Armodafinil improves wakefulness and long-term episodic memory in nCPAP-adherent patients with excessive sleepiness associated with obstructive sleep apnea

Armodafinil as a Potential Pharmacological Treatment for Attention Deficit Hyperactivity Disorder in Adults: A Review

INTRODUCTION

Armodafinil is a psychostimulant that promotes alertness, and it has been shown to improve attention, memory, and fatigue in healthy adults and adults with neurodevelopmental conditions that share symptoms with Attention Deficit Hyperactivity Disorder (ADHD). It is generally well tolerated and safe, and most of the adverse events reported are considered not serious. However, the available evidence on the efficacy of armodafinil for the treatment of ADHD in adults is scarce.

OBJECTIVE

The present review aims to perform a systematized search of the available evidence on the possible therapeutic benefit of armodafinil treatment in adult patients with ADHD.

METHODS

A literature review using PubMed was conducted to compile and summarize the available clinical and scientific evidence on the possible use of armodafinil as a pharmacological treatment in adult patients with ADHD.

RESULTS

From the 86 articles reviewed, the available evidence showed that both acute and chronic treatment with armodafinil can improve wakefulness, memory, impulse control, and executive functions in adults with sleep disorders and other conditions. In addition, evidence of improvement in cognitive functions and mood alterations in other neuropsychiatric conditions was shown.

CONCLUSION

Armodafinil could be useful for the treatment of ADHD in adults, according to the review of the literature from both pre-clinical and clinical studies.

Excessive Daytime Sleepiness in Obstructive Sleep Apnea. Mechanisms and Clinical Management

Many patients with obstructive sleep apnea (OSA) experience excessive daytime sleepiness (EDS), which can negatively affect daily functioning, cognition, mood, and other aspects of well-being. Although EDS can be reduced with primary OSA treatment, such as continuous positive airway pressure (CPAP) therapy, a significant proportion of patients continue to experience EDS despite receiving optimized therapy for OSA. This article reviews the pathophysiology and clinical evaluation and management of EDS in patients with OSA. The mechanisms underlying EDS in CPAP-treated patients remain unclear. Experimental risk factors include chronic intermittent hypoxia and sleep fragmentation, which lead to oxidative injury and changes in neurons and brain circuit connectedness involving noradrenergic and dopaminergic neurotransmission in wake-promoting regions of the brain. In addition, neuroimaging studies have shown alterations in the brain's white matter and gray matter in patients with OSA and EDS. Clinical management of EDS begins with ruling out other potential causes of EDS and evaluating its severity. Tools to evaluate EDS include objective and self-reported assessments of sleepiness, as well as cognitive assessments. Patients who experience residual EDS despite primary OSA therapy may benefit from wake-promoting pharmacotherapy. Agents that inhibit reuptake of dopamine or of dopamine and norepinephrine (modafinil/armodafinil and solriamfetol, respectively) have demonstrated efficacy in reducing EDS and improving quality of life in patients with OSA. Additional research is needed on the effects of wake-promoting treatments on cognition in these patients and to identify individual or disorder-specific responses.

Stimulants associated with reduced risk of hospitalization for motor vehicle accident injury in patients with obstructive sleep apnea-a nationwide cohort study

Background

The risk of injury directly related to hospitalization for motor vehicle accidents (MVAs) in the obstructive sleep apnea (OSA) patients has not been thoroughly understood. Our study aimed to examine the association between the OSA and the hospitalization for an MVA injury.

Methods

This retrospective cohort study used Taiwan’s National Health Insurance Research Database (NHIRD) between 2000 and 2015. The OSA patients aged ≥20 years by age, sex, and index-year matched by non-OSA controls were enrolled (1:3). We used the Cox proportional regression model to evaluate the association between the OSA and the hospitalization for an MVA injury.

Results

The incidence rate of hospitalization for an MVA injury was higher in the OSA cohort (N = 3025) when compared with the non-OSA controls (N = 9075), as 575.3 and 372.0 per 100,000 person-years, respectively (p < 0.001). The Kaplan-Meier analysis showed that the OSA cohort had a significantly higher incidence of hospitalization for the MVA injury (log-rank test, p < 0.001). After adjusting for the covariates, the risk of hospitalization for the MVA injury among the OSA was significantly higher (hazard ratio [HR] =2.18; 95% confidence interval [CI] = 1.79–2.64; p < 0.001). Stimulants usage was associated with a nearly 20% decrease in the risk of an overall hospitalization for an MVA injury in the OSA patients.

Conclusions

This study provides evidence that patients with OSA are at a two-fold higher risk of developing hospitalization for an MVA injury, and the usage of modafinil and methylphenidate was associated with a lower risk of an overall hospitalization for the MVA injury.

Obstructive sleep apnoea and dementia: is there a link?

OBJECTIVE

Obstructive sleep apnoea is a common sleep disturbance in people of all ages, while dementia is an increasing entity among the ageing population of the world. Recent studies have established a link between sleep apnoea and cognitive decline. This literature review explores this relationship and examines the mechanisms, neurobiology and treatment modalities.

DESIGN

The study was conducted with the use of narrative literature overview.

RESULTS AND CONCLUSIONS

While there are numerous studies that establish a clear relationship between obstructive sleep apnoea, cognitive decline and dementia, more work is needed in understanding the mechanism and processes involved. A detailed understanding of pathophysiology of sleep and the relationship with cognitive decline will be vital in addressing the possibility of averting a likely reversible cause of dementia or cognitive decline.

Risk, Russian-roulette and lotteries: Persson and Savulescu on moral enhancement

The literature concerning the possibility and desirability of using new pharmacological and possible future genetic techniques to enhance human characteristics is well-established and the debates follow some well-known argumentative patterns. However, one argument in particular stands out and demands attention. This is the attempt to tie the moral necessity of moral enhancement to the hypothesised risks that allowing cognitive enhancement will bring. According to Persson and Savulescu, cognitive enhancement should occur only if the risks they think it to poses are mitigated by moral enhancement. By this they mean the compulsory and universal amplification of the disposition of altruism and the inflation of our sense of fairness, by chemical and/or genetic means. Their claim is important, intriguing and unsettling. This paper focuses on three central, but relatively neglected, features of their argument. First, there is a pernicious ambiguity in the language of 'risk' used by Persson and Savulescu where they tend to conflate 'risk' and 'uncertainty'. Second, their use of the lottery analogy to render their position more plausible is unconvincing. It tends to distort rather than illuminate the relevant considerations. Third, Persson and Savulescu do not adequately take into account the social and individual benefits that enhancing cognition could have. If they did, it would be apparent that those benefits alone would outweigh the considerations used to justify accompanying CE with ME.

Armodafinil for sarcoidosis-associated fatigue: a double-blind, placebo-controlled, crossover trial

CONTEXT

Fatigue has been identified in more than one-half of patients with sarcoidosis. Although fatigue is not synonymous with impaired quality of life, most studies of sarcoidosis identify fatigue as a major cause of impaired quality of life.

OBJECTIVES

To test the hypothesis that stimulants may have a role in the treatment of fatigued sarcoidosis patients, even without objective evidence of daytime sleepiness.

METHODS

This was a double-blind, placebo-controlled, crossover study of sarcoidosis patients followed up in one sarcoidosis clinic Sarcoidosis patients with fatigue received either armodafinil or placebo with eight weeks of therapy for each arm and a two week washout period before crossover to the other treatment. Initial armodafinil dose was 150mg and increased to 250mg after four weeks. Patients underwent polysomnography and multiple sleep latency testing (MSLT) the following day. Patients with an apnea/hypopnea index <6/hour received either armodafinil or placebo. Polysomnography with MSLT was repeated after each treatment arm.

RESULTS

Fifteen patients received the study drug. Fatigue was assessed using the Fatigue Assessment Scale (the lower the score, the less the fatigue) and the Functional Assessment of Chronic Illness Therapy-Fatigue (FACIT-F) (the higher the score, the less the fatigue). After eight weeks of therapy, there was a significant improvement in the Fatigue Assessment Scale during armodafinil treatment (median -4.5, range -20, 5) compared with placebo treatment (median 3.5, range -9, 14, P<0.05) and for the FACIT-F (armodafinil: median 9, range -12, 26 vs. placebo: median -5, range -17, 11, P<0.005). This improvement in fatigue was seen for both those with and without shortened sleep onset latency time during the MSLT.

CONCLUSION

Armodafinil treatment led to a significant reduction in fatigue in sarcoidosis patients. This effect was seen even in patients who did not have excessive daytime somnolence.

New and unconventional treatments for obstructive sleep apnea

Although continuous positive airway pressure, oral appliances and surgical modifications of the airway are considered as part of the routine management of patients with obstructive sleep apnea, many new and unconventional therapies exist. Many of the trials using these new alternatives have been limited by insufficient data, poor trial design, small sample size, unclear inclusion criteria, lack of randomization, and lack of blinding, and on occasion are biased by retrospective design. Bariatric surgery, positional therapy, auto-titrating positive airway pressure, serotonin agents, wake promoting agents, genioglossus stimulation surgery, supplemental oxygen, nasal dilators, nasal expiratory resistor devices and oropharyngeal exercises will be reviewed. As obstructive sleep apnea impacts the individual and society at large, further research is needed to explore new therapeutic treatment options for obstructive sleep apnea. Therapeutic trials for obstructive sleep apnea must be of rigorous design to prove clinical effectiveness while taking into account both patient satisfaction and cost effectiveness.

Cognition in obstructive sleep apnea-hypopnea syndrome (OSAS): current clinical knowledge and the impact of treatment

Obstructive sleep apnea-hypopnea syndrome (OSAS) is characterized by the presence of disordered breathing events that occur during sleep, as well as symptoms such as sleepiness and snoring. OSAS is associated with a number of adverse health consequences, and a growing literature focuses on its cognitive correlates. Although research in this field is mixed, multiple studies indicate that OSAS patients show impairment in attention, memory, and executive function. Continuous positive airway pressure (CPAP) is the most effective and widely used treatment of OSAS, and supplemental medications may supplement CPAP treatment to ameliorate associated symptoms. Here, we review the literature on OSAS and cognition, including studies that have investigated the impact of CPAP and stimulant medication on cognitive performance in patients with OSAS. In general, no consistent effect of CPAP use on cognitive performance was evident. This may be due, in part, to variability in study design and sampling methodology across studies. Studies of stimulant medications generally reported positive effects on cognitive performance. We conclude with a discussion of the mechanisms that have been proposed to explain cognitive dysfunction in OSAS and directions for future research.

The effect of adjunctive armodafinil on cognitive performance and psychopathology in antipsychotic-treated patients with schizophrenia/schizoaffective disorder: a randomized, double-blind, placebo-controlled trial

BACKGROUND

The efficacy, safety and tolerability of adjunctive armodafinil for cognitive performance, and negative and affective symptoms, were examined in 60 patients with schizophrenia or schizoaffective disorder.

METHOD

This was a 6-week, double-blind, placebo-controlled, fixed dose trial of armodafinil (150 mg/d) augmentation in patients with clinically stable schizophrenia or schizoaffective disorder. Cognition, psychopathology, alertness/wakefulness and adverse effects were assessed with standardized rating instruments. The primary endpoint was performance on measures of attention/vigilance.

RESULTS

Patients were randomly allocated to adjunctive armodafinil or placebo. There was a significant Drug×Time interaction effect for attention/vigilance, due to modest non-significant worsening in the armodafinil group and improvement in the armodafinil group [CPT-Pairs d', F(1,40)=6.2, p=0.017]. However, it became non-significant after correction for multiple comparisons. There were no differences between armodafinil and placebo in other cognitive domains or psychopathology measures. However, armodafinil was associated with significant improvement in the Scale for the Assessment of Negative Symptoms (SANS) anhedonia-asociality [F(1,41)=4.1, p=0.05].

CONCLUSIONS

There were no significant differences in neurocognitive measures between adjunctive armodafinil and placebo in this 6-week study. Armodafinil improved anhedonia-asociality, but not other negative symptom domains.

Treatment options for obstructive sleep apnea

Sleep apnea is a major public health problem that afflicts 9% of women and 24% of men 30 to 60 years of age. It is highly treatable, but when untreated, it has been associated with (but not necessarily linked to) increased probability of cerebral and coronary vascular disease, congestive heart failure, metabolic dysfunction, cognitive dysfunction, excessive daytime sleepiness, motor vehicle accidents, reduced productivity, and decreased quality of life. The gold standard for treatment in adults is positive airway pressure (PAP) therapy: continuous PAP (CPAP), bilevel PAP, autotitrating CPAP, or autotitrating bilevel PAP. Measures to increase compliance with PAP therapy include medical or surgical treatment of any underlying nasal obstruction, setting appropriate pressure level and airflow, mask selection and fitting, heated humidification, desensitization for claustrophobia, patient and partner education, regular follow-up with monitoring of compliance software, and attendance of support groups (eg, AWAKE). Adjunctive treatment modalities include lifestyle or behavioral measures and pharmacologic therapy. Patients with significant upper airway obstruction who are unwilling or unable to tolerate PAP therapy may benefit from surgery. Multilevel surgery of the upper airway addresses obstruction of the nose, oropharynx, and hypopharynx. A systematic approach may combine surgery of the nose, pharynx, and hypopharynx in phase 1, whereas skeletal midface advancement or tracheotomy constitutes phase 2. Clinical outcomes are reassessed through attended diagnostic polysomnogram performed 3 to 6 months after surgery. Oral appliances can be used for patients with symptomatic mild or moderate sleep apnea who prefer them to PAP therapy or for whom PAP therapy has failed or cannot be tolerated. Oral appliances also may be used for patients with severe obstructive sleep apnea who are unable or unwilling to undertake PAP therapy or surgery. For children, the main treatment modality is tonsillectomy and adenoidectomy, with or without turbinate surgery. Children with craniofacial abnormalities resulting in maxillary or mandibular insufficiency may benefit from palatal expansion or maxillary/mandibular surgery. PAP therapy may be used for children who are not surgical candidates or if surgery fails.

Armodafinil in the treatment of sleep/wake disorders

Excessive sleepiness (ES) is a major but underestimated public health concern associated with significant impairments in alertness/wakefulness and significant morbidity. The term ES has been used in the sleep medicine literature for years, but due to its nonspecific symptoms (ie tiredness or fatigue), it frequently goes unrecognized or is misdiagnosed in primary care. In some cases ES arises due to poor sleep habits or self-imposed sleep deprivation; however, ES is also a key component of a number of sleep/wake disorders and multiple medical and psychiatric disorders. Identification and treatment of ES is critical to improve the quality of life and well-being of patients and for the safety of the wider community. The inability of patients to recognize the nature, extent, and symptomatic profile of sleep/wake disorders requires vigilance on the part of healthcare professionals. Interventions to address ES and its associated impairments, treatment of the underlying sleep/wake disorder, and follow-up are a priority given the potential for serious consequences if left untreated. Wakefulness-promoting agents are available that treat ES associated with sleep/wake disorders. This review examines current approaches for managing this debilitating and potentially life-threatening condition, focusing on the place of armodafinil as a wakefulness-promoting agent.

Armodafinil in the treatment of excessive sleepiness

Excessive sleepiness (ES) is a widespread condition, commonly the result of a sleep/ wake disorder such as obstructive sleep apnea (OSA), shift-work disorder (SWD), or narcolepsy. ES poses significant health and safety concerns in patients. Numerous interventions are available to treat the underlying causes of ES and ES itself, including behavioral measures, mechanical devices, and pharmacologic agents. This review explores the evidence supporting the use of armodafinil to treat ES associated with OSA, SWD, and narcolepsy. Armodafinil is an oral non-amphetamine wake-promoting agent, the R-isomer of racemic modafinil. Armodafinil and modafinil share many clinical and pharmacologic properties and are distinct from central nervous system stimulants; however, the mechanisms of action of modafinil and armodafinil are poorly characterized. Compared with modafinil, the wake-promoting effects of armodafinil persist later in the day. It is for this reason that armodafinil may be a particularly appropriate therapy for patients with persistent ES due to OSA, SWD, or narcolepsy.

Pharmacologic approaches for the management of symptoms and cardiovascular consequences of obstructive sleep apnea in adults

INTRODUCTION

Obstructive sleep apnea (OSA) is characterized by intermittent hypoxemia, arousals from sleep, and daytime sleepiness. Accumulating evidence indicates that hypoxemia and sleep disruption contribute to the development of cardiovascular abnormalities in OSA. OSA is effectively treated with continuous positive airway pressure (CPAP) therapy that splints open the airway during sleep. Studies have shown that CPAP therapy improves daytime sleepiness and attenuates cardiovascular abnormalities in patients with OSA. However, not all patients with OSA tolerate or adhere to CPAP therapy. Even patients who regularly use CPAP therapy may have a few hours each night exposed to the negative effects of untreated OSA. As a result, complementary pharmacologic therapies that can be used with CPAP therapy have the potential to reduce symptoms and consequences of OSA.

DISCUSSION

The wake-promoting medications modafinil and armodafinil effectively improve residual sleepiness in patients treated with CPAP therapy. Although results are equivocal so far, modafinil and armodafinil may also improve quality of life and global clinical condition in patients with OSA and residual sleepiness treated with CPAP therapy. Pharmacologic therapies also have the potential to be used with CPAP therapy to minimize cardiovascular perturbations and risk of cardiovascular disease. Preliminary studies suggest that inhibition of the enzyme xanthine oxidase and inhibition of sympathetic nervous system overactivity may have therapeutic potential to reduce cardiovascular harm in patients with OSA.

CONCLUSION

Future studies of pharmacologic therapies to reduce symptoms and cardiovascular consequences of OSA should be increasingly performed as our understanding of the mechanisms mediating the adverse effects of OSA continues to evolve.

Neurophysiology of sleep and wakefulness: basic science and clinical implications

Increased attention to the prevalence of excessive sleepiness has led to a clear need to treat this symptom, thus reinforcing the need for a greater understanding of the neurobiology of sleep and wakefulness. Although the physiological mechanisms of sleep and wakefulness are highly interrelated, recent research reveals that there are distinct differences in the active brain processing and the specific neurochemical systems involved in the two states. In this review, we will examine the specific neuronal pathways, transmitters, and receptors composing the ascending arousal system that flow from the brainstem through the thalamus, hypothalamus, and basal forebrain to the cerebral cortex. We will also discuss the mutually inhibitory interaction between the core neuronal components of this arousal system and the sleep-active neurons in the ventrolateral preoptic nucleus, which serves as a brainstem-switch, regulating the stability of the sleep-wake states. In addition, we will review the role of homeostatic and circadian processes in the sleep-wake cycle, including the influence of the suprachiasmatic nucleus on coordination of sleep-wake systems. Finally, we will summarize how the above processes are reflected in disorders of sleep and wakefulness, including insomnia, narcolepsy, disorders associated with fragmented sleep, circadian rhythm sleep disorders, and primary neurological disorders such as Parkinson’s and Alzheimer’s diseases.

How treatment affects cognitive deficits in patients with sleep disorders: methodological issues and results

Sleep disorders are frequently associated with impaired performance although the type and extent of cognitive deficits varies widely between different types of sleep disorders. Treatment is expected to ameliorate these deficits. However, cognitive functioning and its change with treatment depend on numerous factors. In this chapter we discuss methodological issues, including test selection, and person-specific, task-specific and environmental factors that influence cognitive functioning. In addition, features of study design and sampling strategies are discussed. The chapter ends with a short overview of routes by which treatment may affect cognition in sleep-disordered patients.

Ready for takeoff? A critical review of armodafinil and modafinil for the treatment of sleepiness associated with jet lag

Jet lag syndrome (JLS) is a clinical syndrome of disrupted nocturnal sleep and daytime neurocognitive impairment which occurs in the context of rapid transmeridian travel. Many strategies for treatment of JLS exist, and include hypnotics to enhance nocturnal sleep, chronotherapeutic approaches (eg, light therapy, melatonin, or gradual schedule shifting), and alerting agents to counter daytime sleepiness. Safety concerns have prompted renewed interest in managing JLS-associated excessive daytime sleepiness (JLSAEDS). Off-label use of the newer alerting agents modafinil and armodafinil is increasing for this indication, often at the specific request of patients. In order to better evaluate the potential risks and benefits of these medications for the management of JLSAEDS, clinicians must be aware of what is known - and still not known. In this article, the pharmacology and pharmacokinetics of modafinil and armodafinil are reviewed, along with evidence for their efficacy in treating sleepiness associated with narcolepsy, obstructive sleep apnea and shift work sleep disorder. Clinical trial data for use of alerting agents in the management of JLSAEDS are limited to one three-day trial involving armodafinil, dosed in the morning to treat JLSAEDS in the setting of eastbound transmeridian travel. This study showed improvement in objective measures of daytime sleepiness at doses of 50 and 150 mg per day. However, global impression of clinical severity of symptom scores only improved on day 1 for those patients receiving 150 mg, and were otherwise not superior to placebo. Consideration for the use of modafinil or armodafinil for the treatment of sleepiness associated with JLS involves careful integration of patient-reported goals, a review of medical contraindications, and an awareness of rare adverse events. More research is needed in order to identify those who are most likely to benefit from this intervention and better define the risk-benefit ratio for this indication.

Armodafinil and modafinil have substantially different pharmacokinetic profiles despite having the same terminal half-lives: analysis of data from three randomized, single-dose, pharmacokinetic studies

BACKGROUND AND OBJECTIVE

Armodafinil, a non-amphetamine, wakefulness-promoting medication, is the R- and longer-lasting isomer of racemic modafinil. Armodafinil has been shown to improve wakefulness in patients with excessive sleepiness (ES) associated with treated obstructive sleep apnoea, shift work disorder or narcolepsy. In comparison with modafinil, armodafinil maintains higher plasma concentrations later in the day in healthy subjects. The objective of this analysis was to characterize the pharmacokinetic parameters related to those higher concentrations.

METHODS

Data from three randomized studies in healthy adult subjects receiving single doses of either armodafinil (50, 100, 200, 250, 300 or 400 mg) or modafinil (400 mg) were pooled, and subsequently dose-normalized to a 200 mg dose for each drug. Non-compartmental pharmacokinetic parameters were assessed.

RESULTS

Armodafinil and modafinil both had a mean single-dose terminal elimination half-life of approximately 13 hours, with similar mean maximum plasma drug concentration (C(max)) and median time to C(max) values. After reaching C(max), plasma concentrations appeared to decline in a monophasic manner with armodafinil, but in a biphasic manner with modafinil due to the initial rapid elimination of its S-isomer. As a result, mean area under the plasma drug concentration versus time curve (AUC) from time zero to the time of the last measurable concentration (AUC(last)) and AUC from time zero to infinity (AUC(infinity)) values were 33% and 40% higher, respectively, with armodafinil compared with modafinil on a milligram-to-milligram basis.

CONCLUSIONS

Despite similar half-lives, plasma concentrations following armodafinil administration are higher late in the day than those following modafinil administration on a milligram-to-milligram basis. The different pharmacokinetic profile of armodafinil may result in improved wakefulness throughout the day in patients with ES compared with modafinil.

Obstructive sleep apnea (OSA) and excessive sleepiness associated with OSA: recognition in the primary care setting

Obstructive sleep apnea (OSA) is a common and debilitating condition characterized by recurrent episodes of upper airway obstruction, resulting in intermittent occurrence of apnea-hypopnea. Clinical features include snoring or disturbed sleep, reduced concentration and memory, mood disorders, and excessive sleepiness (ES). Left undiagnosed and untreated, OSA may have detrimental consequences, including cardiovascular (CV) morbidity and mortality, decreased health-related quality of life, and increased incidence of motor vehicle accidents. As most individuals affected by OSA will initially present in the primary care setting, primary care physicians have the opportunity to recognize the condition and refer patients for treatment when necessary. Management of the condition should include lifestyle changes and continuous positive airway pressure (CPAP) treatment if required. Wakefulness-promoting agents may be considered if ES persists despite CPAP. Effective intervention for OSA not only provides symptomatic benefits, but also improves hypertension and reduces the risk for fatal and nonfatal CV events associated with the condition.

Optimal treatment of obstructive sleep apnea and excessive sleepiness

INTRODUCTION

Collapsibility of the upper airway in obstructive sleep apnea (OSA) causes repeated arousals from sleep, decreased oxygen saturation of the blood, and excessive sleepiness (ES). Patients with OSA are at increased risk of cardiovascular and cerebrovascular disease, and experience occupational and vehicular accidents more frequently than the general population. Furthermore, the life expectancy of patients with untreated OSA is significantly reduced.

METHODS

A MEDLINE search of articles published between 2003 and 2008 was conducted using the search terms: obstructive sleep apnea [ti/ab] AND treatment; obstructive sleep apnoea [ti/ab] AND treatment; and excessive sleepiness [ti/ab] AND treatment. Searches were limited to articles in English; clinical trials; meta-analyses; practice guidelines; randomized, controlled trials; and reviews.

RESULTS

Continuous positive airway pressure (CPAP) is the reference-standard treatment for patients with OSA. CPAP addresses the symptoms of OSA and reduces the risk of heart disease and depression associated with this sleep disorder. However, the efficacy of CPAP is contingent on patient adherence, and >or=4 hours of therapy per night are required for patients with OSA to experience significant clinical benefits. However, reports of nonadherence to CPAP therapy range from 29% to 83%. Other therapies are available for patients who refuse or cannot adhere to CPAP treatment, including dental devices and surgery, but these treatments are generally considered to be less efficacious. A significant number of patients continue to experience residual ES despite CPAP treatment. Pharmacologic therapies, eg, modafinil and armodafinil, may be of use in patients with OSA to improve tolerance with CPAP or to address residual ES.

CONCLUSION

There are a variety of treatments available for patients with OSA. Successful treatment involves encouraging patient compliance with CPAP or oral appliances. Primary-care physicians play a crucial role in recognizing this disorder and ensuring the best possible outcome through support and education.

Recognizing and managing obstructive sleep apnea in primary care

OBJECTIVE

This review aims to impart information regarding recognition of obstructive sleep apnea (OSA) and associated excessive sleepiness (ES) in the primary care setting in order to provide optimal care to patients with this common but serious condition. This review will also discuss the prevalence and treatment of depression in patients with OSA.

DATA SOURCES

A MEDLINE search of articles published between 1990 and 2008 was conducted using the search terms obstructive sleep apnea AND excessive sleepiness, obstructive sleep apnea AND depression, and obstructive sleep apnea AND primary care. Searches were limited to articles in English concerned with adult patients.

STUDY SELECTION

In total, 239 articles were identified. Articles concerning other sleep disorders and forms of apnea were excluded. The reference lists of identified articles were searched manually to find additional articles of interest.

DATA SYNTHESIS

Primary care physicians can aid in the diagnosis of OSA and associated ES by being vigilant for lifestyle and physical risk factors associated with this condition. In addition, primary care physicians should maintain a high level of clinical suspicion when presented with illnesses that are commonly comorbid with OSA, such as psychiatric disorders and depression, in particular. Conversely, assessment of patients with OSA for common comorbidities may also improve a patient's prognosis and quality of life.

CONCLUSIONS

Primary care physicians play a vital role in recognizing OSA and ES. These clinicians are crucial in supporting their patients during treatment by ensuring that they have clear, concise information regarding available therapies and the correct application and maintenance of prescribed devices.

Pharmacologic therapy for sleep-related breathing disorders

Sleep-related breathing disorders (SRBDs) are characterized by disruptions in normal breathing patterns, typically caused by increased upper airway resistance or diminished ventilatory drive. SRBDs are often accompanied by impairment in sleep continuity and wakefulness. The full spectrum of features associated with SRBD syndromes can be divided into three components, each of which can be a target for pharmacological intervention: the sleep-breathing event and its immediate physiological consequences; the adverse effects of these events on sleep continuity; and impairment in daytime waking function. A number of pharmacologic agents have been studied for their ability to reduce upper airway resistance or increase ventilatory drive. Other medications have been tested for their ability to treat one or more of the symptoms of sleep or wakefulness in SRBD patients. The purpose of this article is to provide a review of the status of research related to the pharmacologic treatment of SRBDs.