Parasomnias Medication
- Author: David Bienenfeld, MD; Chief Editor: Iqbal Ahmed, MBBS, FRCPsych (UK) more...
Medication Summary
The drugs most commonly used to treat parasomnias are benzodiazepines and anticonvulsants. The general aim of medication treatment is to prevent arousal out of sleep or to suppress rapid eye movement (REM) sleep. Currently, no medications are available that are specifically indicated for these disorders; all medications used for these disorders are used off label.
Anxiolytics, Benzodiazepines
Class Summary
Benzodiazepines help suppress REM sleep and limit arousal.
Diazepam (Valium, Diastat)
Diazepam is the medication most frequently used in children, especially those with night terrors; it is the drug of choice for parasomnias. Other benzodiazepines also may be used.
Alprazolam (Xanax, Niravam)
Alprazolam is the second choice for parasomnias in this category. Its advantages are the brief duration of action and the decreased likelihood of morning effects (eg, grogginess). Its disadvantages include the potential for exacerbating symptoms at lower doses when effects attenuate, owing to possible rebound.
Clonazepam (Klonopin)
Like alprazolam, clonazepam is a good alternative to diazepam. Its main advantage is the presumed specificity for central nervous system (CNS) gamma-aminobutyric acid (GABA) receptors. Its disadvantages include the potential for exacerbating symptoms at lower doses when effects attenuate, owing to possible rebound.
Anticonvulsants
Class Summary
Anticonvulsants inhibit arousal.
Carbamazepine (Tegretol, Carbatrol, Equetro)
Carbamazepine is the most commonly used anticonvulsant for these disorders, but anecdotal evidence supports the possible use of GABA-enhancing agents such as valproate or gabapentin. With respect to all of these agents, both a bedtime dose alone and titration (as for epilepsy) have been reported.
Valproate (Depakene, Depakote, Stavzor, Depacon)
With valproate, as with other drugs in this category, both bedtime and standard doses have been reported to be useful in treating parasomnias.
Gabapentin (Neurontin, Gralise)
Gabapentin has not been used as frequently as the other 2 anticonvulsants, and less information is available. As with the other 2 agents in this category, no information is available, nor has a consensus been reached, regarding the use of bedtime dosing as opposed to standard antiepileptic dosing.
Gabapentin Enacarbil (Horizant)
A prodrug of gabapentin, gabapentin enacarbil has been approved by the FDA. In a randomized, placebo-controlled study, 1200 mg taken orally once daily provided sustained gabapentin exposure and maintained improvements in restless legs syndrome symptoms compared with placebo.
Antiparkinson Agents, Dopamine Agonists
Class Summary
Antiparkinsonian agents are very effective for treating restless legs syndrome (RLS) and periodic limb movement disorder (PLMD). Levodopa-carbidopa is the most commonly used agent, but ropinirole, pergolide, and pramipexole also are effective.
Pergolide was withdrawn from the US market on March 29, 2007, because of heart valve damage resulting in cardiac valve regurgitation. It is important not to stop pergolide abruptly. Health care professionals should assess patients’ need for dopamine agonist therapy and consider alternative treatment. If continued treatment with such an agent is needed, another dopamine agonist should be substituted for pergolide. For more information, see FDA MedWatch Product Safety Alert and Medscape Alerts: Pergolide Withdrawn From US Market.
Levodopa-carbidopa (Sinemet CR, Parcopa)
Levodopa is a large neutral amino acid that is absorbed in the proximal small intestine by a saturable carrier-mediated transport system. Absorption is decreased by meals that include other large neutral amino acids. Only patients with meaningful motor fluctuations need to consider a low-protein or protein-redistributed diet.
Greater consistency of absorption is achieved when levodopa taken 1 hour or more after a meal. Nausea often is reduced if levodopa taken immediately after meals. Some patients with nausea benefit from additional carbidopa in dosages not to exceed 200 mg/day. The half-life of levodopa-carbidopa is approximately 2 hours. The most common acute adverse effects are nausea, hypotension, and hallucinations. Long-term adverse effects include motor fluctuations and dyskinesia (chorea).
Provide at least 70-100 mg/day of carbidopa. When more carbidopa is required, substitute one 25/100 tablet for each 10/100 tablet. When more levodopa is required, substitute a 25/250 tablet for the 25/100 or 10/100 tablet.
The controlled-release (CR) formulation of levodopa-carbidopa is absorbed more slowly and provides more sustained levodopa levels than the immediate-release (IR) form. It is as effective as the IR formulation when levodopa is initially required and may be more convenient when fewer intakes are desired.
Patients with dissipating motor fluctuations (and no dyskinesia) often benefit from prolongation of short-duration response when switched from IR to CR levodopa-carbidopa. However, patients with meaningful fluctuations and dyskinesia often experience an increase in dyskinesia when switched to the CR formulation.
Pramipexole (Mirapex)
Although pramipexole is used for Parkinson disease, it has also been found to be beneficial in RLS and PLMD. Pramipexole is a nonergot dopamine agonist with specificity for the D2 dopamine receptor; it also has been shown to bind to D3 and D4 receptors and possibly may stimulate dopamine activity on the nerves of striatum and substantia nigra.
Ropinirole (Requip)
Ropinirole is a dopamine D2-receptor agonist that has been approved by the FDA for the treatment of Parkinson disease. It has also has been used in patients with restless legs syndrome.
Opioid Analgesics
Class Summary
Opiates such as codeine, propoxyphene, and dihydromorphone have been used in patients with severe RLS who do not benefit from other therapy. Patients should be closely observed for development of tolerance and dependency.
Propoxyphene products were withdrawn from the United States market on November 19, 2010 . The withdrawal was based on new data showing QT prolongation at therapeutic doses. For more information, see the FDA MedWatch safety information.
Hydromorphone (Dilaudid)
Hydromorphone is a potent semisynthetic opiate agonist similar in structure to morphine. It is approximately 7-8 times as potent as morphine on mg-to-mg basis, with a shorter or similar duration of action. It has been used in patients with severe restless legs syndrome who do not benefit from other therapy.
Codeine
This and other opioids can be helpful in decreasing the symptoms of restless legs syndrome, serving as a treatment of second choice when other treatments have failed or caused augmentation problems.
Propoxyphene (Darvon)
Withdrawn from the US market. Propoxyphene has been used for severe restless legs syndrome. It binds to opiate receptors in the CNS, causing inhibition of ascending pain pathways and altering perception of and response to pain.
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