1
|
Sirianansopa K, Amin R. Acetazolamide as a therapeutic alternative for central sleep apnea in pediatric patient with FBXO28 gene mutation: A case report and review of literature. Sleep Med 2024; 124:479-482. [PMID: 39432981 DOI: 10.1016/j.sleep.2024.10.023] [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: 09/13/2024] [Revised: 10/10/2024] [Accepted: 10/15/2024] [Indexed: 10/23/2024]
Abstract
Central sleep apnea (CSA) is a significant concern in children with neurodevelopmental disorders and genetic syndromes, where conventional treatments such as bilevel positive airway pressure (BiLevelPAP) therapy may be poorly tolerated. Acetazolamide, a carbonic anhydrase inhibitor, is an alternative treatment that induces a metabolic acidosis, which may help stabilize respiratory disturbances by enhancing ventilatory drive. However, evidence regarding its use in pediatric populations remains limited. We report the case of a 12-year-old male with an FBXO28 gene-related disorders with significant CSA. Due to intolerance to BiLevelPAP therapy, a trial of acetazolamide was initiated. The dose was adjusted to maintain a mild metabolic acidosis, with regular blood work and clinical monitoring to assess for potential side effects. Follow-up polysomnography (PSG) demonstrated significant improvements in the central apnea-hypopnea index (CAHI) and periodic breathing. No significant adverse effects were reported, and the family noted a substantial improvement in quality of life. BRIEF SUMMARY: This case highlights that maintaining a mild metabolic acidosis with acetazolamide is sufficient to stimulate respiratory drive and stabilize breathing in pediatric CSA, while minimizing risks of electrolyte imbalances and long-term renal consequences. Our findings align with existing literature, which indicates that acetazolamide may be effective for CSA without hypoventilation in children, particularly those with genetic syndromes. Further research is necessary to establish standardized treatment protocols, optimal dosing, and long-term safety.
Collapse
Affiliation(s)
- Kantisa Sirianansopa
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Division of Pulmonary and Critical Care Medicine, Department of Pediatrics, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Reshma Amin
- Division of Respiratory Medicine, The Hospital for Sick Children, Toronto, Canada; Department of Pediatrics, University of Toronto, Toronto, Canada; Child Health and Evaluative Science, SickKids Research Institute, Toronto, Canada.
| |
Collapse
|
2
|
Anwar AI, Byrne S, Sharma A, Sands S, Wellman A, Redeker NS, Yaggi H, Zinchuk AV. Novel physiologic predictors of positive airway pressure effectiveness (NICEPAP) study: rationale, design and methods. Sleep Breath 2024; 28:2005-2015. [PMID: 38995327 DOI: 10.1007/s11325-024-03099-w] [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: 04/03/2024] [Revised: 06/10/2024] [Accepted: 06/28/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE Continuous positive airway pressure (CPAP) is the primary therapy for obstructive sleep apnea (OSA); however the effectiveness of CPAP remains suboptimal. We describe the Novel PhysIologiC prEdictors of Positive Airway Pressure Effectiveness (NICEPAP) study. Its purpose is to determine whether physiological traits of OSA contribute to CPAP effectiveness. METHODS NICEPAP (NCT05067088) is a prospective, observational cohort study conducted at an academic sleep center. Adults newly diagnosed with OSA (n = 267) are assessed for OSA traits of loop gain, arousal threshold, pharyngeal collapsibility, and muscle compensation from baseline polysomnography. We perform a comprehensive assessment of covariates relevant to CPAP adherence, efficacy, and patient-centered outcomes. Participants are followed for 12 months. Primary outcomes include (1) CPAP adherence (hours/night), (2) CPAP efficacy (apneas-hypopneas/hour), and (3) quality of life at six months measured by objective CPAP data and Functional Outcomes of Sleep Questionnaire. Secondary outcomes include sleep quality, sleepiness, insomnia, and neurocognitive function. RESULTS Data on covariates, including demographics, sleep symptoms, medical history, medications, sleep quality, OSA and treatment self-efficacy, decisional balance, and socio-economic and social and partner support, are collected using validated instruments. The analysis for primary outcomes includes a generalized linear mixed model for an outcome (e.g., CPAP adherence) with OSA traits as exposures followed by the addition of relevant covariates. CONCLUSION The findings of the NICEPAP study will inform research aimed to enhance CPAP effectiveness. Understanding the role of physiological OSA traits in CPAP effectiveness is a crucial step toward a precision medicine approach to OSA.
Collapse
Affiliation(s)
- Andira I Anwar
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Sean Byrne
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Akanksha Sharma
- University of Pittsburgh Medical Center Mercy, Pittsburgh, PA, USA
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Nancy S Redeker
- University of Connecticut School of Nursing, Connecticut, USA
| | - Henry Yaggi
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA
| | - Andrey V Zinchuk
- Department of Medicine, Yale University School of Medicine, 300 Cedar Street, New Haven, Connecticut, CT, 06443, USA.
| |
Collapse
|
3
|
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.
Collapse
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
| |
Collapse
|
4
|
Ni YN, Lei F, Tang X, Liang Z, Thomas RJ. The association between the effective apnea-hypopnea index and blood pressure reduction efficacy following CPAP/oxygen treatment. Sleep Med 2024; 117:46-52. [PMID: 38507976 DOI: 10.1016/j.sleep.2024.02.046] [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: 11/27/2023] [Revised: 01/28/2024] [Accepted: 02/29/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The effect of sleep apnea treatment on reducing cardiovascular disease risk remains inconclusive. This study aims to assess if the effective apnea hypopnea index (eAHI), a measure of residual sleep apnea burden post-treatment, is a factor in determining blood pressure (BP) response to continuous positive airway pressure therapy. The eAHI integrates time on therapy, residual apnea, and % of sleep time untreated. METHODS A secondary analysis of the Heart Biomarker Evaluation in Apnea Treatment (HeartBEAT) study, a randomized, controlled, parallel group assessment of continuous positive airway pressure (CPAP), oxygen and sleep hygiene. The Delta-AHI (▲AHI) was defined as the difference between baseline AHI and effective AHI at 12 weeks. Logistic and linear regression models estimated the predictors for nocturnal systolic BP change following sleep apnea therapy. RESULTS One hundred and sixty-nine subjects with a mean age of 62.82 ± 6.99 years were included in the final analysis. Fifty subjects had ▲AHI ≤8/hour of sleep and 119 subjects were higher. After adjustment, baseline mean nighttime systolic blood pressure (OR 1.036, 95% CI 1.015-1.058, p: 0.001) and ▲AHI ≥8/hour (OR 2.406, 95% CI 1.116-5.185, p:0.025) were independent predictors for mean nighttime systolic blood pressure change >3 mm Hg. The higher effective AHI was negatively related with BNP (β: -2.564, SE: 1.167, p: 0.029) and positively related with troponin change (β: 0.703, SE: 0.256, p: 0.007). CONCLUSION The ▲AHI was an independent predictor of the blood pressure response to sleep apnea treatment. REGISTER NUMBER NCT01086800.
Collapse
Affiliation(s)
- Yue-Nan Ni
- Department of Respiratory, Critical Care and Sleep Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Fei Lei
- Sleep Medicine Center, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Xiangdong Tang
- Sleep Medicine Center, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Zongan Liang
- Department of Respiratory, Critical Care and Sleep Medicine, West China School of Medicine and West China Hospital, Sichuan University, 610041, China.
| | - Robert Joseph Thomas
- Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| |
Collapse
|
5
|
Chu Y, Zinchuk A. The Present and Future of the Clinical Use of Physiological Traits for the Treatment of Patients with OSA: A Narrative Review. J Clin Med 2024; 13:1636. [PMID: 38541862 PMCID: PMC10970765 DOI: 10.3390/jcm13061636] [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: 01/17/2024] [Revised: 03/01/2024] [Accepted: 03/01/2024] [Indexed: 01/06/2025] Open
Abstract
People with obstructive sleep apnea (OSA) are a heterogeneous group. While many succeed in the treatment of their OSA, many others struggle with therapy. Herein, we discuss how anatomical and physiological factors that cause sleep apnea (OSA traits) impact treatment response and may offer an avenue for more precise care. These OSA traits, including anatomical (upper-airway collapsibility) and physiological (loop gain, airway muscle responsiveness, and arousal threshold) factors, may help determine who can succeed with continuous positive airway pressure, oral appliances, hypoglossal nerve stimulation, or pharmacotherapy. In the future, identifying OSA traits before initiating treatment may help guide the selection of the most effective and tolerable therapy modalities for each individual.
Collapse
Affiliation(s)
| | - Andrey Zinchuk
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale School of Medicine, 300 Cedar Street, The Anlyan Center, 455SE, New Haven, CT 06519, USA;
| |
Collapse
|
6
|
Supuran CT. Drug interactions of carbonic anhydrase inhibitors and activators. Expert Opin Drug Metab Toxicol 2024; 20:143-155. [PMID: 38450431 DOI: 10.1080/17425255.2024.2328152] [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: 01/22/2024] [Accepted: 03/04/2024] [Indexed: 03/08/2024]
Abstract
INTRODUCTION Carbonic anhydrases (CAs, EC 4.2.1.1) have been established drug targets for decades, with their inhibitors and activators possessing relevant pharmacological activity and applications in various fields. At least 11 sulfonamides/sulfamates are clinically used as diuretics, antiglaucoma, antiepileptic, or antiobesity agents and one derivative, SLC-0111, is in clinical trials as antitumor/antimetastatic agent. The activators were less investigated with no clinically used agent. AREAS COVERED Drug interactions between CA inhibitors/activators and various other agents are reviewed in publications from the period March 2020 - January 2024. EXPERT OPINION Drug interactions involving these agents revealed several interesting findings. Acetazolamide plus loop diuretics is highy effective in acute decompensated heart failure, whereas ocular diseases such as X-linked retinoschisis and macular edema were treated by acetazolamide plus bevacizumab or topical NSAIDs. Potent anti-infective effects of acetazolamide and other CAIs, alone or in combination with other agents were demonstrated for the management of Neisseria gonorrhoea, vancomycin resistant enterococci, Acanthamoeba castellanii, Trichinella spiralis, and Cryptococcus neoformans infections. Topiramate, in combination with phentermine is incresingly used for the management of obesity, whereas zonisamide plus levodopa is highly effective for Parkinson's disease. Acetazolamide, methazolamide, ethoxzolamide, and SLC-0111 showed synergistic antitumor/antimetastatic action in combination with many other antitumor drugs.
Collapse
Affiliation(s)
- Claudiu T Supuran
- Neurofarba Department, Pharmaceutical and Nutraceutical Section, University of Florence, Sesto Fiorentino, FI, Italy
| |
Collapse
|
7
|
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.
Collapse
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
| |
Collapse
|