Insomnia, the Old and the New




One of your patients has successfully been treated for insomnia with zolpidem 10 mg hs. The patient takes the zolpidem about 30 minutes before bedtime, 5 nights per week. Two months after starting treatment the patient returns for follow-up and reports that his sleep is good on nights when he takes the drug. He usually reads for about an hour before bed and finds the book on his chest the next morning. While he is pleased with treatment he reports that he often has no recall of what he read the night before and it can take him weeks to complete a book unless he reads at other times of the day.

Related posts:

2: Physiology 5: Circadian Rhythm Disorders 6: Insomnia 10: Sleep-Related Breathing Disorders 11: Sleep in Other Disorders 3: Sleep Evaluation

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Apr 9, 2017 | Posted by in PSYCHOLOGY | Comments Off on 4: Pharmacology

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