Pharmacologic Management of Sleep Disorders — MCQs
A 32-year-old man comes to the physician complaining of excessive sleepiness for the past several months. He reports falling asleep while dealing with customers and had a near accident when he fell asleep while driving. The patient reports that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move upon awakening. Which of the following is the most appropriate treatment for this patient?
The H3 receptor agonist exhibits all of the following actions except:
Which of the following actions is NOT associated with tricyclic antidepressants?
Which anxiolytic acts through 5-HT1A receptor partial agonism without exhibiting significant anticonvulsant or muscle relaxant properties?
A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?
Shortest acting non benzodiazepine sedative is
Muller's manoeuvre is used to
Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?
A 42-year-old obese male presented with disturbed sleep and daytime somnolence. All of the following are correct except?
What is the minimum diagnostic threshold for obstructive sleep apnoea according to current guidelines?
Pharmacologic Management of Sleep Disorders Indian Medical PG Practice Questions and MCQs
Question 1: A 32-year-old man comes to the physician complaining of excessive sleepiness for the past several months. He reports falling asleep while dealing with customers and had a near accident when he fell asleep while driving. The patient reports that he occasionally hears voices while falling asleep and finds himself "temporarily frozen" and unable to move upon awakening. Which of the following is the most appropriate treatment for this patient?
- A. Melatonin
- B. Modafinil (Correct Answer)
- C. Clonazepam
- D. Continuous positive airway pressure
Explanation: ***Modafinil*** - The patient's symptoms of **excessive daytime sleepiness** (EDS), **hypnagogic hallucinations** (hearing voices while falling asleep), and **sleep paralysis** are classic signs of **narcolepsy**. - **Modafinil** is a **non-amphetamine stimulant** that promotes wakefulness and is a first-line treatment for narcolepsy, improving alertness and reducing EDS. *Melatonin* - **Melatonin** is a hormone involved in regulating the **sleep-wake cycle** and is primarily used for **insomnia**, **jet lag**, or **circadian rhythm disorders**. - It is not effective for treating the hallmark symptoms of narcolepsy, such as cataplexy or excessive daytime sleepiness. *Clonazepam* - **Clonazepam** is a **benzodiazepine** that acts as a central nervous system depressant, primarily used for **anxiety disorders**, seizures, and some sleep disorders like **REM sleep behavior disorder**. - While it can help with some parasomnias, it would worsen daytime sleepiness in a patient with narcolepsy and is not a primary treatment for its core symptoms. *Continuous positive airway pressure* - **Continuous positive airway pressure (CPAP)** is the standard treatment for **obstructive sleep apnea (OSA)**, a condition characterized by recurrent upper airway collapse during sleep. - Although OSA can cause excessive daytime sleepiness, the patient's additional symptoms of hypnagogic hallucinations and sleep paralysis are not typical of OSA, making narcolepsy and its specific treatments more appropriate.
Question 2: The H3 receptor agonist exhibits all of the following actions except:
- A. Inhibition of H1 mediated bronchoconstriction
- B. Negative chronotropic effect on atria
- C. Inhibition of H1 receptors induced wakefulness
- D. Increase in H2 mediated gastric secretion (Correct Answer)
Explanation: ***Increase in H2 mediated gastric secretion*** - H3 receptor agonists inhibit the release of **histamine** from presynaptic terminals. - Less histamine means **reduced stimulation of parietal cells** (which are H2-mediated) and a decrease, not an increase, in gastric acid secretion. - H3 agonists would therefore **reduce, not increase**, H2-mediated gastric secretion. *Inhibition of H1 receptors induced wakefulness* - H3 receptor agonists reduce the release of histamine from histaminergic neurons, leading to **decreased H1 receptor activation** in the brain. - This diminished H1 activation contributes to a **reduction in wakefulness** and promotion of sleep. - This is a **true action** of H3 agonists. *Inhibition of H1 mediated bronchoconstriction* - By decreasing histamine release, H3 receptor agonists lower the amount of histamine available to bind to H1 receptors on **bronchial smooth muscle**. - This results in a **reduction in H1-mediated bronchoconstriction**. - This is a **true action** of H3 agonists. *Negative chronotropic effect on atria* - H3 receptors are present in the heart, and their activation can lead to a **reduction in heart rate** (negative chronotropic effect). - This effect is mediated through the **inhibition of histamine release locally** or directly on cardiac cells. - This is a **true action** of H3 agonists.
Question 3: Which of the following actions is NOT associated with tricyclic antidepressants?
- A. Block 5-HT or NE reuptake
- B. Anticholinergic action
- C. MAO inhibition (Correct Answer)
- D. Causes sedation
Explanation: ***MAO inhibition*** - Tricyclic antidepressants (TCAs) primarily exert their effects by inhibiting the reuptake of **norepinephrine** and **serotonin**, not by inhibiting monoamine oxidase (MAO). - **MAO inhibitors** are a distinct class of antidepressants with a different mechanism of action and side effect profile. *Anticholinergic action* - Many TCAs have significant **anticholinergic effects**, blocking muscarinic receptors and leading to side effects like dry mouth, constipation, and blurred vision. - These effects contribute to the **adverse event profile** of TCAs, especially in elderly patients. *Block 5-HT or NE reuptake* - The primary mechanism of action of TCAs involves the **inhibition of serotonin (5-HT)** and **norepinephrine (NE) reuptake** into presynaptic neurons. - This action increases the concentration of these neurotransmitters in the **synaptic cleft**, thereby potentiating their effects. *Causes sedation* - TCAs frequently cause **sedation**, particularly the more histaminergic ones (e.g., amitriptyline, doxepin), due to their **histamine H1 receptor antagonism**. - This side effect can be beneficial for patients with insomnia but can be problematic for daytime functioning.
Question 4: Which anxiolytic acts through 5-HT1A receptor partial agonism without exhibiting significant anticonvulsant or muscle relaxant properties?
- A. Diazepam
- B. Zolpidem
- C. Phenobarbitone
- D. Buspirone (Correct Answer)
Explanation: ***Buspirone*** - **Buspirone** is a unique anxiolytic that primarily acts as a **partial agonist at 5-HT1A receptors**. - Unlike benzodiazepines, it lacks significant **anticonvulsant**, **muscle relaxant**, or **sedative-hypnotic properties** and does not lead to physical dependence or withdrawal. *Diazepam* - **Diazepam** is a **benzodiazepine** that acts by enhancing the effect of **GABA** at GABA-A receptors, leading to significant anxiolytic, sedative, muscle relaxant, and anticonvulsant effects. - It does not primarily act via **5-HT1A receptor partial agonism**. *Zolpidem* - **Zolpidem** is a **non-benzodiazepine hypnotic** that selectively binds to the **GABA-A receptor** subunit, primarily mediating sedative effects. - While it's used for insomnia, it doesn't primarily act as a **5-HT1A partial agonist** and is not typically used for its anxiolytic properties in the same way as buspirone. *Phenobarbitone* - **Phenobarbitone** is a **barbiturate** that acts by prolonging the opening of **chloride channels** associated with GABA-A receptors, leading to strong sedative, hypnotic, and anticonvulsant effects. - Its mechanism of action is distinct from **5-HT1A receptor partial agonism**, and it carries a high risk of dependence and overdose.
Question 5: A 32-year-old patient with Restless leg syndrome comes to the OPD. What is the most appropriate first line treatment?
- A. Iron Supplementation
- B. Gabapentin (Correct Answer)
- C. Pramipexole
- D. Vitamin B12
Explanation: ***Gabapentin*** - **Gabapentin** and other alpha-2-delta ligands (e.g., pregabalin) are considered **first-line agents** for moderate to severe Restless Legs Syndrome (RLS), particularly when symptoms are bothersome and daily. - They work by modulating **calcium channels** and are effective in reducing RLS symptoms with a generally favorable side effect profile. *Iron Supplementation* - **Iron supplementation** is appropriate as first-line treatment only if **serum ferritin levels** are below 75 mcg/L, indicating iron deficiency. - While RLS is associated with **iron deficiency**, it's not the universal first-line treatment without biochemical confirmation [1]. *Pramipexole* - **Dopamine agonists** like pramipexole are effective for RLS but are generally **second-line treatments** due to concerns about augmentation (worsening of RLS symptoms) and impulse control disorders. - Augmentation is a significant side effect where symptoms worsen paradoxically with continued use, particularly with higher doses. *Vitamin B12* - **Vitamin B12 deficiency** can cause neurological symptoms, but it is **not a primary cause or treatment** for Restless Legs Syndrome. - Supplementation with **Vitamin B12** would only be considered if a confirmed deficiency exists, which is not stated as a contributing factor in this patient.
Question 6: Shortest acting non benzodiazepine sedative is
- A. Zaleplon (Correct Answer)
- B. Eszopiclone
- C. Zopiclone
- D. Zolpidem
Explanation: ***Zaleplon*** - Has the shortest **half-life** (approximately 1 hour) among the non-benzodiazepine hypnotics, allowing for rapid elimination. - This quick elimination makes it ideal for patients who have difficulty **falling asleep** but do not need prolonged sedation. - Particularly useful for **middle-of-the-night** dosing due to its ultra-short duration. *Eszopiclone* - Has a half-life of about 6 hours, which is significantly longer than Zaleplon. - It's the S-enantiomer of zopiclone and is used for both **sleep onset and maintenance**. - Provides more sustained sleep throughout the night compared to Zaleplon. *Zopiclone* - Has a half-life of about 5-6 hours, which is considerably longer than Zaleplon. - It's used for the short-term treatment of **insomnia** and helps both with sleep onset and maintenance. - May cause a characteristic **bitter metallic taste** as a side effect. *Zolpidem* - Has a half-life of 2-3 hours, making it longer-acting than Zaleplon. - It's commonly prescribed for problems with **sleep initiation** and occasionally for sleep maintenance. - Available in extended-release formulations for prolonged action.
Question 7: Muller's manoeuvre is used to
- A. To remove foreign body from ear
- B. To find degree of obstruction in sleep disordered breathing (Correct Answer)
- C. To remove laryngeal foreign body
- D. To find out opening of mouth
Explanation: ***To find degree of obstruction in sleep disordered breathing*** - **Muller's manoeuvre** is a diagnostic technique where the patient attempts to inspire forcefully against a **closed mouth and nostrils** while an endoscope observes the upper airway. - This maneuver helps to simulate the negative intraluminal pressure that occurs during sleep, making it useful in identifying the **site and severity of airway obstruction** in patients with sleep-disordered breathing. *To remove foreign body from ear* - Removing foreign bodies from the ear typically involves **irrigation**, specialized instruments (e.g., alligator forceps), or suction, not a breathing maneuver. - This option is unrelated to the physiological assessment of airway obstruction. *To remove laryngeal foreign body* - The primary methods for removing laryngeal foreign bodies are the **Heimlich maneuver** (abdominal thrusts) or direct laryngoscopy and removal. - Muller's manoeuvre is a diagnostic procedure, not a therapeutic one for foreign body extraction. *To find out opening of mouth* - Measuring the **opening of the mouth** is typically done with a ruler or specific instruments to assess jaw mobility (e.g., for temporomandibular joint disorders or trismus). - This is a simple measurement and does not involve the complex physiological assessment of the upper airway that Muller's manoeuvre provides.
Question 8: Patient with obstructive sleep apnea-hypopnea syndrome is unlikely to have which of the following?
- A. Absence of snoring
- B. Bradycardia during sleep episodes (Correct Answer)
- C. Normal oxygen saturation throughout sleep
- D. Decreased neck circumference
Explanation: ***Bradycardia during sleep episodes*** - While patients with **obstructive sleep apnea (OSA)** commonly experience various cardiovascular complications, **bradycardia** during apneic episodes is *less typical* than **tachycardia**. - The body's initial response to apnea and **hypoxia** usually involves a sympathetic surge leading to tachycardia upon arousal, followed by bradycardia if the apnea is prolonged. However, the dominant pattern is often elevated heart rate variability. *Normal oxygen saturation throughout sleep* - Patients with OSA frequently experience intermittent **hypoxemia** due to repeated apneas and hypopneas, leading to significant drops in **oxygen saturation** [1]. - A *normal oxygen saturation throughout sleep* would effectively rule out significant OSA, as desaturation is a hallmark of the condition [1]. *Absence of snoring* - **Snoring** is a classic and highly prevalent symptom of OSA, caused by the vibration of upper airway tissues as air struggles to pass through an obstructed pharynx. - While not all snorers have OSA, the *absence of snoring* makes OSA less likely, although it can occur in some subsets of patients, particularly those with central sleep apnea or certain anatomical variations. *Decreased neck circumference* - A **large neck circumference** is a well-established anatomical risk factor for OSA, indicating increased soft tissue in the neck that can contribute to upper airway collapse. - A *decreased neck circumference* would generally be protective against OSA, making it less likely for an individual to have the condition.
Question 9: A 42-year-old obese male presented with disturbed sleep and daytime somnolence. All of the following are correct except?
- A. Apnea with fall in saturation
- B. Apnea with awakening
- C. Pharyngeal muscle contraction increases OSA
- D. Apnea with hypercapnia (Correct Answer)
Explanation: ***Apnea with hypercapnia*** - While hypercapnia can occur in severe cases of **obstructive sleep apnea (OSA)**, a direct correlation of hypercapnia with every apnea event is not a defining characteristic for diagnosis in the provided patient. [1] - OSA is primarily defined by **recurrent episodes of upper airway collapse during sleep**, leading to cessation of airflow despite ongoing respiratory effort, which causes hypoxemia and sleep fragmentation, not necessarily hypercapnia with each event. [1] *Apnea with fall in saturation* - **Apnea events** in OSA frequently lead to a significant **fall in oxygen saturation** as the oxygen in the blood is consumed without replenishment due to the blocked airway. [1] - This desaturation is a key diagnostic criterion and a major contributor to the cardiovascular complications associated with OSA. *Apnea with awakening* - Apnea episodes typically end with a brief **arousal or awakening** from sleep, often not consciously remembered by the patient, as the brain signals to resume breathing. [1] - These awakenings disrupt the sleep architecture, leading to the characteristic **daytime somnolence** and disturbed sleep seen in OSA patients. [1] *Pharyngeal muscle contraction increases OSA* - **Relaxation or decreased tone of pharyngeal muscles** during sleep is a primary cause of upper airway collapse and **obstructive sleep apnea (OSA)**. [1] - Increased pharyngeal muscle contraction would typically help keep the airway open, thus *decreasing* the likelihood of OSA, not increasing it.
Question 10: What is the minimum diagnostic threshold for obstructive sleep apnoea according to current guidelines?
- A. AHI <5 events per hour
- B. AHI 15-30 events per hour
- C. AHI >30 events per hour (Correct Answer)
- D. AHI 5-15 events per hour
Explanation: AHI >30 events per hour - An Apnoea-Hypopnoea Index (AHI) greater than 30 events per hour indicates severe obstructive sleep apnea (OSA), which is definitively above the minimum diagnostic threshold [1]. - While an AHI of 5 or more is generally considered diagnostic for OSA, an AHI >30 signifies severe disease and often leads to more pronounced symptoms and health risks [1]. *AHI <5 events per hour* - An AHI score of less than 5 events per hour is typically considered normal or within the non-pathological range for sleep-disordered breathing [1]. - Individuals with an AHI below this threshold usually do not meet the diagnostic criteria for any form of sleep apnea. *AHI 15-30 events per hour* - This range indicates moderate obstructive sleep apnea. While it is diagnostic for OSA, it is not the minimum threshold [1]. - Patients in this category often experience significant symptoms and may require treatment, but it is not the lowest AHI at which a diagnosis can be made. *AHI 5-15 events per hour* - This AHI range is considered mild obstructive sleep apnea. An AHI of 5 or more, accompanied by relevant symptoms, is generally the minimum diagnostic threshold for OSA [1]. - However, the question asks for the minimum diagnostic threshold, and while 5 events per hour is a minimum, "AHI >30 events per hour" indicates a clear and severe diagnostic case.
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