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Gileles-Hillel A, Bhattacharjee R, Gorelik M, Narang I. Advances in Sleep-Disordered Breathing in Children. Clin Chest Med 2024; 45:651-662. [PMID: 39069328 DOI: 10.1016/j.ccm.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2024]
Abstract
Pediatric sleep-disordered breathing disorders are a group of common conditions, from habitual snoring to obstructive sleep apnea (OSA) syndrome, affecting a significant proportion of children. The present article summarizes the current knowledge on diagnosis and treatment of pediatric OSA focusing on therapeutic and surgical advancements in the field in recent years. Advancements in OSA such as biomarkers, improving continuous pressure therapy adherence, novel pharmacotherapies, and advanced surgeries are discussed.
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Affiliation(s)
- Alex Gileles-Hillel
- Neonatal Pulmonology Service, Pediatric Pulmonary and Sleep Unit; Pediatric Division, Hadassah Medical Center, Jerusalem 911111, Israel; The Faculty of Medicine, Hebrew University of Jerusalem; The Wohl Translational Research Institute, Hadassah Medical Center, Kiryat Hadassah, Ein Kerem, Jerusalem 911111, Israel.
| | - Rakesh Bhattacharjee
- Division of Respiratory Medicine, Department of Pediatrics, Rady Children's Hospital, UCSD, San Diego, CA 92123, USA
| | - Michael Gorelik
- Division of Pediatric Otolaryngology, Children's Hospital of Wisconsin, Medical College of Wisconsin, Milwaukee, WI 53226, USA
| | - Indra Narang
- Division of Respiratory Medicine, Faculty Development and EDI, Department of Paediatrics, Translational Medicine, Research Institute, Hospital for Sick Children; Department of Paediatrics, University of Toronto, 51 Banff Road, Toronto M4S2V6, Canada
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Wang J, Ye Y, Shang Z, Zheng Q, Zhang S, Li L, Liu W. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med 2024; 20:1363-1372. [PMID: 38494994 PMCID: PMC11294128 DOI: 10.5664/jcsm.11130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
STUDY OBJECTIVES Randomized controlled trials have shown that combining norepinephrine reuptake inhibitors and antimuscarinics can ameliorate the severity of obstructive sleep apnea. This article explores whether the effectiveness and safety of combining norepinephrine reuptake inhibitors with antimuscarinic agents surpass monotherapy for treating obstructive sleep apnea. METHODS We searched randomized controlled trials including adult patients with obstructive sleep apnea who received combination therapy and monotherapy in 8 databases from inception until April 5, 2023 and evaluated the studies' quality and conducted a meta-analysis and systematic review. The primary outcome was the apnea-hypopnea index. Secondary outcome measures included loop gain, hypoxic burden, oxygen desaturation index, and ventilation at low ventilatory drive, among other indicators. We assessed the quality of the studies using Cochrane Methods criteria. RESULTS We identified 4 randomized controlled trials for systematic review and 2 for meta-analysis. The results of the meta-analysis showed that norepinephrine reuptake inhibitors combined with antimuscarinic agents in patients with obstructive sleep apnea prolonged total sleep time by a mean of 28.20 minutes [95% confidence interval (5.78, 50.61), P = .01] and increased sleep efficiency by 4.73% [95% confidence interval (0.50, 8.97), P = .03] compared with norepinephrine reuptake inhibitors alone. Other indices and adverse events were of no statistical significance. The systematic reviews revealed that norepinephrine reuptake inhibitors combined with antimuscarinics may be superior to monotherapy in improving apnea-hypopnea index and endotypic traits. CONCLUSIONS This evaluation demonstrated the potential advantages of combining norepinephrine reuptake inhibitors plus antimuscarinics for treating OSA compared with norepinephrine reuptake inhibitors alone and revealed no statistically significant difference in drug safety. CITATION Wang J, Ye Y, Shang Z, et al. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(8):1363-1372.
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Affiliation(s)
- Juan Wang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Yucai Ye
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Zhizhong Shang
- Department of Orthopedics, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Qingyong Zheng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Sha Zhang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Leping Li
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Weiying Liu
- Department of Respiratory and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Thomas RJ. REM sleep breathing: Insights beyond conventional respiratory metrics. J Sleep Res 2024:e14270. [PMID: 38960862 DOI: 10.1111/jsr.14270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2024] [Accepted: 05/29/2024] [Indexed: 07/05/2024]
Abstract
Breathing and sleep state are tightly linked. The traditional approach to evaluation of breathing in rapid eye movement sleep has been to focus on apneas and hypopneas, and associated hypoxia or hypercapnia. However, rapid eye movement sleep breathing offers novel insights into sleep physiology and pathology, secondary to complex interactions of rapid eye movement state and cardiorespiratory biology. In this review, morphological analysis of clinical polysomnogram data to assess respiratory patterns and associations across a range of health and disease is presented. There are several relatively unique insights that may be evident by assessment of breathing during rapid eye movement sleep. These include the original discovery of rapid eye movement sleep and scoring of neonatal sleep, control of breathing in rapid eye movement sleep, rapid eye movement sleep homeostasis, sleep apnea endotyping and pharmacotherapy, rapid eye movement sleep stability, non-electroencephalogram sleep staging, influences on cataplexy, mimics of rapid eye movement behaviour disorder, a reflection of autonomic health, and insights into cardiac arrhythmogenesis. In summary, there is rich clinically actionable information beyond sleep apnea encoded in the respiratory patterns of rapid eye movement sleep.
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Affiliation(s)
- Robert Joseph Thomas
- Department of Medicine, Division of Pulmonary Critical Care & Sleep Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Boston, Massachusetts, USA
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Souza Bastos P, Amaral TLD, Yehia HC, Tavares A. Prevalences of sleep-related breathing disorders and severity factors in chronic spinal cord injury and abled-bodied individuals undergoing rehabilitation: a comparative study. J Clin Sleep Med 2024; 20:1119-1129. [PMID: 38420961 PMCID: PMC11217642 DOI: 10.5664/jcsm.11084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 02/15/2024] [Accepted: 02/15/2024] [Indexed: 03/02/2024]
Abstract
STUDY OBJECTIVES The objective of this study was to discern distinguishing characteristics of sleep-related breathing disorders in individuals with chronic spinal cord injury (CSCI) compared with participants without CSCI. Additionally, the study investigated factors associated with sleep-related breathing disorder severity. METHODS This is a cross-sectional analysis of 123 individuals without CSCI, 40 tetraplegics, and 48 paraplegics who underwent attended or partially supervised full polysomnography for suspected sleep-related breathing disorders in a rehabilitation center. Polysomnographic, transcutaneous capnography, and clinical data were collected and compared between the groups. RESULTS Among tetraplegics, apnea-hypopnea index ≥ 30 events/h (67.5%, P = .003), central apnea (17.5%, P = .007), and higher oxygen desaturation index (80.0%, P = .01) prevailed. Sleep-related hypoventilation was present in 15.4% of tetraplegics and 15.8% of paraplegics, compared with 3.2% in participants without CSCI (P = .05). In the group without CSCI and the paraplegic group, snoring and neck circumference were positively correlated with obstructive sleep apnea (OSA) severity. A positive correlation between waist circumference and OSA severity was identified in all groups, and multivariate logistic regression analysis showed that loud snoring and waist circumference had the greatest impact on OSA severity. CONCLUSIONS Severe OSA and central sleep apnea prevailed in tetraplegic participants. Sleep-related hypoventilation was more common in tetraplegics and paraplegics than in participants without CSCI. Loud snoring and waist circumference had an impact on OSA severity in all groups. We recommend the routine implementation of transcutaneous capnography in individuals with CSCI. We underscore the significance of conducting a comprehensive sleep assessment in the rehabilitation process for individuals with CSCI. CITATION Souza Bastos P, Amaral TLD, Yehia HC, Tavares A. Prevalences of sleep-related breathing disorders and severity factors in chronic spinal cord injury and abled-bodied individuals undergoing rehabilitation: a comparative study. J Clin Sleep Med. 2024;20(7):1119-1129.
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Affiliation(s)
- Patrícia Souza Bastos
- Programa de Neurociências, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
- Unidade de Polissonografia, Rede SARAH de Hospitais de Reabilitação, Belo Horizonte, MG, Brazil
| | - Tatiana Leal Dutra Amaral
- Programa de Neurociências, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Hani Camille Yehia
- Programa de Neurociências, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
- Departamento de Engenharia Eletrônica, Faculdade de Engenharia, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
| | - Almir Tavares
- Programa de Neurociências, Instituto de Ciências Biológicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
- Departamento de Psiquiatria, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brazil
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Yamada R, Koike T, Nakakariya M, Kimura H. Orexin receptor 2 agonist activates diaphragm and genioglossus muscle through stimulating inspiratory neurons in the pre-Bötzinger complex, and phrenic and hypoglossal motoneurons in rodents. PLoS One 2024; 19:e0306099. [PMID: 38917189 PMCID: PMC11198781 DOI: 10.1371/journal.pone.0306099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2024] [Accepted: 06/10/2024] [Indexed: 06/27/2024] Open
Abstract
Orexin-mediated stimulation of orexin receptors 1/2 (OX[1/2]R) may stimulate the diaphragm and genioglossus muscle via activation of inspiratory neurons in the pre-Bötzinger complex, which are critical for the generation of inspiratory rhythm, and phrenic and hypoglossal motoneurons. Herein, we assessed the effects of OX2R-selective agonists TAK-925 (danavorexton) and OX-201 on respiratory function. In in vitro electrophysiologic analyses using rat medullary slices, danavorexton and OX-201 showed tendency and significant effect, respectively, in increasing the frequency of inspiratory synaptic currents of inspiratory neurons in the pre-Bötzinger complex. In rat medullary slices, both danavorexton and OX-201 significantly increased the frequency of inspiratory synaptic currents of hypoglossal motoneurons. Danavorexton and OX-201 also showed significant effect and tendency, respectively, in increasing the frequency of burst activity recorded from the cervical (C3-C5) ventral root, which contains axons of phrenic motoneurons, in in vitro electrophysiologic analyses from rat isolated brainstem-spinal cord preparations. Electromyogram recordings revealed that intravenous administration of OX-201 increased burst frequency of the diaphragm and burst amplitude of the genioglossus muscle in isoflurane- and urethane-anesthetized rats, respectively. In whole-body plethysmography analyses, oral administration of OX-201 increased respiratory activity in free-moving mice. Overall, these results suggest that OX2R-selective agonists enhance respiratory function via activation of the diaphragm and genioglossus muscle through stimulation of inspiratory neurons in the pre-Bötzinger complex, and phrenic and hypoglossal motoneurons. OX2R-selective agonists could be promising drugs for various conditions with respiratory dysfunction.
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Affiliation(s)
- Ryuji Yamada
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Tatsuki Koike
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Masanori Nakakariya
- Drug Metabolism and Pharmacokinetics Laboratory, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
| | - Haruhide Kimura
- Neuroscience Drug Discovery Unit, Research, Takeda Pharmaceutical Company Limited, Fujisawa, Kanagawa, Japan
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Van Loo D, Dieltjens M, Engelen S, Verbraecken J, Vanderveken OM. Hypoglossal Nerve Stimulation Therapy in a Belgian Cohort of Obstructive Sleep Apnea Patients. Life (Basel) 2024; 14:788. [PMID: 39063543 PMCID: PMC11278378 DOI: 10.3390/life14070788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2024] [Revised: 06/14/2024] [Accepted: 06/18/2024] [Indexed: 07/28/2024] Open
Abstract
Hypoglossal nerve stimulation (HGNS) has emerged as a widespread and innovative treatment option for selected moderate-to-severe obstructive sleep apnea (OSA) patients who cannot be treated effectively with traditional treatment modalities. In this observational cohort study, the objective and subjective outcomes of Belgian OSA patients treated with HGNS therapy were analyzed at 6 and 12 months post-implantation. Thirty-nine patients implanted with a respiration-synchronized HGNS device at the Antwerp University Hospital w ere included in this study. Patients underwent baseline in-laboratory polysomnography and a follow-up sleep study 6 and 12 months post-implantation. Questionnaires on patient experience and daytime sleepiness were filled out and data on objective therapy usage were collected. All 39 patients completed the 6-month follow-up and 21 patients (54%) completed the 12-month follow-up. Median AHI decreased from 33.8 [26.1;45.0] to 10.2 [4.8;16.4] at the 6-month follow-up, and to 9.6 [4.1;16.4] at the 12-month follow-up (p < 0.001). The surgical success rate, according to the Sher20 criteria, was 80% and 76% at the 6- and 12-month follow-ups, respectively. Median ESS improved from 12.0 [7.0;18.0] at baseline to 6.0 [2.5;11.0] at 6 months (p < 0.001) and to 6.5 [2.8;11.5] at 12 months (p = 0.012). Objective therapy usage was 7.4 [6.6;8.0] and 7.0 [5.9:8.2] h/night at the 6- and 12-month follow-ups, respectively. A high overall clinical effectiveness of HGNS therapy, as shown by a mean disease alleviation of 58%, was demonstrated at 12 months post-implantation. Overall, HGNS therapy using respiration-synchronized neurostimulation of the XII cranial nerve resulted in a significant improvement in both objective and subjective OSA outcomes, with a high level of patient satisfaction and high treatment adherence.
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Affiliation(s)
- Dorine Van Loo
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium
| | - Marijke Dieltjens
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium
| | - Sanne Engelen
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, 2650 Edegem, Belgium;
- Research Group LEMP, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium
| | - Olivier M. Vanderveken
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, 2650 Edegem, Belgium
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, 2610 Wilrijk, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, 2650 Edegem, Belgium;
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Harding CD, Fuentes AL, Malhotra A. Tackling obstructive sleep apnea with pharmacotherapeutics: expert guidance. Expert Opin Pharmacother 2024; 25:1019-1026. [PMID: 38913403 PMCID: PMC11227253 DOI: 10.1080/14656566.2024.2365329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/04/2024] [Indexed: 06/25/2024]
Abstract
INTRODUCTION The efficacy of non-pharmacotherapeutic treatment of obstructive sleep apnea, a highly prevalent condition with serious cardiometabolic and neurocognitive health consequences, is well established. Supplementing traditional treatment strategies with medications can improve symptoms and reduce side effects. Efforts to identify medications that target the causes of sleep apnea have met with mixed success. However, this remains a worthwhile objective for researchers to pursue, given the potential benefit pharmacotherapy could bring to those patients who reject or struggle to adhere to existing treatments. AREAS COVERED This article presents the case for obstructive sleep apnea pharmacotherapy including drugs that reduce the occurrence of apnea events, such as weight loss agents, ventilation activators and muscle and nervous system stimulants, drugs that alleviate symptoms, such as wake-promoting agents for excessive daytime sleepiness, and drugs that improve adherence to existing treatments, such as hypnotics. Literature was accessed from PubMed between 1 March 2024 and 18 April 2024. EXPERT OPINION Exciting recent advances in both our understanding of obstructive sleep apnea pathology and in the techniques used to identify therapeutic agents and their targets combine to embolden a positive outlook for the expanded use of drugs in tackling this consequential disease.
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Affiliation(s)
- Christian D. Harding
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
| | - Ana Lucia Fuentes
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
- Pulmonary and Critical Care Section, Veterans Affairs San Diego Healthcare System, La Jolla, CA, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University of California San Diego (UCSD), La Jolla, CA, USA
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Op de Beeck S, Vena D, Mann D, Azarbarzin A, Huyett P, Van de Perck E, Gell LK, Alex RM, Dieltjens M, Willemen M, Verbraecken J, Wellman A, Vanderveken OM, Sands SA. Polysomnographic airflow shapes and site of collapse during drug-induced sleep endoscopy. Eur Respir J 2024; 63:2400261. [PMID: 38548291 PMCID: PMC11154757 DOI: 10.1183/13993003.00261-2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 03/08/2024] [Indexed: 06/09/2024]
Abstract
BACKGROUND Differences in the pharyngeal site of collapse influence efficacy of non-continuous positive airway pressure therapies for obstructive sleep apnoea (OSA). Notably, complete concentric collapse at the level of the palate (CCCp) during drug-induced sleep endoscopy (DISE) is associated with reduced efficacy of hypoglossal nerve stimulation, but CCCp is currently not recognisable using polysomnography. Here we develop a means to estimate DISE-based site of collapse using overnight polysomnography. METHODS 182 OSA patients provided DISE and polysomnography data. Six polysomnographic flow shape characteristics (mean during hypopnoeas) were identified as candidate predictors of CCCp (primary outcome variable, n=44/182), including inspiratory skewness and inspiratory scoopiness. Multivariable logistic regression combined the six characteristics to predict clear presence (n=22) versus absence (n=128) of CCCp (partial collapse and concurrent tongue base collapse excluded). Odds ratios for actual CCCp between predicted subgroups were quantified after cross-validation. Secondary analyses examined complete lateral wall, tongue base or epiglottis collapse. External validation was performed on a separate dataset (ntotal=466). RESULTS CCCp was characterised by greater scoopiness (β=1.5±0.6 per 2sd, multivariable estimate±se) and skewness (β=11.4±2.4) compared with non-CCCp. The odds ratio for CCCp in predicted positive versus negative subgroups was 5.0 (95% CI 1.9-13.1). The same characteristics provided significant cross-validated prediction of lateral wall (OR 6.3, 95% CI 2.4-16.5), tongue base (OR 3.2, 95% CI 1.4-7.3) and epiglottis (OR 4.4, 95% CI 1.5-12.4) collapse. CCCp and lateral wall collapse shared similar characteristics (skewed, scoopy), diametrically opposed to tongue base and epiglottis collapse characteristics. External validation confirmed model prediction. CONCLUSIONS The current study provides a means to recognise patients with likely CCCp or other DISE-based site of collapse categories using routine polysomnography. Since site of collapse influences therapeutic responses, polysomnographic airflow shape analysis could facilitate precision site-specific OSA interventions.
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Affiliation(s)
- Sara Op de Beeck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- These authors contributed equally to this work
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
- These authors contributed equally to this work
| | - Dwayne Mann
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Australia
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Phillip Huyett
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, USA
| | - Eli Van de Perck
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Raichel M Alex
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marijke Dieltjens
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Willemen
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Johan Verbraecken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
- Laboratory of Experimental Medicine and Pediatrics (LEMP), Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Olivier M Vanderveken
- Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
- Department of ENT, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Dharmakulaseelan L, Boulos MI. Sleep Apnea and Stroke: A Narrative Review. Chest 2024:S0012-3692(24)00665-2. [PMID: 38815623 DOI: 10.1016/j.chest.2024.04.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 04/16/2024] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
TOPIC IMPORTANCE Stroke is the second-leading cause of death worldwide. OSA is an independent risk factor for stroke and is associated with multiple vascular risk factors. Poststroke OSA is prevalent and closely linked with various stroke subtypes, including cardioembolic stroke and cerebral small vessel disease. Observational studies have shown that untreated poststroke OSA is associated with an increased risk of recurrent stroke, mortality, poorer functional recovery, and longer hospitalizations. REVIEW FINDINGS Poststroke OSA tends to be underdiagnosed and undertreated, possibly because stroke patients with OSA present atypically compared with the general population with OSA. Objective testing, such as the use of ambulatory sleep testing or in-laboratory polysomnography, is recommended for diagnosing OSA. The gold standard for treating OSA is CPAP therapy. Randomized controlled trials (RCTs) have shown that treatment of poststroke OSA using CPAP improves nonvascular outcomes such as cognition and neurologic recovery. However, findings from RCTs that have evaluated the effect of CPAP on recurrent stroke risk and mortality have been largely negative. SUMMARY There is a need for high-quality RCTs in poststroke OSA that may provide evidence to support the utility of CPAP (and/or other treatment modalities) in reducing recurrent vascular events and mortality. This goal may be achieved by examining treatment strategies that have yet to be trialed in poststroke OSA, tailoring interventions according to poststroke OSA endotypes and phenotypes, selecting high-risk populations, and using metrics that reflect the physiological abnormalities that underlie the harmful effects of OSA on cardiovascular outcomes.
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Affiliation(s)
- Laavanya Dharmakulaseelan
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Mark I Boulos
- Department of Medicine, Division of Neurology, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Hurvitz Brain Sciences Research Program, Sunnybrook Health Sciences Centre, Toronto, ON, Canada; Sleep Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
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10
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Moreau M, Madani A, Dard R, Bourgeois T, d'Ortho MP, Delclaux C, Janel N, Matrot B. [Use of murine models for the study of obstructive sleep apnea syndrome in Down syndrome]. Rev Mal Respir 2024; 41:279-282. [PMID: 38461093 DOI: 10.1016/j.rmr.2024.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 03/11/2024]
Abstract
Down syndrome (DS), or trisomy 21, is a genetic disorder caused by the presence of an extra copy of chromosome 21, leading to various characteristic physical features as well as developmental and cognitive delays. Obstructive sleep apnea syndrome (OSAS) is a common disorder in both adult and pediatric patients with DS. Several characteristics of DS may contribute to the development or worsening of OSAS. Numerous murine models of DS exist. A number of studies have explored apneas and the risk of upper airway obstruction in these models, but up until now, only in adulthood.
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Affiliation(s)
- M Moreau
- Université Paris Cité, BFA, UMR 8251, CNRS, 75013 Paris, France
| | - A Madani
- NeuroDiderot, université Paris Cité, Inserm, 75019 Paris, France.
| | - R Dard
- Université Paris Cité, BFA, UMR 8251, CNRS, 75013 Paris, France
| | - T Bourgeois
- NeuroDiderot, université Paris Cité, Inserm, 75019 Paris, France
| | - M-P d'Ortho
- NeuroDiderot, université Paris Cité, Inserm, 75019 Paris, France; Service de physiologie-explorations fonctionnelles, hôpital Bichat, AP-HP, 75018 Paris, France
| | - C Delclaux
- NeuroDiderot, université Paris Cité, Inserm, 75019 Paris, France; Service d'explorations fonctionnelles pédiatriques, hôpital Robert-Debré, AP-HP, 75019 Paris, France
| | - N Janel
- Université Paris Cité, BFA, UMR 8251, CNRS, 75013 Paris, France
| | - B Matrot
- NeuroDiderot, université Paris Cité, Inserm, 75019 Paris, France
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Wu Y, Gan Q, Liu Q, Wu K. Combination of Aroxybutynin and Atomoxetine in Obstructive Sleep Apnea: Is the Effect of One Plus One Greater than Two? Am J Respir Crit Care Med 2024; 209:763-764. [PMID: 38190697 PMCID: PMC10945053 DOI: 10.1164/rccm.202310-1799le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024] Open
Affiliation(s)
- Yanjuan Wu
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; and
| | - Qiming Gan
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; and
| | - Quanzhen Liu
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; and
- Nanshan School, Guangzhou Medical University, Guangzhou, China
| | - Kang Wu
- Sleep Medicine Center, State Key Laboratory of Respiratory Disease, National Clinical Research Center for Respiratory Disease, Guangzhou Institute of Respiratory Health, National Center for Respiratory Disease, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China; and
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12
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Schweitzer PK. Reply to: Combination of Aroxybutynin and Atomoxetine in Obstructive Sleep Apnea: Is the Effect One Plus One Greater Than Two? Am J Respir Crit Care Med 2024; 209:764-765. [PMID: 38190720 PMCID: PMC10945069 DOI: 10.1164/rccm.202311-2055le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 01/04/2024] [Indexed: 01/10/2024] Open
Affiliation(s)
- Paula K Schweitzer
- Sleep Medicine and Research Center, St. Luke's Hospital, Chesterfield, Missouri
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13
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Siciliano M, Bradicich M, Tondo P, Gunduz Gurkan C, Kuczyński W, Martini A, Aydin Güçlü Ö, Testelmans D, Sánchez-de-la-Torre M, Randerath W, Schwarz EI, Schiza S. ERS International Congress 2023: highlights from the Sleep Disordered Breathing Assembly. ERJ Open Res 2024; 10:00823-2023. [PMID: 38529349 PMCID: PMC10962453 DOI: 10.1183/23120541.00823-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 11/02/2023] [Indexed: 03/27/2024] Open
Abstract
The topic of sleep-related breathing disorders is always evolving, and during the European Respiratory Society (ERS) International Congress 2023 in Milan, Italy, the latest research and clinical topics in respiratory medicine were presented. The most interesting issues included new diagnostic tools, such as cardiovascular parameters and artificial intelligence, pathophysiological traits of sleep disordered breathing from routine polysomnography or polygraphy signals, and new biomarkers and the diagnostic approach in patients with excessive daytime sleepiness. This article summarises the most relevant studies and topics presented at the ERS International Congress 2023. Each section has been written by early career members of ERS Assembly 4.
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Affiliation(s)
- Matteo Siciliano
- Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
- Contributed equally
| | - Matteo Bradicich
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Contributed equally
| | - Pasquale Tondo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
- HP2 Laboratory, Université Grenoble Alpes, Grenoble, France
- Contributed equally
| | - Canan Gunduz Gurkan
- Department of Chest Diseases, Sureyyapasa Chest Diseases and Thoracic Surgery Training and Research Hospital, Istanbul, Turkey
- Contributed equally
| | - Wojciech Kuczyński
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, Lodz, Poland
- Contributed equally
| | - Alessia Martini
- Fondazione Policlinico Universitario A. Gemelli IRCCS – Università Cattolica del Sacro Cuore, Rome, Italy
- Contributed equally
| | - Özge Aydin Güçlü
- Uludag University Faculty of Medicine, Department of Pulmonary Medicine, Bursa, Turkey
- Contributed equally
| | - Dries Testelmans
- Department of Pulmonology, University Hospitals Leuven, Leuven, Belgium
- Contributed equally
| | - Manuel Sánchez-de-la-Torre
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
- Precision Medicine in Chronic Diseases, Hospital Universitari Arnau de Vilanova-Santa Maria, IRB Lleida, Department of Nursing and Physiotherapy, Faculty of Nursing and Physiotherapy, University of Lleida, Lleida, Spain
- Contributed equally
| | - Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
- Contributed equally
| | - Esther Irene Schwarz
- Department of Pulmonology, University Hospital Zurich, Zurich, Switzerland
- Contributed equally
| | - Sophia Schiza
- Sleep Disorders Centre, Dept of Respiratory Medicine, School of Medicine, University of Crete, Heraklion, Greece
- Contributed equally
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14
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Osman AM, Toson B, Naik GR, Mukherjee S, Delbeck M, Hahn M, Muller T, Weimann G, Eckert DJ. A novel TASK channel antagonist nasal spray reduces sleep apnea severity in physiological responders: a randomized, blinded, trial. Am J Physiol Heart Circ Physiol 2024; 326:H715-H723. [PMID: 38214905 DOI: 10.1152/ajpheart.00541.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Revised: 12/25/2023] [Accepted: 12/28/2023] [Indexed: 01/13/2024]
Abstract
Preclinical and human physiological studies indicate that topical, selective TASK 1/3 K+ channel antagonism increases upper airway dilator muscle activity and reduces pharyngeal collapsibility during anesthesia and nasal breathing during sleep. The primary aim of this study was to determine the effects of BAY2586116 nasal spray on obstructive sleep apnea (OSA) severity and whether individual responses vary according to differences in physiological responses and route of breathing. Ten people (5 females) with OSA [apnea-hypopnea index (AHI) = 47 ± 26 events/h (means ± SD)] who completed previous sleep physiology studies with BAY2586116 were invited to return for three polysomnography studies to quantify OSA severity. In random order, participants received either placebo nasal spray (saline), BAY2586116 nasal spray (160 µg), or BAY2586116 nasal spray (160 µg) restricted to nasal breathing (chinstrap or mouth tape). Physiological responders were defined a priori as those who had improved upper airway collapsibility (critical closing pressure ≥2 cmH2O) with BAY2586116 nasal spray (NCT04236440). There was no systematic change in apnea-hypopnea index (AHI3) from placebo versus BAY2586116 with either unrestricted or nasal-only breathing versus placebo (47 ± 26 vs. 43 ± 27 vs. 53 ± 33 events/h, P = 0.15). However, BAY2586116 (unrestricted breathing) reduced OSA severity in physiological responders compared with placebo (e.g., AHI3 = 28 ± 11 vs. 36 ± 12 events/h, P = 0.03 and ODI3 = 18 ± 10 vs. 28 ± 12 events/h, P = 0.02). Morning blood pressure was also lower in physiological responders after BAY2586116 versus placebo (e.g., systolic blood pressure = 137 ± 24 vs. 147 ± 21 mmHg, P < 0.01). In conclusion, BAY2586116 reduces OSA severity during sleep in people who demonstrate physiological improvement in upper airway collapsibility. These findings highlight the therapeutic potential of this novel pharmacotherapy target in selected individuals.NEW & NOTEWORTHY Preclinical findings in pigs and humans indicate that blocking potassium channels in the upper airway with topical nasal application increases pharyngeal dilator muscle activity and reduces upper airway collapsibility. In this study, BAY2586116 nasal spray (potassium channel blocker) reduced sleep apnea severity in those who had physiological improvement in upper airway collapsibility. BAY2586116 lowered the next morning's blood pressure. These findings highlight the potential for this novel therapeutic approach to improve sleep apnea in certain people.
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Affiliation(s)
- Amal M Osman
- Adelaide Institute for Sleep Health and FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Barbara Toson
- Adelaide Institute for Sleep Health and FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Ganesh R Naik
- Adelaide Institute for Sleep Health and FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Sutapa Mukherjee
- Adelaide Institute for Sleep Health and FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Respiratory and Sleep Service, Southern Adelaide Local Health Network, SA Health, Adelaide, South Australia, Australia
| | - Martina Delbeck
- Research & Development, Bayer AG, Pharmaceuticals, Wuppertal, Germany
| | - Michael Hahn
- Research & Development, Bayer AG, Pharmaceuticals, Wuppertal, Germany
| | - Thomas Muller
- Research & Development, Bayer AG, Pharmaceuticals, Wuppertal, Germany
| | - Gerrit Weimann
- Research & Development, Bayer AG, Pharmaceuticals, Wuppertal, Germany
| | - Danny J Eckert
- Adelaide Institute for Sleep Health and FHMRI Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Liu J, Yang X, Li G, Liu P. Pharmacological interventions for the treatment of obstructive sleep apnea syndrome. Front Med (Lausanne) 2024; 11:1359461. [PMID: 38495117 PMCID: PMC10943699 DOI: 10.3389/fmed.2024.1359461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 02/22/2024] [Indexed: 03/19/2024] Open
Abstract
Obstructive Sleep Apnea Syndrome (OSAS) affects 13-33% of males and 6-9% of females globally and poses significant treatment challenges, including poor adherence to Continuous Positive Airway Pressure (CPAP) and residual excessive sleepiness (RES). This review aims to elucidate the emerging interest in pharmacological treatments for OSAS, focusing on recent advancements in this area. A thorough analysis of extensive clinical trials involving various drugs, including selective dopamine reuptake inhibitors, selective norepinephrine inhibitors, combined antimuscarinic agents, and orexin agonists, was conducted. These trials focused on ameliorating respiratory metrics and enhancing sleep quality in individuals affected by OSAS. The studied pharmacological agents showed potential in improving primary outcomes, notably the apnea-hypopnea index (AHI) and the Epworth sleepiness scale (ESS). These improvements suggest enhanced sleep quality and symptom management in OSAS patients. With a deeper understanding of OSAS, pharmacological interventions are emerging as a promising direction for its effective management. This review provides a comprehensive overview of the current state of drug research in OSAS, highlighting the potential of these treatments in addressing the disorder's complex challenges.
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Affiliation(s)
- Jin Liu
- Department of Central Hospital of Tujia and Miao Autonomous Prefecture, Hubei University of Medicine, Shiyan, China
| | - Xiaolan Yang
- Department of Pediatrics, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Guangcai Li
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
| | - Peijun Liu
- Department of Respiratory and Critical Care Medicine, The Central Hospital of Enshi Tujia and Miao Autonomous Prefecture, Enshi City, China
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Sands SA, Collet J, Gell LK, Calianese N, Hess LB, Vena D, Azarbarzin A, Bertisch SM, Landry S, Thomson L, Joosten SA, Hamilton GS, Edwards BA. Combination pharmacological therapy targeting multiple mechanisms of sleep apnoea: a randomised controlled cross-over trial. Thorax 2024; 79:259-268. [PMID: 38286618 DOI: 10.1136/thorax-2023-220184] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 09/23/2023] [Indexed: 01/31/2024]
Abstract
RATIONALE Acetazolamide and atomoxetine-plus-oxybutynin ('AtoOxy') can improve obstructive sleep apnoea (OSA) by stabilising ventilatory control and improving dilator muscle responsiveness respectively. Given the different pathophysiological mechanisms targeted by each intervention, we tested whether AtoOxy-plus-acetazolamide would be more efficacious than AtoOxy alone. METHODS In a multicentre randomised crossover trial, 19 patients with moderate-to-severe OSA received AtoOxy (80/5 mg), acetazolamide (500 mg), combined AtoOxy-plus-acetazolamide or placebo at bedtime for three nights (half doses on first night) with a 4-day washout between conditions. Outcomes were assessed at baseline and night 3 of each treatment period. Mixed model analysis compared the reduction in Apnoea-Hypopnoea Index (AHI) from baseline between AtoOxy-plus-acetazolamide and AtoOxy (primary outcome). Secondary outcomes included hypoxic burden and arousal index. RESULTS Although AtoOxy lowered AHI by 49 (33, 62)%baseline (estimate (95% CI)) vs placebo, and acetazolamide lowered AHI by+34 (14, 50)%baseline vs placebo, AtoOxy-plus-acetazolamide was not superior to AtoOxy alone (difference: -2 (-18, 11)%baseline, primary outcome p=0.8). Likewise, the hypoxic burden was lowered with AtoOxy (+58 (37, 71)%baseline) and acetazolamide (+37 (5, 58)%baseline), but no added benefit versus AtoOxy occurred when combined (difference: -13 (-5, 39)%baseline). Arousal index was also modestly reduced with each intervention (11%baseline-16%baseline). Mechanistic analyses revealed that similar traits (ie, higher baseline compensation, lower loop gain) were associated with both AtoOxy and acetazolamide efficacy. CONCLUSIONS While AtoOxy halved AHI, and acetazolamide lowered AHI by a third, the combination of these leading experimental interventions provided no greater efficacy than AtoOxy alone. Failure of acetazolamide to further increase efficacy suggests overlapping physiological mechanisms. TRIAL REGISTRATION NUMBER NCT03892772.
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Affiliation(s)
- Scott A Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Jinny Collet
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lauren B Hess
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne M Bertisch
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Shane Landry
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Luke Thomson
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
| | - Simon A Joosten
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Garun S Hamilton
- School of Clinical Sciences, Monash University, Clayton, Victoria, Australia
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia
- Monash Partners - Epworth, Melbourne, Victoria, Australia
| | - Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Clayton, Victoria, Australia
- School of Psychological Sciences, Monash University, Clayton, Victoria, Australia
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17
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Nobre ML, Sarmento ACA, de Oliveira PF, Wanderley FF, Diniz Júnior J, Gonçalves AK. Pharmacological treatment for obstructive sleep apnea: A systematic review and meta-analysis. Clinics (Sao Paulo) 2024; 79:100330. [PMID: 38341903 PMCID: PMC10869242 DOI: 10.1016/j.clinsp.2024.100330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 12/21/2023] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE Summarize the evidence on drug therapies for obstructive sleep apnea. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, Scopus, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched on February 17th, 2023. A search strategy retrieved randomized clinical trials comparing the Apnea-Hypopnea Index (AHI) in pharmacotherapies. Studies were selected and data was extracted by two authors independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. RevMan 5.4. was used for data synthesis. RESULTS 4930 articles were obtained, 68 met inclusion criteria, and 29 studies (involving 11 drugs) were combined in a meta-analysis. Atomoxetine plus oxybutynin vs placebo in AHI mean difference of -7.71 (-10.59, -4.83) [Fixed, 95 % CI, I2 = 50 %, overall effect: Z = 5.25, p < 0.001]. Donepezil vs placebo in AHI mean difference of -8.56 (-15.78, -1.33) [Fixed, 95 % CI, I2 = 21 %, overall effect: Z = 2.32, p = 0.02]. Sodium oxybate vs placebo in AHI mean difference of -5.50 (-9.28, -1.73) [Fixed, 95 % CI, I2 = 32 %, overall effect: Z = 2.86, p = 0.004]. Trazodone vs placebo in AHI mean difference of -12.75 (-21.30, -4.19) [Fixed, 95 % CI, I2 = 0 %, overall effect: Z = 2.92, p = 0.003]. CONCLUSION The combination of noradrenergic and antimuscarinic drugs shows promising results. Identifying endotypes may be the key to future drug therapies for obstructive sleep apnea. Moreover, studies with longer follow-up assessing the safety and sustained effects of these treatments are needed. PROSPERO REGISTRATION NUMBER CRD42022362639.
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Affiliation(s)
- Maria Luísa Nobre
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ayane Cristine Alves Sarmento
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Clinical Analysis and Toxicology, Universidade Federal do Rio Grande do Norte, RN, Brazil
| | | | | | - José Diniz Júnior
- Department of Surgery, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ana Katherine Gonçalves
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Gynecology and Obstetrics, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
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18
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Qin H, Fietze I, Mazzotti DR, Steenbergen N, Kraemer JF, Glos M, Wessel N, Song L, Penzel T, Zhang X. Obstructive sleep apnea heterogeneity and autonomic function: a role for heart rate variability in therapy selection and efficacy monitoring. J Sleep Res 2024; 33:e14020. [PMID: 37709966 DOI: 10.1111/jsr.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 07/23/2023] [Accepted: 08/03/2023] [Indexed: 09/16/2023]
Abstract
Obstructive sleep apnea is a highly prevalent sleep-related breathing disorder, resulting in a disturbed breathing pattern, changes in blood gases, abnormal autonomic regulation, metabolic fluctuation, poor neurocognitive performance, and increased cardiovascular risk. With broad inter-individual differences recognised in risk factors, clinical symptoms, gene expression, physiological characteristics, and health outcomes, various obstructive sleep apnea subtypes have been identified. Therapeutic efficacy and its impact on outcomes, particularly for cardiovascular consequences, may also vary depending on these features in obstructive sleep apnea. A number of interventions such as positive airway pressure therapies, oral appliance, surgical treatment, and pharmaceutical options are available in clinical practice. Selecting an effective obstructive sleep apnea treatment and therapy is a challenging medical decision due to obstructive sleep apnea heterogeneity and numerous treatment modalities. Thus, an objective marker for clinical evaluation is warranted to estimate the treatment response in patients with obstructive sleep apnea. Currently, while the Apnea-Hypopnea Index is used for severity assessment of obstructive sleep apnea and still considered a major guide to diagnosis and managements of obstructive sleep apnea, the Apnea-Hypopnea Index is not a robust marker of symptoms, function, or outcome improvement. Abnormal cardiac autonomic modulation can provide additional insight to better understand obstructive sleep apnea phenotyping. Heart rate variability is a reliable neurocardiac tool to assess altered autonomic function and can also provide cardiovascular information in obstructive sleep apnea. Beyond the Apnea-Hypopnea Index, this review aims to discuss the role of heart rate variability as an indicator and predictor of therapeutic efficacy to different modalities in order to optimise tailored treatment for obstructive sleep apnea.
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Affiliation(s)
- Hua Qin
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ingo Fietze
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
- The Fourth People's Hospital of Guangyuan, Guangyuan, China
| | - Diego R Mazzotti
- Division of Medical Informatics, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | - Jan F Kraemer
- Department of Physics, Humboldt-Universität zu Berlin, Berlin, Germany
- Information Processing and Analytics Group, School of Library and Information Science, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Glos
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Niels Wessel
- Department of Physics, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Medicine, Medical School Berlin, Berlin, Germany
| | - Lijun Song
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Xiaowen Zhang
- Department of Otolaryngology, Head and Neck Surgery, State Key Laboratory of Respiratory Disease, The Key Laboratory of Advanced Interdisciplinary Studies Center, The First Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
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19
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Nobre ML, Sarmento ACA, Medeiros KS, Serquiz N, Júnior JD, Gonçalves AK. Drug therapies for obstructive sleep apnoea: a systematic review and meta-analysis protocol. BMJ Open 2024; 14:e076456. [PMID: 38272544 PMCID: PMC10824059 DOI: 10.1136/bmjopen-2023-076456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 12/01/2023] [Indexed: 01/27/2024] Open
Abstract
INTRODUCTION Obstructive sleep apnoea (OSA) is a common disorder that can affect the quality of life and increase the risk for psychiatric, neurological and cardiometabolic diseases. Despite the significant burden, it poses on health and well-being, there is a lack of evidence regarding the use of drug therapies in these patients. This work aims to evaluate the efficacy and safety of pharmacological treatment alternatives for patients with OSA. METHODS AND ANALYSIS Databases, including PubMed, Embase, Web of Science, SciELO, LILACS, Scopus, Cochrane Register of Controlled Trials and ClinicalTrials.gov, will be used for the search. A search strategy was developed to retrieve clinical trials that have evaluated polysomnographic primary outcome (Apnoea-Hypopnoea index) and secondary outcomes (eg, daytime sleepiness, adverse events) of any drug therapy used for OSA. No date or language restrictions will be applied. Two authors will independently select the studies meeting the inclusion criteria by screening the title, abstract and full text. Data will be extracted, and the risk of bias will be evaluated using the Cochrane Risk of Bias Tool. Review Manager V.5.4.1 will be used for data synthesis. The Grading of Recommendation Assessment, Development and Evaluation will be used to assess the strength of the evidence. ETHICS AND DISSEMINATION As a review of published data, it is not necessary to obtain ethical approval. The findings of this systematic review will be published in a peer-reviewed journal. PROSPERO REGISTRATION NUMBER CRD42022362639.
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Affiliation(s)
- Maria Luisa Nobre
- Surgery Department, Federal University of Rio Grande do Norte, Natal, Brazil
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Ayane Cristine Alves Sarmento
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Clinical and Toxicological Analysis, Federal University of Rio Grande do Norte, Natal, Brazil
| | | | - Nicoli Serquiz
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Obstetrics and Gynecology, Federal University of Rio Grande do Norte, Natal, Brazil
| | - José Diniz Júnior
- Surgery Department, Federal University of Rio Grande do Norte, Natal, Brazil
| | - Ana Katherine Gonçalves
- Postgraduate Program student in Health Science, Federal University of Rio Grande do Norte, Natal, Brazil
- Department of Obstetrics and Gynecology, Federal University of Rio Grande do Norte, Natal, Brazil
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20
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Shahbazi M, Heidari R, Tafakhori A, Samadi S, Nikeghbalian Z, Amirifard H, Najafi A. The effects of atomoxetine and trazodone combination on obstructive sleep apnea and sleep microstructure: A double-blind randomized clinical trial study. Sleep Med 2024; 113:13-18. [PMID: 37979502 DOI: 10.1016/j.sleep.2023.11.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Revised: 10/30/2023] [Accepted: 11/02/2023] [Indexed: 11/20/2023]
Abstract
STUDY OBJECTIVES we aimed to compare the effects of atomoxetine and trazodone (A-T) in combination with placebo in patients with obstructive sleep apnea (OSA). METHODS This randomized, placebo-controlled, double-blind, crossover trial study was conducted in adults with OSA referred to a Sleep Clinic. Participants with eligibility criteria were recruited. Patients were studied on two separate nights with one-week intervals, once treated with trazodone (50 mg) and atomoxetine (80 mg) combination and then with a placebo and the following polysomnography tests. RESULTS A total of 18 patients with OSA completed the study protocol, 9(50%) were male, the mean age was 47.5 years (SD = 9.8) and the mean Body mass index of participants was 28.4 kg/m2 (SD = 3.4). Compared with the placebo, the A-T combination resulted in significant differences in AHI (28.3(A-T) vs. 42.7 (placebo), p = 0.025), duration of the REM stage (1.3%TST (A-T) vs. 13.1%TST (placebo), p = 0.001), and the number of REM cycles (0.8 (A-T) vs. 4.7 (placebo), p = 0.001), number of apneas (38.3 (A-T) vs. 79.3 (placebo), p = 0.011), number of obstructive apneas (37.2 (A-T) vs. 75.2 (placebo), p = 0.011), oxygen desaturation index (29.5 (A-T) vs. 42.3 (placebo), p = 0.022) and number of respiratory arousals (43.2 (A-T) vs. 68.5 (placebo), p = 0.048). This decrement effect did not change among those with a low-arousal phenotype of OSA. CONCLUSIONS The A-T combination significantly improved respiratory events' indices compared with placebo in patients with OSA. This combination is recommended to be assessed in a large trial. It could be an alternative for those who do not adhere to the standard available treatments for OSA.
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Affiliation(s)
- Mojtaba Shahbazi
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Reihaneh Heidari
- Otolaryngology Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Abbas Tafakhori
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran
| | - Shahram Samadi
- Sleep Breathing Disorders Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Zahra Nikeghbalian
- Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamed Amirifard
- Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences, Tehran, Iran; Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran.
| | - Arezu Najafi
- Sleep Breathing Disorders Research Center, Tehran University of Medical Sciences, Tehran, Iran; Occupational Sleep Research Center, Baharloo Hospital, Tehran University of Medical Sciences, Tehran, Iran
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21
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Schweitzer PK, Taranto-Montemurro L, Ojile JM, Thein SG, Drake CL, Rosenberg R, Corser B, Abaluck B, Sangal RB, Maynard J. The Combination of Aroxybutynin and Atomoxetine in the Treatment of Obstructive Sleep Apnea (MARIPOSA): A Randomized Controlled Trial. Am J Respir Crit Care Med 2023; 208:1316-1327. [PMID: 37812772 PMCID: PMC10765395 DOI: 10.1164/rccm.202306-1036oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/09/2023] [Indexed: 10/11/2023] Open
Abstract
Rationale: Obstructive sleep apnea (OSA) is a common sleep disorder for which the principal treatment option, continuous positive airway pressure, is often poorly tolerated. There is currently no approved pharmacotherapy for OSA. However, recent studies have demonstrated improvement in OSA with combined antimuscarinic and noradrenergic drugs. Objectives: The aim of this study was to evaluate the efficacy and safety of AD109, a combination of the novel antimuscarinic agent aroxybutynin and the norepinephrine reuptake inhibitor atomoxetine, in the treatment of OSA. Methods: Phase II randomized, double-blind, placebo-controlled, parallel-group, 4-week trial comparing AD109 2.5/75 mg, AD109 5/75 mg, atomoxetine 75 mg alone, and placebo (www.clinicaltrials.gov identifier NCT05071612). Measurements and Main Results: Of 211 randomized patients, 181 were included in the prespecified efficacy analyses. Sleep was assessed by two baseline and two treatment polysomnograms. Apnea-hypopnea index with a 4% desaturation criterion (primary outcome) was reduced from a median (IQR) of 20.5 (12.3-27.2) to 10.8 (5.6-18.5) in the AD109 2.5/75 mg arm (-47.1%), from 19.4 (13.7-26.4) to 9.5 (6.1-19.3) in the AD109 5/75 mg arm (-42.9%; both P < 0.0001 vs. placebo), and from 19.0 (11.8-28.8) to 11.8 (5.5-21.5) with atomoxetine alone (-38.8%; P < 0.01 vs. placebo). Apnea-hypopnea index with a 4% desaturation criterion decreased from 20.1 (11.9-25.9) to 16.3 (11.1-28.9) in the placebo arm. Subjectively, there was improvement in fatigue with AD109 2.5/75 mg (P < 0.05 vs. placebo and atomoxetine). Atomoxetine taken alone decreased total sleep time (P < 0.05 vs. AD109 and placebo). The most common adverse events were dry mouth, insomnia, and urinary hesitancy. Conclusions: AD109 showed clinically meaningful improvement in OSA, suggesting that further development of the compound is warranted. Clinical trial registered with www.clinicaltrials.gov (NCT05071612).
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Affiliation(s)
- Paula K. Schweitzer
- Sleep Medicine and Research Center, St. Luke’s Hospital, Chesterfield, Missouri
| | | | | | - Stephen G. Thein
- Pacific Research Network, an Evolution Research Group Portfolio Site, San Diego, California
| | - Christopher L. Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, Michigan
| | | | | | - Brian Abaluck
- Sleep Medicine, Brian Abaluck, M.D., Malvern, Pennsylvania
| | - R. Bart Sangal
- Sleep & Attention Disorders Institute, Sterling Heights, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan; and
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22
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Combs D, Edgin J, Hsu CH, Bottrill K, Van Vorce H, Gerken B, Matloff D, La Rue S, Parthasarathy S. The combination of atomoxetine and oxybutynin for the treatment of obstructive sleep apnea in children with Down syndrome. J Clin Sleep Med 2023; 19:2065-2073. [PMID: 37555595 PMCID: PMC10692944 DOI: 10.5664/jcsm.10764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/02/2023] [Accepted: 08/02/2023] [Indexed: 08/10/2023]
Abstract
STUDY OBJECTIVES Children with Down syndrome (DS) are at very high risk for obstructive sleep apnea (OSA). Current OSA treatments have limited effectiveness in this population. We evaluated the effectiveness of atomoxetine and oxybutynin (ato-oxy) to treat OSA in children with Down syndrome. METHODS Children ages 6-7 years old with Down syndrome and OSA participated in a double-blind crossover clinical trial evaluating two dose regimens of ato-oxy. Participants received low-dose ato-oxy (0.5 mg/kg atomoxetine and 5 mg oxybutynin) and high-dose ato-oxy (1.2 mg/kg atomoxetine and 5 mg oxybutynin) for 1 month in random order. The primary study outcome was change in obstructive apnea-hypopnea index. Health-related quality of life as measured by the OSA-18 as well as changes in sleep architecture were secondary outcomes. RESULTS Fifteen participants qualified for randomization and 11 participants had complete data at all points. Baseline obstructive apnea-hypopnea index was 7.4 ± 3.7 (mean ± standard deviation), obstructive apnea-hypopnea index with low-dose ato-oxy was 3.6 ± 3.3 (P = .001 vs baseline), and obstructive apnea-hypopnea index with high-dose ato-oxy was 3.9 ± 2.8 (P = .003 vs baseline). No significant sleep architecture differences were present with ato-oxy. No significant difference in OSA-18 score was present. OSA-18 total score was 51 ± 19 at baseline, 45 ± 17 (P = .09) at the end of 4 weeks of low-dose ato-oxy, and 45 ± 16 (P = .37) at the end of high-dose ato-oxy therapy. The most common adverse effects were irritability and fatigue, and these were generally mild. CONCLUSIONS Ato-oxy is a promising treatment for OSA in children with Down syndrome. CLINICAL TRIAL REGISTRATION Registry: Clinicaltrials.gov; Name: Medications for Obstructive Sleep Apnea In Children With Down Syndrome (MOSAIC); URL: https://clinicaltrials.gov/ct2/show/NCT04115878; Identifier: NCT04115878. CITATION Combs D, Edgin J, Hsu C-H, et al. The combination of atomoxetine and oxybutynin for the treatment of obstructive sleep apnea in children with Down syndrome. J Clin Sleep Med. 2023;19(12):2065-2073.
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Affiliation(s)
- Daniel Combs
- UAHS Center for Sleep & Circadian Sciences, University of Arizona, Tucson, Arizona
- Department of Pediatrics, University of Arizona, Tucson, Arizona
| | - Jamie Edgin
- Department of Psychology, University of Arizona, Tucson, Arizona
| | - Chiu-Hsieh Hsu
- Mel and Enid Zuckerman College of Public Health, University of Arizona, Tucson, Arizona
| | - Kenneth Bottrill
- Department of Psychology, University of Arizona, Tucson, Arizona
| | - Hailey Van Vorce
- Department of Psychology, University of Arizona, Tucson, Arizona
| | - Blake Gerken
- UAHS Center for Sleep & Circadian Sciences, University of Arizona, Tucson, Arizona
| | - Daniel Matloff
- UAHS Center for Sleep & Circadian Sciences, University of Arizona, Tucson, Arizona
| | - Sicily La Rue
- UAHS Center for Sleep & Circadian Sciences, University of Arizona, Tucson, Arizona
| | - Sairam Parthasarathy
- UAHS Center for Sleep & Circadian Sciences, University of Arizona, Tucson, Arizona
- Department of Medicine, University of Arizona, Tucson, Arizona
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23
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Bokov P, Boujemla I, Dahan J, Dudoignon B, Delclaux C. Obstructive sleep apnea in children with Down syndrome: contribution of upper airway and chemosensitivity. Pediatr Res 2023; 94:1990-1997. [PMID: 37429910 DOI: 10.1038/s41390-023-02718-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Revised: 05/24/2023] [Accepted: 06/15/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND The high prevalence of obstructive sleep apnea syndrome (OSAS) in children with Down syndrome (DS) has been attributed to a reduced upper airway size, while the role of ventilatory control is unclear. The objectives of our case-control study were to evaluate the upper airway reduction in children with DS and moderate to severe OSAS as compared to typically developing (TD) children with similar OSAS severity and to evaluate the degree of chemical loop gain modifications including its components: controller and plant gains (CG, PG). METHODS Thirteen children with DS were matched for age, sex, OSAS severity and ethnicity with 26 TD children. They had undergone acoustic rhinometry and pharyngometry, chemical LG obtained during awake tidal breathing measurement and hypercapnic-hyperoxic ventilatory response testing. RESULTS As compared to TD, children with DS depicted reduced oropharyngeal dimensions, significantly lower CG and LG and no different PG. Their hypercapnic ventilatory response slopes were not different. CONCLUSIONS We concluded that the decreased CG in DS was related to decreased peripheral chemoreceptor sensitivity, and while central chemosensitivity was normal, the former explained the increased end-tidal PCO2 observed in children with DS as compared to TD. Pharyngeal dimensions are reduced in children with DS and OSAS. IMPACT Reduced upper airway size and nocturnal alveolar hypoventilation in children with Down syndrome (DS) have been previously reported. We confirmed that children with DS and moderate-to-severe OSA have reduced oropharyngeal size as compared to typically developing children with similar OSAS severity and demonstrated decreased peripheral chemosensitivity explaining the alveolar hypoventilation observed in children with DS. Central chemosensitivity appears to be intact in children with DS and moderate to severe OSAS Our results support growing evidence that Down syndrome is associated with autonomic nervous system dysfunction.
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Affiliation(s)
- Plamen Bokov
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil, INSERM NeuroDiderot, F-75019, Paris, France.
| | - Imene Boujemla
- AP-HP, Hôpital Robert Debré, Service d'Oto-Rhino-Laryngologie, F-75019, Paris, France
| | - Jacques Dahan
- AP-HP, Hôpital Robert Debré, Service de Stomatologie et Chirurgie Plastique, F-75019, Paris, France
| | - Benjamin Dudoignon
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil, INSERM NeuroDiderot, F-75019, Paris, France
| | - Christophe Delclaux
- Université de Paris-Cité, AP-HP, Hôpital Robert Debré, Service de Physiologie Pédiatrique-Centre du Sommeil, INSERM NeuroDiderot, F-75019, Paris, France
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24
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Pıhtılı A, Gündüz Gürkan C, Ali Habeşoğlu M, Öztürk Ö, Özsancak Uğurlu A, Sezai Taşbakan M, Peker Y. A Narrative Review of the Clinical Trials in Sleep-Related Breathing Disorders from 2022 to Present. THORACIC RESEARCH AND PRACTICE 2023; 25. [PMID: 38015164 PMCID: PMC11160422 DOI: 10.5152/thoracrespract.2023.23104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 11/29/2023]
Abstract
Sleep-related breathing disorders (SRBD) comprise obstructive sleep apnea (OSA), central sleep apnea (CSA), obesity-hypoventilation syndrome (OHS), as well as isolated sleep-related hypoxemia (ISRH), according to the recent International Classification of Sleep Disorders 3. During the last decades, there have been cumulative research reports indicating an association between the SRBD and increased cardiometabolic illness and death, as well as decreased quality of life. Notwithstanding, the results have been inconclusive, and the evidence level was not high regarding the effect of treatment for the SRBD on adverse outcomes. In the current work, we aim to give a comprehensive review of the clinical trials published from January 2022 to August 31, 2023. We highlight the heterogeneity of cardiometabolic disorders among adults with SRBD and particularly emphasize OSA management, drug therapy for OSA, positive airway pressure (PAP) therapy and cardiovascular outcomes, other effects of PAP in pregnancy and neurocognitive function, as well as the effects of surgical treatment and oral appliances. We also underline future directions in OSA management, telemonitoring, and druginduced sleep endoscopy in managing the SRBD, especially OSA. We ascertain that more studies are needed within the CSA, OHS, and ISRH research fields.
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Affiliation(s)
- Aylin Pıhtılı
- Department of Pulmonary Medicine, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Canan Gündüz Gürkan
- Department of Pulmonary Medicine, Süreyyapaşa Chest Diseases Research and Training Hospital, İstanbul, Turkey
| | - Mehmet Ali Habeşoğlu
- Department of Pulmonary Medicine, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Önder Öztürk
- Department of Pulmonary Medicine, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey
| | - Aylin Özsancak Uğurlu
- Department of Pulmonary Medicine, Başkent University Faculty of Medicine, Ankara, Turkey
| | | | - Yüksel Peker
- Department of Pulmonary Medicine, Ege University Faculty of Medicine, İzmir, Turkey
- Department of Pulmonary Medicine, Koç University Faculty of Medicine, İstanbul, Turkey
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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25
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Ayas N, Pépin JL. Pharmacologic Therapy for Obstructive Sleep Apnea: Are We Seeing Some Light at the End of the Tunnel? Am J Respir Crit Care Med 2023; 208:1263-1264. [PMID: 37939168 PMCID: PMC10765387 DOI: 10.1164/rccm.202310-1778ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 11/08/2023] [Indexed: 11/10/2023] Open
Affiliation(s)
- Najib Ayas
- UBC, Medicine, Vancouver, British Columbia, Canada;
| | - Jean-Louis Pépin
- Centre Hospitalier Universitaire de Grenoble, 36724, Grenoble, France
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26
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Rudy SL, Wealing JC, Banayat T, Black C, Funk GD, Revill AL. A muscarinic, GIRK channel-mediated inhibition of inspiratory-related XII nerve motor output emerges in early postnatal development in mice. J Appl Physiol (1985) 2023; 135:1041-1052. [PMID: 37767557 PMCID: PMC10911762 DOI: 10.1152/japplphysiol.00042.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 09/06/2023] [Accepted: 09/21/2023] [Indexed: 09/29/2023] Open
Abstract
In neonatal rhythmic medullary slices, muscarinic acetylcholine receptor (mAChR) activation of hypoglossal (XII) motoneurons that innervate the tongue has a net excitatory effect on XII inspiratory motor output. Conversely, during rapid eye movement sleep in adult rodents, XII motoneurons experience a loss of excitability partly due to activation of mAChRs. This may be mediated by activation of G-protein-coupled inwardly rectifying potassium (GIRK) channels. Therefore, this study was designed to evaluate whether muscarinic modulation of XII inspiratory motor output in mouse rhythmic medullary slices includes GIRK channel-mediated inhibition and, if so, when this inhibitory mechanism emerges. Local pressure injection of the mAChR agonist muscarine potentiated inspiratory bursting by 150 ± 28% in postnatal day (P)0-P5 rhythmic medullary slice preparations. In the absence of muscarine, pharmacological GIRK channel block by Tertiapin-Q did not affect inspiratory burst parameters, whereas activation with ML297 decreased inspiratory burst area. Blocking GIRK channels by local preapplication of Tertiapin-Q revealed a developmental change in muscarinic modulation of inspiratory bursting. In P0-P2 rhythmic medullary slices, Tertiapin-Q preapplication had no significant effect on muscarinic potentiation of inspiratory bursting (a negligible 6% decrease). However, preapplication of Tertiapin-Q to P3-P5 rhythmic medullary slices caused a 19% increase in muscarinic potentiation of XII inspiratory burst amplitude. Immunofluorescence experiments revealed expression of GIRK 1 and 2 subunits and M1, M2, M3, and M5 mAChRs from P0 to P5. Overall, these data support that mechanisms underlying muscarinic modulation of inspiratory burst activity change postnatally and that potent GIRK-mediated inhibition described in adults emerges early in postnatal life.NEW & NOTEWORTHY Muscarinic modulation of inspiratory bursting at hypoglossal motoneurons has a net excitatory effect in neonatal rhythmic medullary slice preparations and a net inhibitory effect in adult animals. We demonstrate that muscarinic modulation of inspiratory bursting undergoes maturational changes from postnatal days 0 to 5 that include emergence of an inhibitory component mediated by G-protein-coupled inwardly rectifying potassium channels after postnatal day 3 in neonatal mouse rhythmic medullary slice preparations.
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Affiliation(s)
- Samantha L Rudy
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, United States
| | - Jesse C Wealing
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, United States
| | - Tatum Banayat
- Department of Physiology, College of Graduate Studies, Midwestern University, Glendale, Arizona, United States
| | - Chody Black
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, United States
| | - Gregory D Funk
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Alberta, Canada
- Department of Physiology, University of Alberta, Edmonton, Alberta, Canada
- Women and Children's Health Research Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Ann L Revill
- Arizona College of Osteopathic Medicine, Midwestern University, Glendale, Arizona, United States
- Department of Physiology, College of Graduate Studies, Midwestern University, Glendale, Arizona, United States
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27
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He S, Cistulli PA, de Chazal P. A Review of Novel Oximetry Parameters for the Prediction of Cardiovascular Disease in Obstructive Sleep Apnoea. Diagnostics (Basel) 2023; 13:3323. [PMID: 37958218 PMCID: PMC10649141 DOI: 10.3390/diagnostics13213323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/18/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is a sleep disorder with repetitive collapse of the upper airway during sleep, which leads to intermittent hypoxic events overnight, adverse neurocognitive, metabolic complications, and ultimately an increased risk of cardiovascular disease (CVD). The standard diagnostic parameter for OSA, apnoea-hypopnoea index (AHI), is inadequate to predict CVD morbidity and mortality, because it focuses only on the frequency of apnoea and hypopnoea events, and fails to reveal other physiological information for the prediction of CVD events. Novel parameters have been introduced to compensate for the deficiencies of AHI. However, the calculation methods and criteria for these parameters are unclear, hindering their use in cross-study analysis and studies. This review aims to discuss novel parameters for predicting CVD events from oximetry signals and to summarise the corresponding computational methods.
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Affiliation(s)
- Siying He
- Charles Perkins Centre, Faculty of Engineering, Sydney University, Camperdown, NSW 2050, Australia;
| | - Peter A. Cistulli
- Charles Perkins Centre, Faculty of Medicine and Health, Sydney University, Camperdown, NSW 2050, Australia;
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital, St Leonards, NSW 2065, Australia
| | - Philip de Chazal
- Charles Perkins Centre, Faculty of Engineering, Sydney University, Camperdown, NSW 2050, Australia;
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Arslan RS. Sleep disorder and apnea events detection framework with high performance using two-tier learning model design. PeerJ Comput Sci 2023; 9:e1554. [PMID: 37810361 PMCID: PMC10557519 DOI: 10.7717/peerj-cs.1554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/04/2023] [Indexed: 10/10/2023]
Abstract
Sleep apnea is defined as a breathing disorder that affects sleep. Early detection of sleep apnea helps doctors to take intervention for patients to prevent sleep apnea. Manually making this determination is a time-consuming and subjectivity problem. Therefore, many different methods based on polysomnography (PSG) have been proposed and applied to detect this disorder. In this study, a unique two-layer method is proposed, in which there are four different deep learning models in the deep neural network (DNN), gated recurrent unit (GRU), recurrent neural network (RNN), RNN-based-long term short term memory (LSTM) architecture in the first layer, and a machine learning-based meta-learner (decision-layer) in the second layer. The strategy of making a preliminary decision in the first layer and verifying/correcting the results in the second layer is adopted. In the training of this architecture, a vector consisting of 23 features consisting of snore, oxygen saturation, arousal and sleep score data is used together with PSG data. A dataset consisting of 50 patients, both children and adults, is prepared. A number of pre-processing and under-sampling applications have been made to eliminate the problem of unbalanced classes. Proposed method has an accuracy of 95.74% and 99.4% in accuracy of apnea detection (apnea, hypopnea and normal) and apnea types detection (central, mixed and obstructive), respectively. Experimental results demonstrate that patient-independent consistent results can be produced with high accuracy. This robust model can be considered as a system that will help in the decisions of sleep clinics where it is expected to detect sleep disorders in detail with high performance.
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29
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He D, Chen J, Du X, Xu L. Summary of drug therapy to treat cognitive impairment-induced obstructive sleep apnea. Front Cell Neurosci 2023; 17:1222626. [PMID: 37731463 PMCID: PMC10507626 DOI: 10.3389/fncel.2023.1222626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/01/2023] [Indexed: 09/22/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a severe sleep disorder associated with intermittent hypoxia and sleep fragmentation. Cognitive impairment is a signifi- cant and common OSA complication often described in such patients. The most commonly utilized methods in clinical OSA treatment are oral appliances and continuous positive airway pressure (CPAP). However, the current therapeutic methods for improving cognitive function could not achieve the expected efficacy in same patients. Therefore, further understanding the molecular mechanism behind cognitive dysfunction in OSA disease will provide new treatment methods and targets. This review briefly summarized the clinical manifestations of cognitive impairment in OSA disease. Moreover, the pathophysiological molecular mechanism of OSA was outlined. Our study concluded that both SF and IH could induce cognitive impairment by multiple signaling pathways, such as oxidative stress activation, inflammation, and apoptosis. However, there is a lack of effective drug therapy for cognitive impairment in OSA. Finally, the therapeutic potential of some novel compounds and herbal medicine was evaluated on attenuating cognitive impairment based on certain preclinical studies.
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Affiliation(s)
- Daqiang He
- Department of Laboratory Medicine, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
| | - Jian Chen
- School of Basic Medical Sciences and Forensic Medicine, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xiaoxue Du
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Linhao Xu
- Key Laboratory of Clinical Cancer Pharmacology and Toxicology Research of Zhejiang Province, Translational Medicine Research Center, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Cardiology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China
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30
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Thomas E, Micic G, Adams R, Eckert DJ. Pharmacological management of co-morbid obstructive sleep apnoea and insomnia. Expert Opin Pharmacother 2023; 24:1963-1973. [PMID: 38099435 DOI: 10.1080/14656566.2023.2292186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA. AREAS COVERED This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities. EXPERT OPINION There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.
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Affiliation(s)
- Emma Thomas
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Gorica Micic
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Robert Adams
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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Gell LK, Vena D, Grace K, Azarbarzin A, Messineo L, Hess LB, Calianese N, Labarca G, Taranto-Montemurro L, White DP, Wellman A, Sands SA. Drive versus Pressure Contributions to Genioglossus Activity in Obstructive Sleep Apnea. Ann Am Thorac Soc 2023; 20:1326-1336. [PMID: 37411045 PMCID: PMC10502881 DOI: 10.1513/annalsats.202301-083oc] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 06/26/2023] [Indexed: 07/08/2023] Open
Abstract
Rationale: Loss of pharyngeal dilator muscle activity is a key determinant of respiratory events in obstructive sleep apnea (OSA). After the withdrawal of wakefulness stimuli to the genioglossus at sleep onset, mechanoreceptor negative pressure and chemoreceptor ventilatory drive feedback govern genioglossus activation during sleep, but the relative contributions of drive and pressure stimuli to genioglossus activity across progressive obstructive events remain unclear. We recently showed that drive typically falls during events, whereas negative pressures increase, providing a means to assess their individual contributions to the time course of genioglossus activity. Objectives: For the first time, we critically test whether the loss of drive could explain the loss of genioglossus activity observed within events in OSA. Methods: We examined the time course of genioglossus activity (EMGgg; intramuscular electromyography), ventilatory drive (intraesophageal diaphragm electromyography), and esophageal pressure during spontaneous respiratory events (using the ensemble-average method) in 42 patients with OSA (apnea-hypopnea index 5-91 events/h). Results: Multivariable regression demonstrated that the falling-then-rising time course of EMGgg may be well explained by falling-then-rising drive and rising negative pressure stimuli (model R = 0.91 [0.88-0.98] [95% confidence interval]). Overall, EMGgg was 2.9-fold (0.47-∞) more closely associated with drive than pressure stimuli (ratio of standardized coefficients, βdrive:βpressure; ∞ denotes absent pressure contribution). However, individual patient results were heterogeneous: approximately one-half (n = 22 of 42) exhibited drive-dominant responses (i.e., βdrive:βpressure > 2:1), and one-quarter (n = 11 of 42) exhibited pressure-dominant EMGgg responses (i.e., βdrive:βpressure < 1:2). Patients exhibiting more drive-dominant EMGgg responses experienced greater event-related EMGgg declines (12.9 [4.8-21.0] %baseline/standard deviation of βdrive:βpressure; P = 0.004, adjusted analysis). Conclusions: Loss of genioglossus activity precipitating events in patients with OSA is strongly associated with a contemporaneous loss of drive and is greatest in those whose activity tracks drive rather than pressure stimuli. These findings were upheld for events without prior arousal. Responding to falling drive rather than rising negative pressure during events may be deleterious; future therapeutic strategies whose aim is to sustain genioglossus activity by preferentially enhancing responses to rising pressure rather than falling drive are of interest.
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Affiliation(s)
- Laura K. Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Kevin Grace
- Department of Neurological Surgery, University of California, Davis, Sacramento, California
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
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Aishah A, Tong BKY, Osman AM, Pitcher G, Donegan M, Kwan BCH, Brown E, Altree TJ, Adams R, Mukherjee S, Eckert DJ. Stepwise Add-On and Endotype-informed Targeted Combination Therapy to Treat Obstructive Sleep Apnea: A Proof-of-Concept Study. Ann Am Thorac Soc 2023; 20:1316-1325. [PMID: 37159953 DOI: 10.1513/annalsats.202210-892oc] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 05/09/2023] [Indexed: 05/11/2023] Open
Abstract
Rationale: Oral appliance therapy (OAT) is an effective treatment for many people with obstructive sleep apnea (OSA). However, OSA pathogenesis is heterogeneous, and, in ∼50% of cases, OAT does not fully control OSA. Objectives: This study aimed to control OSA in individuals with an incomplete response to OAT alone by using additional targeted therapies informed by OSA endotype characterization. Methods: Twenty-three people with OSA (apnea-hypopnea index [AHI], 41 ± 19 events/h) not fully resolved (AHI, >10 events/h) with OAT alone were prospectively recruited. OSA endotypes were characterized pretherapy during a detailed physiology study night. Initially, an expiratory positive airway pressure (EPAP) valve and supine avoidance device therapy were added to target the impaired anatomical endotype. Those with residual OSA (AHI, >10 events/h) then received one or more nonanatomical interventions based on endotype characterization. This included O2 (4 L/min) to reduce high loop gain (unstable respiratory control) and 80/5 mg atomoxetine-oxybutynin to increase pharyngeal muscle activity. Finally, if required, OAT was combined with EPAP and continuous positive airway pressure (CPAP) therapy. Results: Twenty participants completed the study. OSA was successfully controlled (AHI, <10 events/h) with combination therapy in all but one participant (17 of 20 without CPAP). OAT plus EPAP and supine avoidance therapy treated OSA in 10 (50%) participants. OSA was controlled in five (25%) participants with the addition of O2 therapy, one with atomoxetine-oxybutynin, and one required O2 plus atomoxetine-oxybutynin. Two participants required CPAP for their OSA, and another was CPAP intolerant. Conclusions: These novel prospective findings highlight the potential of precision medicine to inform targeted combination therapy to treat OSA. Clinical trial registered with the Australian New Zealand Clinical Trials Registry (ACTRN12618001995268).
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Affiliation(s)
- Atqiya Aishah
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Benjamin K Y Tong
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Amal M Osman
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Geoffrey Pitcher
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Michelle Donegan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Benjamin C H Kwan
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Elizabeth Brown
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
| | - Thomas J Altree
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
| | - Robert Adams
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Sutapa Mukherjee
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
- Respiratory and Sleep Services, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Danny J Eckert
- *Neuroscience Research Australia, Sydney, New South Wales, Australia
- School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
- *Adelaide Institute for Sleep Health and Flinders Health and Medical Research Institute, Flinders University, Bedford Park, South Australia, Australia; and
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McNicholas WT, Korkalainen H. Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: a narrative review. Front Neurol 2023; 14:1239016. [PMID: 37693751 PMCID: PMC10483231 DOI: 10.3389/fneur.2023.1239016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Obstructive Sleep Apnea (OSA) arises due to periodic blockage of the upper airway (UA) during sleep, as negative pressure generated during inspiration overcomes the force exerted by the UA dilator muscles to maintain patency. This imbalance is primarily seen in individuals with a narrowed UA, attributable to factors such as inherent craniofacial anatomy, neck fat accumulation, and rostral fluid shifts in the supine posture. Sleep-induced attenuation of UA dilating muscle responsiveness, respiratory instability, and high loop gain further exacerbate UA obstruction. The widespread comorbidity profile of OSA, encompassing cardiovascular, metabolic, and neuropsychiatric domains, suggests complex bidirectional relationships with conditions like heart failure, stroke, and metabolic syndrome. Recent advances have delineated distinct OSA phenotypes beyond mere obstruction frequency, showing links with specific symptomatic manifestations. It is vital to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to enhance our understanding of OSA and its interplay with related outcomes. This knowledge could stimulate the development of tailored therapies targeting specific phenotypic and pathophysiological endotypes. This review aims to elucidate the multifaceted pathophysiology of OSA, focusing on the relationships between UA anatomy, functional traits, clinical manifestations, and comorbidities. The ultimate objective is to pave the way for a more personalized treatment paradigm in OSA, offering alternatives to continuous positive airway pressure therapy for selected patients and thereby optimizing treatment efficacy and adherence. There is an urgent need for personalized treatment strategies in the ever-evolving field of sleep medicine, as we progress from a 'one-size-fits-all' to a 'tailored-therapy' approach.
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Affiliation(s)
- Walter T. McNicholas
- School of Medicine and the Conway Research Institute, University College Dublin, Dublin, Ireland
- Department of Respiratory and Sleep Medicine, St. Vincent’s Hospital Group, Dublin, Ireland
| | - Henri Korkalainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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Aggarwal J, Ladha R, Liu WY, Liu H, Horner RL. Optical and pharmacological manipulation of hypoglossal motor nucleus identifies differential effects of taltirelin on sleeping tonic motor activity and responsiveness. Sci Rep 2023; 13:12299. [PMID: 37516800 PMCID: PMC10387086 DOI: 10.1038/s41598-023-39562-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 07/27/2023] [Indexed: 07/31/2023] Open
Abstract
Pharyngeal muscle activity and responsiveness are key pathophysiological traits in human obstructive sleep apnea (OSA) and strong contributors to improvements with pharmacotherapy. The thyrotropin-releasing hormone (TRH) analog taltirelin is of high pre-clinical interest given its neuronal-stimulant properties, minimal endocrine activity, tongue muscle activation following microperfusion into the hypoglossal motor nucleus (HMN) or systemic delivery, and high TRH receptor expression at the HMN compared to rest of the brain. Here we test the hypothesis that taltirelin increases HMN activity and/or responsivity to excitatory stimuli applied across sleep-wake states in-vivo. To target hypoglossal motoneurons with simultaneous pharmacological and optical stimuli we used customized "opto-dialysis" probes and chronically implanted them in mice expressing a light sensitive cation channel exclusively on cholinergic neurons (ChAT-ChR2, n = 12) and wild-type mice lacking the opsin (n = 10). Both optical stimuli applied across a range of powers (P < 0.001) and microperfusion of taltirelin into the HMN (P < 0.020) increased tongue motor activity in sleeping ChAT-ChR2 mice. Notably, taltirelin increased tonic background tongue motor activity (P < 0.001) but not responsivity to excitatory optical stimuli across sleep-wake states (P > 0.098). This differential effect on tonic motor activity versus responsivity informs human studies of the potential beneficial effects of taltirelin on pharyngeal motor control and OSA pharmacotherapy.
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Affiliation(s)
- Jasmin Aggarwal
- Department of Physiology, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Raina Ladha
- Department of Physiology, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Wen-Ying Liu
- Department of Physiology, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Hattie Liu
- Department of Physiology, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada
| | - Richard L Horner
- Department of Physiology, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
- Department of Medicine, University of Toronto, 3206 Medical Sciences Building, 1 King's College Circle, Toronto, ON, M5S 1A8, Canada.
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Toh ST. Pharmacotherapy for obstructive sleep apnea: Reality or Pipe Dream? Sleep Med Rev 2023; 70:101817. [PMID: 37480826 DOI: 10.1016/j.smrv.2023.101817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 06/29/2023] [Indexed: 07/24/2023]
Affiliation(s)
- Song Tar Toh
- Department of Otorhinolaryngology-Head and Neck Surgery, Singapore General Hospital, Singapore; Singhealth Duke-NUS Sleep Centre, Singapore; National University of Singapore, Yong Loo Lin School of Medicine and Duke-NUS Medical School Structured, Singapore.
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Horner RL. Targets for obstructive sleep apnea pharmacotherapy: principles, approaches, and emerging strategies. Expert Opin Ther Targets 2023; 27:609-626. [PMID: 37494064 DOI: 10.1080/14728222.2023.2240018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a common and serious breathing disorder. Several pathophysiological factors predispose individuals to OSA. These factors are quantifiable, and modifiable pharmacologically. AREAS COVERED Four key pharmacotherapeutic targets are identified and mapped to the major determinants of OSA pathophysiology. PubMed and Clinicaltrials.gov were searched through April 2023. EXPERT OPINION Target #1: Pharyngeal Motor Effectors. Increasing pharyngeal muscle activity and responsivity with noradrenergic-antimuscarinic combination is central to recent breakthrough OSA pharmacotherapy. Assumptions, knowledge gaps, future directions, and other targets are identified. #2: Upper Airway Sensory Afferents. There is translational potential of sensitizing and amplifying reflex pharyngeal dilator muscle responses to negative airway pressure via intranasal delivery of new potassium channel blockers. Rationales, advantages, findings, and potential strategies to enhance effectiveness are identified. #3: Chemosensory Afferents and Ventilatory Control. Strategies to manipulate ventilatory control system sensitivity by carbonic anhydrase inhibitors are supported in theory and initial studies. Intranasal delivery of agents to stimulate central respiratory activity are also introduced. #4: Sleep-Wake Mechanisms. Arousability is the fourth therapeutic target rationalized. Evolving automated tools to measure key pathophysiological factors predisposing to OSA will accelerate pharmacotherapy. Although not currently ready for general clinical settings, the identified targets are of future promise.
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Affiliation(s)
- Richard L Horner
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 62] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Perger E, Bertoli S, Lombardi C. Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits. Expert Rev Respir Med 2023; 17:663-673. [PMID: 37646222 DOI: 10.1080/17476348.2023.2241353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive. AREAS COVERED Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain. EXPERT OPINION Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.
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Affiliation(s)
- Elisa Perger
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Simona Bertoli
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
- Lab of Nutrition and Obesity Research, Istituto Auxologico Italiano, IRCCS, Milan, Carolina
| | - Carolina Lombardi
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Turnbull CD, Stradling JR. Endotyping, phenotyping and personalised therapy in obstructive sleep apnoea: are we there yet? Thorax 2023; 78:726-732. [PMID: 37217289 DOI: 10.1136/thorax-2023-220037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/24/2023]
Abstract
Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.
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Affiliation(s)
- Chris D Turnbull
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford, UK
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
| | - John R Stradling
- NIHR Oxford Biomedical Research Centre, University of Oxford, Oxford, UK
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Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med 2023; 19:1183-1190. [PMID: 36805833 PMCID: PMC10315604 DOI: 10.5664/jcsm.10528] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
STUDY OBJECTIVES The potential sedative effect of dronabinol and the high expression of cannabinoid receptors on the hypoglossal motor nuclei makes this agent a good candidate for obstructive sleep apnea (OSA) pharmacotherapy to be tested with atomoxetine, a noradrenergic reuptake inhibitor that reduced OSA severity in combination with oxybutynin. Here we tested the effect of atomoxetine 80 mg plus dronabinol (Ato-Dro) at 2 different doses (5 and 10 mg) vs. baseline and atomoxetine alone in a 2-center, open-label, dose-escalating trial. The primary outcome was the effect of Ato-Dro vs. baseline on OSA severity (apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation). Safety of the combination and self-reported outcomes were also assessed. METHODS Fifteen patients with OSA received progressively increasing Ato-Dro doses (dose escalation was performed every week, starting from Ato-Dro 40-2.5 mg, then 80-5 mg and finally 80-10 mg). A clinical, in-lab polysomnography was performed at baseline, on Ato-Dro 80-5 and Ato-Dro 80-10 mg. RESULTS Ato-Dro 80-10 mg did not significantly reduce apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation, and hypoxic burden and yielded limited clinical benefit vs. baseline and atomoxetine alone. However, Ato-Dro 80-5 mg did improve OSA severity (Δapnea-hypopnea index = 8.3[0.3, 16.3] events/h; mean [confidence interval]; Δhypoxic burden = 37.7[12.5, 62.7] %min/h) and multiple self-reported outcomes vs. baseline and/or atomoxetine alone. Ato-Dro administration was characterized by several potentially harmful side effects and treatment discontinuation in 1/3 of cases. CONCLUSIONS Ato-Dro 80-5 mg might be useful to reduce OSA severity and lead to self-reported improvement in those who could tolerate the combination. However, given the numerous side effects and the exploratory nature of this open-label study, our results warrant further validation in larger trials. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Study for Efficacy and Dose Escalation of AD313 + Atomoxetine (SEED) (SEED); URL: https://clinicaltrials.gov/ct2/show/NCT05101122; Identifier: NCT05101122. CITATION Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med. 2023;19(7):1183-1190.
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Affiliation(s)
- Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Daniel Norman
- Santa Monica Clinical Trials, Los Angeles, California
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Lee YC, Lu CT, Chuang LP, Lee LA, Fang TJ, Cheng WN, Li HY. Pharmacotherapy for obstructive sleep apnea - A systematic review and meta-analysis of randomized controlled trials. Sleep Med Rev 2023; 70:101809. [PMID: 37423095 DOI: 10.1016/j.smrv.2023.101809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 04/01/2023] [Accepted: 06/11/2023] [Indexed: 07/11/2023]
Abstract
Continuous positive airway pressure is the first-line and gold-standard treatment for obstructive sleep apnea (OSA). Pharmacotherapy is not commonly used in treating OSA until recently. Combined noradrenergic and antimuscarinic agents have been clinically applied for OSA patients with variable results. This meta-analysis study aimed to investigate the efficacy of the combined regimen on OSA. A systematic literature search was performed up to November 2022 for the effects of the combined regimen on OSA. Eight randomized controlled trials were identified and systematically reviewed for meta-analysis. There were significant mean differences between OSA patients taking a combined regimen and placebo in apnea-hypopnea index (AHI) [mean difference (MD) -9.03 events/h, 95%CI (-16.22, -1.83 events/h; P = 0.01] and lowest oxygen saturation [MD 5.61%, 95% CI % (3.43, 7.80); P < 0.01]. Meta-regression showed that a higher proportion of male participants was associated with a greater reduction of AHI (p = 0.04). This study showed a positive but modest effect of pharmacotherapy in the reduction of OSA severity. The combination drugs are most applicable to male OSA patients based on their efficacy and pharmacological susceptibility. Pharmacotherapy may be applied as an alternative, adjunctive or synergistic treatment under careful consideration of its side effects.
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Affiliation(s)
- Yi-Chieh Lee
- Department of Otolaryngology-Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan; London School of Hygiene and Tropical Medicine, London, WC1E 7HT, UK
| | - Chun-Ting Lu
- Department of Otolaryngology-Head and Neck Surgery, New Taipei Municipal Tucheng Hospital, New Taipei City, Taiwan
| | - Li-Pang Chuang
- Sleep Center, Department of Pulmonary and Critical Care Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan; School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Li-Ang Lee
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Tuan-Jen Fang
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan
| | - Wen-Nuan Cheng
- Department of Sports Sciences, University of Taipei, Taipei, 100, Taiwan
| | - Hsueh-Yu Li
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan; Department of Otolaryngology-Head and Neck Surgery, Chang Gung Memorial Hospital at Linkou, Taoyuan, Taiwan.
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Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med 2023; 19:1035-1042. [PMID: 36734173 PMCID: PMC10235724 DOI: 10.5664/jcsm.10464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES Pharmacotherapy for obstructive sleep apnea (OSA) regained consideration after the discovery that atomoxetine and oxybutynin greatly reduced OSA severity. However, atomoxetine and oxybutynin reduced the arousal threshold and may therefore be poorly tolerated in patients with OSA and disturbed sleep. As a result, we tested the combination of atomoxetine plus 2 hypnotics in patients with OSA. The effects of atomoxetine plus: (1) trazodone (Ato-Trazo) and (2) lemborexant vs placebo on apnea-hypopnea index, hypoxic burden, arousal threshold, and total sleep time were assessed. Drug safety was also ascertained, together with the effect of the combinations on other OSA traits, self-reported sleep quality, and next-day alertness. METHODS Following a baseline study, 15 patients with mild-to-severe OSA with moderate upper airway collapsibility were administered Ato-Trazo, atomoxetine and lemborexant, and matching placebo according to a double-blind, randomized, crossover design. Apnea-hypopnea index and other objective outcomes were calculated from 3 clinical, in-laboratory polysomnograms. RESULTS Ato-Trazo significantly reduced apnea-hypopnea index from a median [interquartile range] of 18.2 [11.8 to 31.3] on placebo to 7.4 [5.4 to 16.1] events/h, P = .024, and hypoxic burden from 46.3 [25.1 to 88.3] on placebo to 18.7 [14.9 to 43.5], P = .003. This effect was likely driven by an increase in polysomnography-estimated pharyngeal muscle activity during the events (P = .029). Atomoxetine and lemborexant had smaller statistically insignificant effects. Contrary to atomoxetine and oxybutynin, Ato-Trazo and atomoxetine and lemborexant did not reduce the arousal threshold. Both combinations had no effect on total sleep time but worsened self-reported sleep quality. CONCLUSIONS Ato-Trazo has the potential to become a useful drug combination, however, longer trials are needed to determine the best dosage and the subgroup of patients who may benefit most from this combination. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Crossover Trial of AD182 and AD504 in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT04645524; Identifier: NCT04645524. CITATION Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med. 2023;19(6):1035-1042.
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Affiliation(s)
| | - Erica Eves
- Sleep Management Institute, Cincinnati, Ohio
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Lv R, Liu X, Zhang Y, Dong N, Wang X, He Y, Yue H, Yin Q. Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome. Signal Transduct Target Ther 2023; 8:218. [PMID: 37230968 DOI: 10.1038/s41392-023-01496-3] [Citation(s) in RCA: 46] [Impact Index Per Article: 46.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2022] [Revised: 05/09/2023] [Accepted: 05/11/2023] [Indexed: 05/27/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is a common breathing disorder in sleep in which the airways narrow or collapse during sleep, causing obstructive sleep apnea. The prevalence of OSAS continues to rise worldwide, particularly in middle-aged and elderly individuals. The mechanism of upper airway collapse is incompletely understood but is associated with several factors, including obesity, craniofacial changes, altered muscle function in the upper airway, pharyngeal neuropathy, and fluid shifts to the neck. The main characteristics of OSAS are recurrent pauses in respiration, which lead to intermittent hypoxia (IH) and hypercapnia, accompanied by blood oxygen desaturation and arousal during sleep, which sharply increases the risk of several diseases. This paper first briefly describes the epidemiology, incidence, and pathophysiological mechanisms of OSAS. Next, the alterations in relevant signaling pathways induced by IH are systematically reviewed and discussed. For example, IH can induce gut microbiota (GM) dysbiosis, impair the intestinal barrier, and alter intestinal metabolites. These mechanisms ultimately lead to secondary oxidative stress, systemic inflammation, and sympathetic activation. We then summarize the effects of IH on disease pathogenesis, including cardiocerebrovascular disorders, neurological disorders, metabolic diseases, cancer, reproductive disorders, and COVID-19. Finally, different therapeutic strategies for OSAS caused by different causes are proposed. Multidisciplinary approaches and shared decision-making are necessary for the successful treatment of OSAS in the future, but more randomized controlled trials are needed for further evaluation to define what treatments are best for specific OSAS patients.
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Affiliation(s)
- Renjun Lv
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xueying Liu
- Department of Endocrinology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China
| | - Yue Zhang
- Department of Geriatrics, the 2nd Medical Center, Chinese PLA General Hospital, Beijing, 100853, China
| | - Na Dong
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Xiao Wang
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Yao He
- The First School of Clinical Medicine, Lanzhou University, Lanzhou, 730000, China
| | - Hongmei Yue
- Department of Pulmonary and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, 730000, China.
| | - Qingqing Yin
- Department of Geriatric Neurology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, 250021, China.
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Wang Y, Zhang J, He Y, Pan Z, Zhang X, Liu P, Hu K. The theranostic value of acetylation gene signatures in obstructive sleep apnea derived by machine learning. Comput Biol Med 2023; 161:107058. [PMID: 37244148 DOI: 10.1016/j.compbiomed.2023.107058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 05/09/2023] [Accepted: 05/20/2023] [Indexed: 05/29/2023]
Abstract
Epigenetic modifications are implicated in the onset and progression of obstructive sleep apnea (OSA) and its complications through their bidirectional relationship with long-term chronic intermittent hypoxia (IH). However, the exact role of epigenetic acetylation in OSA is unclear. Here we explored the relevance and impact of acetylation-related genes in OSA by identifying molecular subtypes modified by acetylation in OSA patients. Twenty-nine significantly differentially expressed acetylation-related genes were screened in a training dataset (GSE135917). Six common signature genes were identified using the lasso and support vector machine algorithms, with the powerful SHAP algorithm used to judge the importance of each identified feature. DSCC1, ACTL6A, and SHCBP1 were best calibrated and discriminated OSA patients from normal in both training and validation (GSE38792) datasets. Decision curve analysis showed that patients could benefit from a nomogram model developed using these variables. Finally, a consensus clustering approach characterized OSA patients and analyzed the immune signatures of each subgroup. OSA patients were divided into two acetylation patterns (higher acetylation scores in Group B than in Group A) that differed significantly in terms of immune microenvironment infiltration. This is the first study to reveal the expression patterns and key role played by acetylation in OSA, laying the foundation for OSA epitherapy and refined clinical decision-making.
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Affiliation(s)
- Yixuan Wang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Jingyi Zhang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Yang He
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Zhou Pan
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Xinyue Zhang
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Peijun Liu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China
| | - Ke Hu
- Department of Respiratory and Critical Care Medicine, Renmin Hospital of Wuhan University, 430060, China; Central Laboratory, Renmin Hospital of Wuhan University, Wuhan, 430060, China.
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45
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Zitting KM, Lockyer BJ, Azarbarzin A, Sands SA, Wang W, Wellman A, Quan SF. Association of cortical arousals with sleep-disordered breathing events. J Clin Sleep Med 2023; 19:899-912. [PMID: 36708264 PMCID: PMC10152355 DOI: 10.5664/jcsm.10492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 12/16/2022] [Accepted: 12/16/2022] [Indexed: 01/29/2023]
Abstract
STUDY OBJECTIVES The American Academy of Sleep Medicine recommends scoring hypopneas in adults when there is a ≥ 3% oxygen desaturation or when the event is associated with an arousal. However, there is no rule regarding the duration of the interval between the event termination and the associated arousal. The purpose of this study is to explore the timing between arousals and sleep-disordered breathing (SDB) events. METHODS We analyzed cortical arousals (> 1.6 million) and SDB events (> 350,000 apneas and > 1.9 million hypopneas) from 11,400 manually scored polysomnography recordings. Only arousals that started within ±30 seconds from the end of SDB events were included. We used the 2 local minimums on either side of the arousal distribution as the start/end times for the distribution and to define which arousals are associated with SDB events. Finally, we calculated arousal probability near the end of SDB events. RESULTS Cortical arousals with start times that fell within the 2 minimums were considered to be associated with SDB events. Using this definition, we found that 90% of apnea-associated arousals started no earlier than 4 seconds before and no later than 9 seconds after the end of apneas. Similarly, 90% of hypopnea-associated arousals started no earlier than 6 seconds before and no later than 14 seconds after the end of hypopneas, with the peak of the distribution coinciding with event end time. Arousal probability was highest during the first 10 seconds after the end of the event and was higher for longer events. CONCLUSIONS Our results suggest that 90% of SDB-associated arousals start no earlier than 6 seconds before and no later than 14 seconds after the end of the respiratory events. CITATION Zitting K-M, Lockyer BJ, Azarbarzin A, et al. Association of cortical arousals with sleep-disordered breathing events. J Clin Sleep Med. 2023;19(5):899-912.
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Affiliation(s)
- Kirsi-Marja Zitting
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Brandon J. Lockyer
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Wei Wang
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
| | - Stuart F. Quan
- Division of Sleep and Circadian Disorders, Department of Medicine, Brigham and Women’s Hospital and Division of Sleep Medicine, Harvard Medical School, Boston, Massachusetts
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Genta PR, Taranto-Montemurro L. Task Accomplished: Promising Effects of a New Topical Potassium Channel Antagonist in OSA. Chest 2023; 163:749-750. [PMID: 37031981 DOI: 10.1016/j.chest.2023.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 01/05/2023] [Indexed: 04/11/2023] Open
Affiliation(s)
- Pedro R Genta
- Heart Institute, University of São Paulo, São Paulo, Brazil
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Molecular Pathology, Oxidative Stress, and Biomarkers in Obstructive Sleep Apnea. Int J Mol Sci 2023; 24:ijms24065478. [PMID: 36982552 PMCID: PMC10058074 DOI: 10.3390/ijms24065478] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Revised: 03/06/2023] [Accepted: 03/10/2023] [Indexed: 03/18/2023] Open
Abstract
Obstructive sleep apnea syndrome (OSAS) is characterized by intermittent hypoxia (IH) during sleep due to recurrent upper airway obstruction. The derived oxidative stress (OS) leads to complications that do not only concern the sleep-wake rhythm but also systemic dysfunctions. The aim of this narrative literature review is to investigate molecular alterations, diagnostic markers, and potential medical therapies for OSAS. We analyzed the literature and synthesized the evidence collected. IH increases oxygen free radicals (ROS) and reduces antioxidant capacities. OS and metabolic alterations lead OSAS patients to undergo endothelial dysfunction, osteoporosis, systemic inflammation, increased cardiovascular risk, pulmonary remodeling, and neurological alterations. We treated molecular alterations known to date as useful for understanding the pathogenetic mechanisms and for their potential application as diagnostic markers. The most promising pharmacological therapies are those based on N-acetylcysteine (NAC), Vitamin C, Leptin, Dronabinol, or Atomoxetine + Oxybutynin, but all require further experimentation. CPAP remains the approved therapy capable of reversing most of the known molecular alterations; future drugs may be useful in treating the remaining dysfunctions.
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Sands SA, Alex RM, Mann D, Vena D, Terrill PI, Gell LK, Zinchuk A, Sofer T, Patel SR, Taranto-Montemurro L, Azarbarzin A, Rueschman M, White DP, Wellman A, Redline S. Pathophysiology Underlying Demographic and Obesity Determinants of Sleep Apnea Severity. Ann Am Thorac Soc 2023; 20:440-449. [PMID: 36287615 PMCID: PMC9993145 DOI: 10.1513/annalsats.202203-271oc] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 10/14/2022] [Indexed: 11/20/2022] Open
Abstract
Rationale: Sleep apnea is the manifestation of key endotypic traits, including greater pharyngeal collapsibility, reduced dilator muscle compensation, and elevated chemoreflex loop gain. Objectives: We investigated how endotypic traits vary with obesity, age, sex, and race/ethnicity to influence sleep apnea disease severity (apnea-hypopnea index [AHI]). Methods: Endotypic traits were estimated from polysomnography in a diverse community-based cohort study (Multi-Ethnic Study of Atherosclerosis, N = 1,971; age range, 54-93 yr). Regression models assessed associations between each exposure (continuous variables per 2 standard deviations [SDs]) and endotypic traits (per SD) or AHI (events/h), independent of other exposures. Generalizability was assessed in two independent cohorts. Results: Greater AHI was associated with obesity (+19 events/h per 11 kg/m2 [2 SD]), male sex (+13 events/h vs. female), older age (+7 events/h per 20 yr), and Chinese ancestry (+5 events/h vs. White, obesity adjusted). Obesity-related increase in AHI was best explained by elevated collapsibility (+0.40 SD) and greater loop gain (+0.38 SD; percentage mediated, 26% [95% confidence interval (CI), 20-32%]). Male-related increase in AHI was explained by elevated collapsibility (+0.86 SD) and reduced compensation (-0.40 SD; percentage mediated, 57% [95% CI, 50-66%]). Age-related AHI increase was explained by elevated collapsibility (+0.37 SD) and greater loop gain (+0.15 SD; percentage mediated, 48% [95% CI, 34-63%]). Increased AHI with Chinese ancestry was explained by collapsibility (+0.57 SD; percentage mediated, 87% [95% CI, 57-100]). Black race was associated with reduced collapsibility (-0.30 SD) and elevated loop gain (+0.29 SD). Similar patterns were observed in the other cohorts. Conclusions: Different subgroups exhibit different underlying pathophysiological pathways to sleep apnea, highlighting the variability in mechanisms that could be targeted for intervention.
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Affiliation(s)
- Scott A. Sands
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Raichel M. Alex
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dwayne Mann
- Institute for Social Science Research and
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Queensland, Australia
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Philip I. Terrill
- School of Information Technology and Electrical Engineering, The University of Queensland, Brisbane, Queensland, Australia
| | - Laura K. Gell
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrey Zinchuk
- Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Tamar Sofer
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Sanjay R. Patel
- Department of Medicine, Center for Sleep and Cardiovascular Outcomes Research, and
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Michael Rueschman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - David P. White
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
| | - Susan Redline
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts
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Kinouchi T, Terada J, Sakao S, Koshikawa K, Sasaki T, Sugiyama A, Sato S, Sakuma N, Abe M, Shikano K, Hayama N, Shiko Y, Ozawa Y, Ikeda S, Suzuki T, Tatsumi K. Effects of the combination of atomoxetine and oxybutynin in Japanese patients with obstructive sleep apnoea: A randomized controlled crossover trial. Respirology 2023; 28:273-280. [PMID: 36184258 DOI: 10.1111/resp.14383] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 09/12/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND OBJECTIVE The possibility of combination therapy with atomoxetine (ATO) and oxybutynin (OXY) has been suggested for obstructive sleep apnoea (OSA). However, the effectiveness of this treatment remains uninvestigated in Japanese OSA patients. Therefore, we performed a randomized, crossover, phase II, single-centre prospective trial to examine the effects of ATO-OXY therapy in Japanese OSA patients. METHODS In total, 17 OSA patients participated in this study. The effects of one night of 80-mg ATO plus 5-mg OXY administration were compared with those of no medication administered before sleep. The primary and secondary outcomes comprised the apnoea-hypopnoea index (AHI) and nadir SpO2 , SpO2 drop time and sleep architecture, respectively. The safety endpoints included drug side effects and adverse events. RESULTS The values of AHI, nadir SpO2 , 3% oxygen desaturation index (ODI), 4% ODI, and SpO2 drop time of <90% did not significantly differ between patients receiving ATO-OXY administration and no medication. Sleep architecture exhibited a significant change: ATO-OXY increased sleep stage N1 (p < 0.0001) and decreased stage N2 (p = 0.03), rapid eye movement (p < 0.0001) and sleep efficiency (p = 0.02). However, the subanalysis demonstrated an obvious decrease in AHI in five responder patients. Total sleep time and basal sleep efficiency tended to be lower in the responders compared with nonresponders (p = 0.065). No patients experienced severe adverse events or side effects. CONCLUSION Overall, ATO-OXY therapy does not reduce AHI in Japanese OSA patients, although AHI was decreased in a proportion of patients. Future studies for identifying treatment response group characteristics are warranted.
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Affiliation(s)
- Toru Kinouchi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Jiro Terada
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Seiichiro Sakao
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Ken Koshikawa
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Tsuyoshi Sasaki
- Department of Child Psychiatry, Chiba University Hospital, Chiba, Japan
| | - Atsuhiko Sugiyama
- Department of Neurology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Shun Sato
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Noriko Sakuma
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Mitsuhiro Abe
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Kohei Shikano
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Nami Hayama
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Yuki Shiko
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Yoshihito Ozawa
- Biostatistics Section, Clinical Research Center, Chiba University Hospital, Chiba, Japan
| | - Shinobu Ikeda
- Department of Laboratory Center, Chiba University Hospital, Chiba, Japan
| | - Takuji Suzuki
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Koichiro Tatsumi
- Department of Respirology, Graduate School of Medicine, Chiba University, Chiba, Japan
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Edwards BA, Joosten SA. Variability in the response to atomoxetine and oxybutynin for OSA: Highlighting the need for personalized medicine. Respirology 2023; 28:215-216. [PMID: 36257913 DOI: 10.1111/resp.14395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Accepted: 10/12/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Bradley A Edwards
- Department of Physiology, Biomedical Discovery Institute, Monash University, Melbourne, Victoria, Australia.,Turner Institute for Brain and Mental Health, Monash University, Melbourne, Victoria, Australia
| | - Simon A Joosten
- Monash Lung, Sleep, Allergy, and Immunity, Monash Health, Clayton, Victoria, Australia.,School of Clinical Sciences, Monash University, Melbourne, Victoria, Australia.,Monash Partners - Epworth, Melbourne, Victoria, Australia
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