The pharmacotherapeutic management of obstructive sleep apnea

Pathophysiological mechanisms and therapeutic approaches in obstructive sleep apnea syndrome

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.

Effects of solriamfetol on on-the-road driving performance in participants with excessive daytime sleepiness associated with obstructive sleep apnoea

OBJECTIVE

To evaluate the impact of solriamfetol, a dopamine and norepinephrine reuptake inhibitor, on on-the-road driving in participants with excessive daytime sleepiness (EDS) associated with obstructive sleep apnoea (OSA).

METHODS

Eligible participants were aged 21-75 years with OSA and EDS (Maintenance of Wakefulness Test mean sleep latency <30 minutes and Epworth Sleepiness Scale score ≥10). Participants were randomised 1:1 to solriamfetol (150 mg/day [3 days], then 300 mg/day [4 days]) or placebo for 7 days, before crossover to the other treatment paradigm. On Day 7 of each period, standardised on-road driving tests occurred (2 and 6 hours postdose). Standard deviation of lateral position (SDLP) was the primary endpoint.

RESULTS

Solriamfetol significantly reduced SDLP at 2 (n = 34; least squares mean difference, -1.1 cm; 95% CI, -1.85, -0.32; p = 0.006) and 6 hours postdose (n = 32; least squares mean difference, -0.8 cm; 95% CI, -1.58, -0.03; p = 0.043). Two hours postdose, 4 placebo-treated and 1 solriamfetol-treated participants had incomplete driving tests; 6 hours postdose, 7 and 3 participants, respectively, had incomplete tests. Common treatment-emergent adverse events included headache, nausea, and insomnia.

CONCLUSIONS

Solriamfetol 300 mg/day significantly improved on-the-road driving performance in participants with EDS associated with OSA.

Overview of the Role of Pharmacological Management of Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) remains a prominent disease state characterized by the recurrent collapse of the upper airway while sleeping. To date, current treatment may include continuous positive airway pressure (CPAP), lifestyle changes, behavioral modification, mandibular advancement devices, and surgical treatment. However, due to the desire for a more convenient mode of management, pharmacological treatment has been thoroughly investigated as a means for a potential alternative in OSA treatment. OSA can be distinguished into various endotypic or phenotypic classes, allowing pharmacological treatment to better target the root cause or symptoms of OSA. Some medications available for use include antidepressants, CNS stimulants, nasal decongestants, carbonic anhydrase inhibitors, and potassium channel blockers. This review will cover the findings of currently available and future study medications that could potentially play a role in OSA therapy.

An Exploratory Study on the Treatment of Obstructive Apnea-Hypopnea Syndrome by Nasal Cavity Expansion

Background

Respiratory disorder is a disease with a very high incidence, in which obstructive apnea-hypopnea syndrome is the most harmful. It has become a common and frequently occurring disease, which seriously influences the health of the affected population. The pathogenesis of obstructive sleep apnea/hypopnea syndrome (OSAHS) is numerous. With the continuous research on OSAHS disease, it has been found that one of its main pathogeneses is caused by the anatomical characteristics of upper airway obstruction induced during sleep. The narrowing and collapse of any plane can affect the ventilation of the upper respiratory tract. In recent years, with the deepening of research, the importance of the upper respiratory tract obstruction as a source of the disease has attracted increasing attention. Nasal stenosis can cause increased nasal resistance, increased pharyngeal inhalation negative pressure, soft palate collapse, and narrow pharyngeal cavity, resulting in open mouth breathing, which can be the initiating factor of the upper airway obstruction. With the development and popularization of nasal endoscopy technology, domestic and foreign scholars have reported more on the treatment of rhinogenic OSAHS with nasal cavity expansion, but they are different. There is still more controversy; the main controversy centered on the effective rate of surgical treatment and the improvement of objective indicators. Therefore, this study performed individualized nasal cavity expansion for patients with OSAHS who are mainly rhinogenic, from subjective symptoms, objective indicators, and effective rate of surgery. Methods and Patients. Conduct research and analysis to provide references for the clinical treatment of such patients. For patients with the obstructive apnea-hypopnea syndrome with nasal congestion, individualized nasal cavity expansion was performed to study the clinical effect of nasal cavity expansion in the treatment of OSAHS. This article mainly screens cases through big data and selects a large hospital in China to perform individualized nasal cavity expansion surgery to treat 43 adult OSAHS patients with nasal congestion.

Results

There are uploaded sleep monitoring, nasal reflex, nasal resistance, and nasal symptoms before and after surgery.

Conclusion

Spirometer examination records, along with apnea-hypopnea index and minimum arterial blood oxygen saturation, the minimum cross-sectional area of the nasal cavity, nasal cavity volume, nasal airway resistance, total nasal respiratory volume, and other information. Also we fill in the nasal obstruction symptom assessment scale, sleepiness scale, and study and analyze the surgical effect of nasal cavity expansion.

Diagnostik und Therapie der residualen Tagesschläfrigkeit bei Patienten mit therapierter obstruktiver Schlafapnoe

Die residuale Tagesschläfrigkeit tritt bei 12–65 % der Schlafapnoe-Patienten unter eingeleiteter Positivdrucktherapie („positive airway pressure“) auf. Eine häufige Ursache ist die geringe PAP-Nutzungszeit. Mögliche weitere Gründe sind ein hoher Rest-Apnoe-Hypopnoe-Index und eine vorhandene Komorbidität. Prädiktoren sind ein initial hoher Epworth-Schläfrigkeitsscore, jüngeres Alter und die erst kurze PAP-Nutzung. Gesichert wird die Restschläfrigkeit mittels objektiver Testverfahren (z. B. multipler Wachbleibetest oder Oxford Sleep Resistance Test [Osler-Test]). Eine der wesentlichen Ursachen für die residuale Schläfrigkeit nach Ausschluss konkurrierender Auslöser ist die stattgehabte intermittierende nächtliche Hypoxämie, die zu nervalen Zellschädigungen, zu hormonellen und genetischen Veränderungen und zu Änderungen des Mikrobioms führen kann.

Die klinischen Beschwerden werden bestimmt durch eine ausgeprägte Tagesschläfrigkeit, depressive Verstimmung und eine Minderung der Lebensqualität.

Nach Ausschluss möglicher therapiebedingter Ursachen kann die residuale Tagesschläfrigkeit medikamentös mit u. a. Modafinil, Armodafinil, Pitolisant oder Solriamfetol behandelt werden. Die genannten Arzneimittel haben unterschiedliche Wirkmechanismen. Die Studien und die Effekte der Substanzen auf die Tagesschläfrigkeit, die Lebensqualität und die Leistungsfähigkeit der Betroffenen werden vorgestellt. Das Nebenwirkungsprofil der Wirkstoffe ist ähnlich. Für die Indikation residuale Schläfrigkeit einer therapierten obstruktiven Schlafapnoe ist in Europa derzeit nur Solriamfetol zugelassen.

Ein vom Autorenteam entworfener Behandlungspfad für Patienten mit therapierter obstruktiver Schlafapnoe mit residualer Tagesschläfrigkeit, von der Erstvorstellung nach Therapiebeginn über die Therapieoptimierung bis hin zu einer medikamentösen Behandlung, wird vorgestellt.

The Sleep and Recovery Practices of Athletes

BACKGROUND

Athletes maintain a balance between stress and recovery and adopt recovery modalities that manage fatigue and enhance recovery and performance. Optimal TST is subject to individual variance. However, 7-9 h sleep is recommended for adults, while elite athletes may require more quality sleep than non-athletes.

METHODS

A total of 338 (elite n = 115, 74 males and 41 females, aged 23.44 ± 4.91 years; and sub-elite n = 223, 129 males and 94 females aged 25.71 ± 6.27) athletes were recruited from a variety of team and individual sports to complete a battery of previously validated and reliable widely used questionnaires assessing sleep, recovery and nutritional practices.

RESULTS

Poor sleep was reported by both the elite and sub-elite athlete groups (i.e., global PSQI score ≥5-elite 64% [n = 74]; sub-elite 65% [n = 146]) and there was a significant difference in sport-specific recovery practices (3.22 ± 0.90 vs. 2.91 ± 0.90; p < 0.001). Relatively high levels of fatigue (2.52 ± 1.32), stress (1.7 ± 1.31) and pain (50%, n = 169) were reported in both groups. A range of supplements were used regularly by athletes in both groups; indeed, whey (elite n = 22 and sub-elite n = 48) was the most commonly used recovery supplement in both groups. Higher alcohol consumption was observed in the sub-elite athletes (12%, n = 26) and they tended to consume more units of alcohol per drinking bout.

CONCLUSION

There is a need for athletes to receive individualised support and education regarding their sleep and recovery practices.

New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review

Obstructive sleep apnea (OSA) is the most common form of sleep-disordered breathing characterized by intermittent partial or complete closure of the upper airway during sleep. If left untreated, OSA is associated with adverse cardiovascular outcomes such as hypertension, coronary heart disease, heart failure, cardiac arrhythmia, stroke, and death. Positive airway pressure (PAP) is often considered the first-line treatment for OSA. While PAP can be very effective in reducing the number of obstructive apneas and hypopneas, its impact on prevention of adverse cardiovascular consequences remains controversial, and treatment adherence is often poor. Hence, the necessity for novel treatment options to help those who cannot adhere to positive airway pressure treatment. Different classes of medications have been tested with regards to their effect on OSA severity. This review 1) provides an update on the epidemiology and pathophysiology of OSA, 2) outlines the mechanistic rationale for medication classes tested as OSA treatment and 3) discusses the effects of these medications on OSA. Several wake-promoting medications are approved for management of persistent sleepiness despite OSA treatment; discussion of these symptomatic treatments is outside the scope of this review. Herein, the authors review the current evidence for pharmacological management of OSA and provide future directions.