This CE activity is co-sponsored by ProCE, Inc. and Hospital Pharmacy. ProCE, Inc. is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy education. ACPE Universal Activity Number 0221-9999-15-001-H01-P has been assigned to this knowledge-based home-study CE activity (initial release date 01-01-2015). This CE activity is approved for 1.5 contact hours (0.15 CEUs) in states that recognize ACPE providers. This CE activity is provided at no cost to participants. Completion of the evaluation and the post-test with a score of 70% or higher are required to receive CE credit. No partial credit will be given.

Faculty: Dennis J. Cada, PharmD, FASHP, FASCP (Editor), Founder and Contributing Editor, The Formulary; Terri L. Levien, Pharm.D., Clinical Professor, College of Pharmacy, Washington State University; and Danial E. Baker, PharmD, FASHP, FASCP, Director, Drug Information Center, and Professor of Pharmacy Practice, College of Pharmacy, Washington State University. The authors indicate no relationships that could be perceived as a conflict of interest. This activity is self-funded by Hospital Pharmacy.

Release Date: January 1, 2015

Expiration Date: January 1, 2017

Continuing Education for this activity is processed through the ProCE online CE Center. To receive CE credit, please go to: 

• www.ProCE.com/HPJFDR
• Click to access the activity page to enroll and complete the Post-Test and Evaluation

For questions related to registering for and obtaining CE credit, contact ProCE at 630-540-2848 or Info@ProCE.com.

1. The US Food and Drug Administration (FDA)-approved indication for suvorexant is for the:
   1. Short-term treatment of insomnia characterized by difficulties with sleep onset.
   2. Treatment of insomnia characterized by difficulties with sleep maintenance.
   3. Short-term treatment of insomnia characterized by difficulties with sleep maintenance.
   4. Treatment of insomnia characterized by difficulties with sleep onset and/or maintenance.
      
      
2. Suvorexant produces its sleep-promoting effects by:
   1. Binding the benzodiazepine receptor.
   2. Antagonizing cholinergic receptors.
   3. Binding the orexin-1 and orexin-2 receptors.
   4. Binding the melatonin receptor. 
      
      
3. After oral administration of suvorexant, the time to maximum concentration (T_max) and half-life (t_1/2) are:
   1. 30 minutes, 7 hours.
   2. 2 hours, 12 hours.
   3. 6 hours, 10 hours.
   4. 6 hours, 14 hours.
      
      
4. Which of the following is a contraindication to the use of suvorexant?
   1. Concomitant fluvoxamine use
   2. Use of a monoamine oxidase inhibitor within 2 weeks
   3. Narcolepsy
   4. Obstructive sleep apnea
      
      
5. Suvorexant is in Pregnancy Category:
   1. A.
   2. B.
   3. C.
   4. X.

Case History

R.Q. is a 29-year-old female patient with insomnia refractory to previous treatments. She reports trouble getting to sleep along with multiple waking episodes during the night. Her previous insomnia treatments include amitriptyline, trazodone, and zolpidem. Her medical history includes frequent urinary tract infections, for which she is receiving cephalexin 250 mg daily. She has also received occasional fluconazole for treatment of vaginal candidiasis, but is not currently receiving antifungal treatment. She is a social drinker and non-smoker. Her clinician has approached you about starting treatment with either suvorexant or ramelteon.

6. How should R.Q. be counseled to take suvorexant?
   1. At least 1 hour prior to bedtime with a snack
   2. Within 30 minutes prior to bedtime on an empty stomach
   3. At least 10 hours prior to expected awakening time
   4. Within 1 hour prior to bedtime on an empty stomach
      
      
7. What is the recommended initial dose of suvorexant for R.Q.?
   1. 5 mg
   2. 10 mg
   3. 20 mg
   4. All are potential starting doses.
      
      
8. R.Q. should be educated about all of the following effects which are warnings for the use of suvorexant EXCEPT:
   1. Risk of withdrawal with abrupt discontinuation.
   2. Increased effects when taken with alcohol.
   3. Impaired next day wakefulness.
   4. Sleep paralysis.
      
      
9. What is the maximum approved dose for R.Q.?
   1. 5 mg daily
   2. 10 mg daily
   3. 15 mg daily
   4. 20 mg daily
      
      
10. Which medication in R.Q.’s profile has been reported to interact with suvorexant?
    1. Fluconazole
    2. Cephalexin
    3. Both A and B
    4. Neither A nor B
       
       
11. Four weeks after starting treatment with 10 mg of suvorexant daily, R.Q. was diagnosed with a urinary tract infection. Her treatment includes ciprofloxacin for 3 days followed by 2 doses of fluconazole separated by 3 days. What dose of suvorexant would you recommend for her during her treatment?
    1. Discontinue use of suvorexant
    2. Reduce dose to 5 mg daily
    3. Maintain her dose 
    4. Increase her dose to 20 mg daily
       
       
12. The most common side effects associated with suvorexant include: 
    1. Somnolence, headache, and dizziness.
    2. Headache, cough, and diarrhea.
    3. Dry mouth, upper respiratory tract infections, and headache.
    4. Abnormal dreams, dizziness, and dry mouth.
       
       
13. What characteristic of R.Q. would make you less likely to use ramelteon?
    1. Frequent urinary tract infections
    2. Age less than 35 years
    3. Frequent awakenings
    4. Treatment refractory to trazodone
       
       
14. What monitoring would you perform for R.Q.?
    1. Response and new onset depression or suicidal ideation
    2. ALT/AST levels
    3. Serum creatinine
    4. Complete blood count
       
       
15. Suvorexant exposure is increased and a dosage adjustment may be recommended in each of the following types of patients EXCEPT:
    1. Obese patients.
    2. Renal impairment.
    3. Female patients.
    4. Those receiving CYP3A inhibitors.