Disorders That Disrupt Sleep (Parasomnias) (cont.)

The common classes of drugs used for the treatment of parasomnias are benzodiazepines and anticonvulsants. The general aim of drug treatment is to prevent arousal out of sleep or to suppress REM sleep.

Benzodiazepines 

Benzodiazepines help suppress REM sleep and limit arousal. They include the following drugs:

• Diazepam (Valium) is most frequently used in children, especially children with night terrors.
  
  
• Alprazolam (Xanax) is the second choice in this category for parasomnias. It has a brief duration of action; therefore, the likelihood of morning effects, such as grogginess, is decreased. However, it has a potential for exacerbating symptoms at lower doses when effects attenuate, owing to possible rebound.
  
  
• Clonazepam (Klonopin) is similar to alprazolam; it is a good alternative option to diazepam.

Anticonvulsants 

Anticonvulsants inhibit arousal. They include the following drugs:

• Carbamazepine (Tegretol, Carbatrol) is the most commonly used drug for parasomnias.
  
  
• Valproate (Depakene, Depakote) has been reported to be effective in treating parasomnias, in both a once nightly dosage schedule and a standard dosage schedule.
  
  
• Gabapentin (Neurontin) has not been used as frequently as the other 2 anticonvulsants. As with carbamazepine and valproate, no information is available and no consensus has been reached regarding the use of a once nightly dosage versus a standard antiepileptic dosage.

Antiparkinsonian 

Antiparkinsonian drugs are very effective for the treatment of persons with restless legs syndrome and periodic limb movement disorder.

• Levodopa is the most commonly used drug for the treatment of restless legs syndrome and periodic limb movement disorder. An oral dose of 50-100 mg, controlled-release formulation, is prescribed as initial therapy for restless legs syndrome.
  
  
• For periodic limb movement disorder, a controlled-release preparation of levodopa combined with a decarboxylase inhibitor (carbidopa) at a dose of 50-100 mg is started.
  
  
• A dose increase not to exceed 200 mg may be required to completely suppress restless legs syndrome and periodic limb movement disorder.
  
  
• The major adverse effects of levodopa therapy are (1) rebound of symptoms during the daytime and (2) tardive dyskinesia (difficulty in performing voluntary movements), which is extremely uncommon.
  
  
• Ropinirole (Requip), pergolide (Permax), and pramipexole (Mirapex) cause fewer side effects compared with levodopa and have become first-line drugs in the treatment of restless legs syndrome and periodic limb movement disorder. Pramipexole is started at a lowest dose of one half tablet of 0.25 mg once a day for 5 days and then increased to 0.25 mg per day. The dose may be increased to a maximum of 0.5 mg per day. Ropinirole is started at 0.25 mg at bedtime for individuals with primarily nighttime symptoms. For those with symptoms throughout the day, it may be given 2 times per day. The dose may be gradually increased each week. Average doses are 2.5 mg per day.

Opiates
 
Opiates, such as codeine, propoxyphene, and dihydromorphone, have been used in persons who have severe restless legs syndrome and who do not benefit from other therapy. One should be closely observed for development of tolerance and dependency.