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Albadi AM, Alshahrani MM, Allehebi RO. Sleep-related breathing disorder (central sleep apnoea) improved coincidentally by medical therapy with fumarates (dimethyl fumarate). Drugs Context 2023; 12:2023-6-3. [PMID: 38046472 PMCID: PMC10688778 DOI: 10.7573/dic.2023-6-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 10/24/2023] [Indexed: 12/05/2023] Open
Abstract
Central sleep apnoea (CSA) is a sleep disorder characterized by the repeated cessation or reduction of both airflow and ventilatory effort when sleeping. Individuals with central breathing disorders have difficulty in receiving appropriate medical treatment. In this article, we describe a case study of a 31-year-old woman known to have multiple sclerosis and concomitant severe CSA. She received the medication dimethyl fumarate for the treatment of multiple sclerosis, and her CSA significantly improved to mild CSA after the treatment.
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Affiliation(s)
- Abdulmajeed M Albadi
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
- Prince Mohammad bin Abdulaziz Medical City, Aljouf, Saudi Arabia
| | - Mana M Alshahrani
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Riyad O Allehebi
- Department of Pulmonary Medicine, Sleep Medicine Unit, King Fahad Medical City, Riyadh, Saudi Arabia
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2
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Turner JA, Laslett LL, Padgett C, Lim CK, Taylor B, van der Mei I, Honan CA. Disease-modifying therapies do not affect sleep quality or daytime sleepiness in a large Australian MS cohort. Mult Scler Relat Disord 2023; 78:104902. [PMID: 37517312 DOI: 10.1016/j.msard.2023.104902] [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: 01/16/2023] [Revised: 05/08/2023] [Accepted: 07/16/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND Poor sleep is common in multiple sclerosis (MS) and may impact daily functioning. The extent to which disease-modifying therapies (DMTs) contribute to sleep outcomes is under-examined. OBJECTIVE To compare the effects of DMTs on sleep outcomes in an Australian cohort of people with MS and investigate associations between DMT use and beliefs about sleep problems and daily functioning (social functioning and activity engagement). METHODS Sleep outcomes were assessed using the Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale. DMT use and functioning were self-reported. RESULTS Of 1,715 participants, 64% used a DMT. No differences in sleep outcomes were detected between participants who did and did not use DMTs, the type of DMT used (lower vs higher efficacy, interferon-β vs other DMTs), the timing of administration, or adherence to standard administration recommendations. Beliefs that DMT use worsened sleep were associated with poorer sleep quality and perceptions that sleep problems interfered with daily functioning. CONCLUSION The use of a DMT does not appear to affect self-reported sleep outcomes in people with MS. However, beliefs that DMT use makes sleep worse were associated with poorer sleep quality and increased interference in daily functioning, suggesting a need for education to diminish negative perceptions of DMT use.
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Affiliation(s)
- Jason A Turner
- School of Psychological Sciences, College of Health and Medicine, University of Tasmania, Hobart and Launceston, Australia
| | - Laura L Laslett
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Christine Padgett
- School of Psychological Sciences, College of Health and Medicine, University of Tasmania, Hobart and Launceston, Australia
| | - Chai K Lim
- Macquarie Medical School, Macquarie University, Sydney, Australia
| | - Bruce Taylor
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Ingrid van der Mei
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | - Cynthia A Honan
- School of Psychological Sciences, College of Health and Medicine, University of Tasmania, Hobart and Launceston, Australia; Launceston General Hospital, Launceston, Tasmania, Australia.
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3
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Hoff E, Zou D, Grote L, Stenlöf K, Hedner J. The placebo effect in pharmacological treatment of obstructive sleep apnea, a systematic review and meta-analysis. Sleep Med 2023; 106:1-7. [PMID: 37023489 DOI: 10.1016/j.sleep.2023.03.019] [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: 01/12/2023] [Revised: 03/09/2023] [Accepted: 03/20/2023] [Indexed: 04/07/2023]
Abstract
OBJECTIVE New drug treatments are under development in obstructive sleep apnea (OSA). The placebo effect is well recognized in various conditions, but its relevance in OSA is debated. In the current study we determined the influence of a placebo effect in studies of drug therapy in OSA. METHODS A systematic review and meta-analysis (PROSPERO CRD42021229410) with searches in MEDLINE, Scopus, Web of Science and Cochrane CENTRAL from inception to 2021-01-19. Inclusion criteria were (i) RCTs of adults with OSA, (ii) drug intervention with placebo baseline and follow-up sleep study (iii) outcomes: apnea hypopnea index (AHI), mean oxygen saturation (mSaO2), oxygen desaturation index (ODI) and/or Epworth Sleepiness Scale (ESS). Risk-of-bias was assessed with Cochrane RoB 2. RESULTS 7436 articles were identified and 29 studies included (n = 413). Studies were generally small (median n = 14), with 78% men, baseline AHI range 9-74 events/h and treatment duration range 1-120 days. Meta-analyses were conducted for main outcomes. Mean change of the primary outcome, AHI, was -0.84 (95% CI -2.98 to 1.30); mSaO2 and ODI estimations were also non-significant. ESS showed a trend towards a reduction of -1 unit. Subgroup analysis did not show significant differences. Risk-of-bias assessment indicated mostly low risk but studies were small with wide confidence intervals. CONCLUSIONS In this meta-analysis we did not identify systematic placebo effects on the AHI, ODI or mSaO2 while ESS score showed a trend for a small reduction. These results have an impact on the design and interpretation of drug trials in OSA.
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Affiliation(s)
- Erik Hoff
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Södra Älvsborgs Hospital, Department of Infectious Diseases, Borås, Sweden.
| | - Ding Zou
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Ludger Grote
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Centre for Sleep Medicine, Department of Pulmonary Medicine, Gothenburg, Sweden.
| | - Kaj Stenlöf
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden.
| | - Jan Hedner
- Centre for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden; Region Västra Götaland, Sahlgrenska University Hospital, Centre for Sleep Medicine, Department of Pulmonary Medicine, Gothenburg, Sweden.
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4
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Comi G, Leocani L, Ferini-Strambi L, Radaelli M, Costa GD, Lanzillo R, Lus G, Bianchi V, Traccis S, Capone F, Grimaldi LME, Salemi G. Impact of treatment with dimethyl fumarate on sleep quality in patients with relapsing-remitting multiple sclerosis: A multicentre Italian wearable tracker study. Mult Scler J Exp Transl Clin 2023; 9:20552173221144229. [PMID: 36776745 PMCID: PMC9912562 DOI: 10.1177/20552173221144229] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 11/23/2022] [Indexed: 02/11/2023] Open
Abstract
Background Sleep disorders are common in patients with multiple sclerosis and have a bidirectional interplay with fatigue and depression. Objective To evaluate the effect of treatment with oral dimethyl fumarate on the quality of sleep in relapsing-remitting multiple sclerosis. Methods This was a multicentre observational study with 223 relapsing-remitting multiple sclerosis subjects starting treatment with dimethyl fumarate (n=177) or beta interferon (n=46). All patients underwent subjective (Pittsburgh Sleep Quality Index) and objective (wearable tracker) measurements of quality of sleep. Fatigue, depression, and quality of life were also investigated and physical activity was monitored. Results Patients treated with dimethyl fumarate had significant improvement in the quality of sleep as measured with the Pittsburgh Sleep Quality Index (p<0.001). At all-time points, no significant changes in Pittsburgh Sleep Quality Index score were observed in the interferon group. Total and deep sleep measured by wearable tracker decreased at week 12 with both treatments, then remained stable for the total study duration. Depression significantly improved in patients treated with dimethyl fumarate. No significant changes were observed in mobility, fatigue and quality of life. Conclusion In patients with relapsing-remitting multiple sclerosis, the treatment with dimethyl fumarate was associated with improvements in patient-reported quality of sleep. Further randomised clinical trials are needed to confirm the benefits of long-term treatment with dimethyl fumarate.
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Affiliation(s)
- Giancarlo Comi
- Giancarlo Comi, Centro Sclerosi Multipla
Ospedale di Gallarate, ASST Valle Olona, Italy.
| | - Letizia Leocani
- Experimental Neurophysiology Unit, INSPE IRCCS
Ospedale San Raffaele, Università Vita Salute San Raffaele, Milan,
Italy
| | - Luigi Ferini-Strambi
- Department of Clinical Neurosciences, San
Raffaele Scientific Institute, Sleep Disorders Center, Università Vita
Salute San Raffaele, Milan, Italy
| | - Marta Radaelli
- Experimental Neurophysiology Unit, INSPE IRCCS
Ospedale San Raffaele, Università Vita Salute San Raffaele, Milan,
Italy
| | - Gloria D Costa
- Experimental Neurophysiology Unit, INSPE IRCCS
Ospedale San Raffaele, Università Vita Salute San Raffaele, Milan,
Italy
| | - Roberta Lanzillo
- Neurosciences, Reproductive and
Odontostomatological Sciences Department, Federico II, University of Naples,
Italy
| | - Giacomo Lus
- Multiple Sclerosis Center, II Division of
Neurology, University of Campania ‘L. Vanvitelli’ Napoli, Italy
| | | | | | | | - Luigi ME Grimaldi
- Centro Sclerosi Multipla Fondazione Istituto
‘G. Giglio’, Cefalù (PA), Italy
| | - Giuseppe Salemi
- UOC Neurologia e Neurofisiopatologia
Policlinico ‘Paolo Giaccone’, Palermo, Italy
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Thomas SD, Jha NK, Sadek B, Ojha S. Repurposing Dimethyl Fumarate for Cardiovascular Diseases: Pharmacological Effects, Molecular Mechanisms, and Therapeutic Promise. Pharmaceuticals (Basel) 2022; 15:ph15050497. [PMID: 35631325 PMCID: PMC9143321 DOI: 10.3390/ph15050497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/16/2022] Open
Abstract
Dimethyl fumarate (DMF) is a small molecule that has been shown to assert potent in vivo immunoregulatory and anti-inflammatory therapeutic actions. The drug has been approved and is currently in use for treating multiple sclerosis and psoriasis in the USA and Europe. Since inflammatory reactions have been significantly implicated in the etiology and progression of diverse disease states, the pharmacological actions of DMF are presently being explored and generalized to other diseases where inflammation needs to be suppressed and immunoregulation is desirable, either as a monotherapeutic agent or as an adjuvant. In this review, we focus on DMF, and present an overview of its mechanism of action while briefly discussing its pharmacokinetic profile. We further discuss in detail its pharmacological uses and highlight its potential applications in the treatment of cardiovascular diseases. DMF, with its unique combination of anti-inflammatory and vasculoprotective effects, has the potential to be repurposed as a therapeutic agent in patients with atherosclerotic cardiovascular disease. The clinical studies mentioned in this review with respect to the beneficial effects of DMF in atherosclerosis involve observations in patients with multiple sclerosis and psoriasis in small cohorts and for short durations. The findings of these studies need to be assessed in larger prospective clinical trials, ideally with a double-blind randomized study design, investigating the effects on cardiovascular endpoints as well as morbidity and mortality. The long-term impact of DMF therapy on cardiovascular diseases also needs to be confirmed.
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Affiliation(s)
- Shilu Deepa Thomas
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates;
- Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates
| | - Niraj Kumar Jha
- Department of Biotechnology, School of Engineering and Technology (SET), Sharda University, Greater Noida 201310, India;
| | - Bassem Sadek
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates;
- Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates
- Correspondence: (B.S.); (S.O.)
| | - Shreesh Ojha
- Department of Pharmacology and Therapeutics, College of Medicine and Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates;
- Zayed Bin Sultan Center for Health Sciences, United Arab Emirates University, Al Ain P.O. Box 15551, United Arab Emirates
- Correspondence: (B.S.); (S.O.)
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Cantrell MS, Soto-Avellaneda A, Wall JD, Ajeti AD, Morrison BE, Warner LR, McDougal OM. Repurposing Drugs to Treat Heart and Brain Illness. Pharmaceuticals (Basel) 2021; 14:ph14060573. [PMID: 34208502 PMCID: PMC8235459 DOI: 10.3390/ph14060573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/09/2021] [Accepted: 06/11/2021] [Indexed: 11/17/2022] Open
Abstract
Drug development is a complicated, slow and expensive process with high failure rates. One strategy to mitigate these factors is to recycle existing drugs with viable safety profiles and have gained Food and Drug Administration approval following extensive clinical trials. Cardiovascular and neurodegenerative diseases are difficult to treat, and there exist few effective therapeutics, necessitating the development of new, more efficacious drugs. Recent scientific studies have led to a mechanistic understanding of heart and brain disease progression, which has led researchers to assess myriad drugs for their potential as pharmacological treatments for these ailments. The focus of this review is to survey strategies for the selection of drug repurposing candidates and provide representative case studies where drug repurposing strategies were used to discover therapeutics for cardiovascular and neurodegenerative diseases, with a focus on anti-inflammatory processes where new drug alternatives are needed.
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Affiliation(s)
- Maranda S. Cantrell
- Biomolecular Sciences Ph.D. Program, Boise State University, Boise, ID 83725, USA; (M.S.C.); (A.S.-A.)
- Department of Chemistry and Biochemistry, Boise State University, Boise, ID 83725, USA; (J.D.W.); (A.D.A.)
| | - Alejandro Soto-Avellaneda
- Biomolecular Sciences Ph.D. Program, Boise State University, Boise, ID 83725, USA; (M.S.C.); (A.S.-A.)
- Department of Biology, Boise State University, Boise, ID 83725, USA
| | - Jackson D. Wall
- Department of Chemistry and Biochemistry, Boise State University, Boise, ID 83725, USA; (J.D.W.); (A.D.A.)
| | - Aaron D. Ajeti
- Department of Chemistry and Biochemistry, Boise State University, Boise, ID 83725, USA; (J.D.W.); (A.D.A.)
| | - Brad E. Morrison
- Department of Biology, Boise State University, Boise, ID 83725, USA
- Correspondence: (B.E.M.); (L.R.W.); (O.M.M.)
| | - Lisa R. Warner
- Biomolecular Sciences Ph.D. Program, Boise State University, Boise, ID 83725, USA; (M.S.C.); (A.S.-A.)
- Correspondence: (B.E.M.); (L.R.W.); (O.M.M.)
| | - Owen M. McDougal
- Biomolecular Sciences Ph.D. Program, Boise State University, Boise, ID 83725, USA; (M.S.C.); (A.S.-A.)
- Correspondence: (B.E.M.); (L.R.W.); (O.M.M.)
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7
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Singh M, Gavidia R, Dunietz GL, Washnock-Schmid E, Romeo AR, Hershner S, Chervin RD, Braley TJ. Validation of an obstructive sleep apnea symptom inventory in persons with multiple sclerosis. Mult Scler 2021; 28:280-288. [PMID: 34048308 DOI: 10.1177/13524585211013014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Improved screening for obstructive sleep apnea (OSA) could enhance multiple sclerosis (MS) clinical care; yet the utility of current screening tools for OSA have yet to be evaluated in persons with multiple sclerosis (PwMS). OBJECTIVES The STOP-Bang Questionnnaire is an 8-item screening tool for OSA that is commonly used in non-MS samples. The aim of this study was to assess the validity of the STOP-Bang in PwMS. METHODS STOP-Bang and polysomnography data were analyzed from n = 200 PwMS. Sensitivity, specificity, positive-, and negative-predictive value (PPV and NPV) were calculated, with receiving operating characteristic (ROC) curves, for each STOP-Bang threshold score, against polysomnography-confirmed OSA diagnosis at three apnea severity thresholds (mild, moderate, and severe). RESULTS Nearly 70% had a STOP-Bang score of ⩾3% and 78% had OSA. The STOP-Bang at a threshold score of 3 provided sensitivities of 87% and 91% to detect moderate and severe OSA, respectively; and NPV of 84% and 95% to identify PwMS without moderate or severe OSA, respectively. Sensitivity to detect milder forms of OSA was 76%. The NPV to identify persons without milder forms of OSA was 40%. CONCLUSION The STOP-Bang Questionnaire is an effective tool to screen for moderate and severe OSA in PwMS, but may be insufficient to exclude mild OSA.
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Affiliation(s)
- Mini Singh
- Department of Neurology, Medical University of South Carolina, Charleston, SC, USA
| | - Ronald Gavidia
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Galit Levi Dunietz
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Elizabeth Washnock-Schmid
- Division of Multiple Sclerosis and Clinical Neuroimmunology, Department of Neurology, University of Michigan, Ann Arbor, MI, USA/VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Andrew R Romeo
- Division of Multiple Sclerosis and Clinical Neuroimmunology, Department of Neurology, University of Michigan, Ann Arbor, MI, USA/VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Shelley Hershner
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Ronald D Chervin
- Division of Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Tiffany J Braley
- Divisions of Multiple Sclerosis, Clinical Neuroimmunology and Sleep Medicine, Department of Neurology, University of Michigan, Ann Arbor, MI, USA/Division of Multiple Sclerosis and Clinical Neuroimmunology, Department of Neurology, University of Michigan, Ann Arbor, MI, USA/VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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8
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Leung TN, Cheng JW, Chan AK. Paediatrics: how to manage obstructive sleep apnoea syndrome. Drugs Context 2021; 10:dic-2020-12-5. [PMID: 33828609 PMCID: PMC8007210 DOI: 10.7573/dic.2020-12-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/19/2021] [Indexed: 02/02/2023] Open
Abstract
Obstructive sleep apnoea syndrome (OSAS) is defined as the intermittent reduction or cessation of airflow due to partial or complete obstruction of the upper airway during sleep. Paediatric OSAS has specific contributing factors, presenting symptoms and management strategies in various age groups. Untreated OSAS can lead to detrimental effects on neurocognitive development and cardiovascular and metabolic functions of a growing child. In the past decade, practice guidelines have been developed to guide the evaluation and management of OSAS. This article provides a narrative review on the current diagnostic and treatment options for paediatric OSAS. Alternative diagnostic tools other than the standard polysomnography are discussed. Adenotonsillectomy is considered the first-line therapy yet it is not suitable for treatment of all OSAS cases. Nocturnal non-invasive positive airway pressure ventilation is effective and could be the priority treatment for patients with complex comorbidities, residual OSAS post-adenotonsillectomy or obesity. However, intolerance and non-adherence are major challenges of positive airway pressure therapy especially in young children. There is increasing evidence for watchful waiting and other gentler alternative treatment options in mild OSAS. The role of anti-inflammatory drugs as the primary or adjunctive treatment is discussed. Other treatment options, including weight reduction, orthodontic procedures and myofunctional therapy, are indicated for selected patients. Nevertheless, the successful management of paediatric OSAS often requires a multidisciplinary team approach.
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Affiliation(s)
- Theresa Nh Leung
- Department of Paediatrics and Adolescent Medicine, University of Hong Kong, Hong Kong SAR, China
| | - James Wch Cheng
- Department of Paediatrics and Adolescent Medicine, United Christian Hospital, Hong Kong SAR, China
| | - Anthony Kc Chan
- Department of Pediatrics, McMaster University, Hamilton, Ontario, Canada
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Schütz SG, Dunn A, Braley TJ, Pitt B, Shelgikar AV. New frontiers in pharmacologic obstructive sleep apnea treatment: A narrative review. Sleep Med Rev 2021; 57:101473. [PMID: 33853035 DOI: 10.1016/j.smrv.2021.101473] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Revised: 02/23/2021] [Accepted: 02/24/2021] [Indexed: 12/22/2022]
Abstract
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.
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Affiliation(s)
- Sonja G Schütz
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA.
| | - Abbey Dunn
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA
| | - Tiffany J Braley
- Department of Neurology Multiple Sclerosis and Sleep Disorders Center, University of Michigan, Ann Arbor, MI, USA
| | - Bertram Pitt
- Department of Internal Medicine Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Anita V Shelgikar
- Department of Neurology Sleep Disorders Center, University of Michigan Ann Arbor, MI, USA
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Kourakis S, Timpani CA, Campelj DG, Hafner P, Gueven N, Fischer D, Rybalka E. Standard of care versus new-wave corticosteroids in the treatment of Duchenne muscular dystrophy: Can we do better? Orphanet J Rare Dis 2021; 16:117. [PMID: 33663533 PMCID: PMC7934375 DOI: 10.1186/s13023-021-01758-9] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 02/18/2021] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Pharmacological corticosteroid therapy is the standard of care in Duchenne Muscular Dystrophy (DMD) that aims to control symptoms and slow disease progression through potent anti-inflammatory action. However, a major concern is the significant adverse effects associated with long term-use. MAIN: This review discusses the pros and cons of standard of care treatment for DMD and compares it to novel data generated with the new-wave dissociative corticosteroid, vamorolone. The current status of experimental anti-inflammatory pharmaceuticals is also reviewed, with insights regarding alternative drugs that could provide therapeutic advantage. CONCLUSIONS Although novel dissociative steroids may be superior substitutes to corticosteroids, other potential therapeutics should be explored. Repurposing or developing novel pharmacological therapies capable of addressing the many pathogenic features of DMD in addition to anti-inflammation could elicit greater therapeutic advantages.
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Affiliation(s)
- Stephanie Kourakis
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia
| | - Cara A Timpani
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia
| | - Dean G Campelj
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia.,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia
| | - Patricia Hafner
- Division of Neuropediatrics and Developmental Medicine, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Nuri Gueven
- School of Pharmacy and Pharmacology, University of Tasmania, Hobart, TAS, Australia
| | - Dirk Fischer
- Division of Neuropediatrics and Developmental Medicine, University Children's Hospital of Basel (UKBB), Basel, Switzerland
| | - Emma Rybalka
- Institute for Health and Sport (IHeS), Victoria University, Melbourne, VIC, Australia. .,Australian Institute for Musculoskeletal Science (AIMSS), St Albans, VIC, Australia.
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11
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Bock JM, Vungarala S, Karim S, Somers VK. Obstructive Sleep Apnea as a Cardiovascular Risk Factor-Beyond CPAP. Can J Cardiol 2021; 37:756-765. [PMID: 33610689 DOI: 10.1016/j.cjca.2021.01.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 01/28/2021] [Accepted: 01/31/2021] [Indexed: 12/14/2022] Open
Abstract
Patients with obstructive sleep apnea (OSA) experience repetitive partial or complete airway collapse during sleep resulting in nocturnal hypoxia-normoxia cycling, and are at increased cardiovascular risk. The number of apneas and hypopneas indexed per hour of sleep (apnea-hypopnea index) along with the associated intermittent hypoxia predict the increased cardiovascular risk; thus, their attenuation or prevention are objectives of OSA therapy. Continuous positive airway pressure (CPAP) is the gold standard treatment for OSA and, when effective, mitigates the apnea-hypopnea index and hypoxemia. As such, it is reasonable to expect CPAP would decrease cardiovascular risk. However, 3 recent randomized clinical trials of CPAP vs usual care did not show any significant effects of CPAP in attenuating incident cardiovascular events in patients with OSA. In this review, we discuss these studies in addition to potential complementary therapeutic options to CPAP (eg, neurostimulation) and conclude with suggested therapeutic targets for future interventional studies (eg, the autonomic nervous system). Although these areas of research are exciting, they have yet to be tested to any similar degree of rigour as CPAP.
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Affiliation(s)
- Joshua M Bock
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Soumya Vungarala
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Shahid Karim
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Virend K Somers
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota, USA.
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Boulos MI, Dharmakulaseelan L, Brown DL, Swartz RH. Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches. Stroke 2020; 52:366-372. [PMID: 33349009 DOI: 10.1161/strokeaha.120.031709] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
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Affiliation(s)
- Mark I Boulos
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laavanya Dharmakulaseelan
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor (D.L.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
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Yagishita Y, Gatbonton-Schwager TN, McCallum ML, Kensler TW. Current Landscape of NRF2 Biomarkers in Clinical Trials. Antioxidants (Basel) 2020; 9:antiox9080716. [PMID: 32784785 PMCID: PMC7464243 DOI: 10.3390/antiox9080716] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 08/02/2020] [Accepted: 08/05/2020] [Indexed: 12/12/2022] Open
Abstract
The transcription factor NF-E2 p45-related factor 2 (NRF2; encoded by NFE2L2) plays a critical role in the maintenance of cellular redox and metabolic homeostasis, as well as the regulation of inflammation and cellular detoxication pathways. The contribution of the NRF2 pathway to organismal homeostasis is seen in many studies using cell lines and animal models, raising intense attention towards targeting its clinical promise. Over the last three decades, an expanding number of clinical studies have examined NRF2 inducers targeting an ever-widening range of diseases. Full understanding of the pharmacokinetic and pharmacodynamic properties of drug candidates rely partly on the identification, validation, and use of biomarkers to optimize clinical applications. This review focuses on results from clinical trials with four agents known to target NRF2 signaling in preclinical studies (dimethyl fumarate, bardoxolone methyl, oltipraz, and sulforaphane), and evaluates the successes and limitations of biomarkers focused on expression of NRF2 target genes and others, inflammation and oxidative stress biomarkers, carcinogen metabolism and adduct biomarkers in unavoidably exposed populations, and targeted and untargeted metabolomics. While no biomarkers excel at defining pharmacodynamic actions in this setting, it is clear that these four lead clinical compounds do touch the NRF2 pathway in humans.
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Wen WW, Sun HL, Yang YX, Jia YF, Huang ML, Du YH, Qin YW, Fang F, Zhang M, Wei YX. The association between circulating APRIL levels and severity of obstructive sleep apnea in Chinese adults. Clin Chim Acta 2020; 508:161-169. [PMID: 32417211 DOI: 10.1016/j.cca.2020.05.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/12/2020] [Accepted: 05/13/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is the most common type of sleep breathing disorder and is characterized by chronic intermittent hypoxia, which could cause inflammation and nuclear factor kappa B (NF-KB)-dependent inflammatory pathways activation. Circulating APRIL (a proliferation-inducing ligand) play an important role in promoting inflammation and NF-KB-dependent inflammatory pathways activation. We explored the role of APRIL as a potential mechanism of inflammation in OSA patients. METHODS After detailed sleep evaluated, venous blood and demographic data were collected from 155 subjects with varying severity of OSA and 52 control subjects. Plasma levels of APRIL were measured by human Magnetic Luminex assay. RESULTS Plasma APRIL levels were significantly higher in OSA subjects compared with control subjects. Categorization of the OSA subjects into mild, moderate, and severe OSA subgroups found that plasma levels of APRIL increased with the severity of OSA. After adjusting confounding factors, found that increased plasma APRIL levels were conferred a higher odds ratio of OSA. Moreover, plasma APRIL levels were positively associated with the apnea-hypopnea index, which represents the severity of OSA. Furthermore, plasma APRIL showed higher discriminatory accuracy in predicting the presence of OSA. CONCLUSIONS Plasma APRIL levels were significantly associated with the occurrence of OSA and its severity. APRIL could be a plasma biomarker with a positive diagnostic value for inflammation and NF-KB-dependent inflammatory pathways activation in subjects with OSA. TRIAL REGISTRATION The project was approved by the Chinese Clinical Trial Registry (No. ChiCTRROC-17011027).
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Affiliation(s)
- Wan-Wan Wen
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hai-Li Sun
- Department of Otolaryngology Head & Neck Surgery, Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yun-Xiao Yang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yi-Fan Jia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Meng-Ling Huang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yun-Hui Du
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yan-Wen Qin
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fang Fang
- Department of Otolaryngology Head & Neck Surgery, Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Ming Zhang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
| | - Yong-Xiang Wei
- Department of Otolaryngology Head & Neck Surgery, Key Laboratory of Upper Airway Dysfunction-related Cardiovascular Diseases, Beijing Institute of Heart Lung and Blood Vessel Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China.
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Hennig P, Fenini G, Di Filippo M, Beer HD. Electrophiles Against (Skin) Diseases: More Than Nrf2. Biomolecules 2020; 10:E271. [PMID: 32053878 PMCID: PMC7072181 DOI: 10.3390/biom10020271] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 02/04/2020] [Accepted: 02/06/2020] [Indexed: 12/11/2022] Open
Abstract
The skin represents an indispensable barrier between the organism and the environment and is the first line of defense against exogenous insults. The transcription factor NRF2 is a central regulator of cytoprotection and stress resistance. NRF2 is activated in response to oxidative stress by reactive oxygen species (ROS) and electrophiles. These electrophiles oxidize specific cysteine residues of the NRF2 inhibitor KEAP1, leading to KEAP1 inactivation and, subsequently, NRF2 activation. As oxidative stress is associated with inflammation, the NRF2 pathway plays important roles in the pathogenesis of common inflammatory diseases and cancer in many tissues and organs, including the skin. The electrophile and NRF2 activator dimethyl fumarate (DMF) is an established and efficient drug for patients suffering from the common inflammatory skin disease psoriasis and the neuro-inflammatory disease multiple sclerosis (MS). In this review, we discuss possible molecular mechanisms underlying the therapeutic activity of DMF and other NRF2 activators. Recent evidence suggests that electrophiles not only activate NRF2, but also target other inflammation-associated pathways including the transcription factor NF-κB and the multi-protein complexes termed inflammasomes. Inflammasomes are central regulators of inflammation and are involved in many inflammatory conditions. Most importantly, the NRF2 and inflammasome pathways are connected at different levels, mainly antagonistically.
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Affiliation(s)
- Paulina Hennig
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH-8091 Zurich, Switzerland; (P.H.); (G.F.); (M.D.F.)
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Gabriele Fenini
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH-8091 Zurich, Switzerland; (P.H.); (G.F.); (M.D.F.)
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Michela Di Filippo
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH-8091 Zurich, Switzerland; (P.H.); (G.F.); (M.D.F.)
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
| | - Hans-Dietmar Beer
- Department of Dermatology, University Hospital of Zurich, Gloriastrasse 31, CH-8091 Zurich, Switzerland; (P.H.); (G.F.); (M.D.F.)
- Faculty of Medicine, University of Zurich, 8006 Zurich, Switzerland
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Rommer PS, Sellner J. Repurposing multiple sclerosis drugs: a review of studies in neurological and psychiatric conditions. Drug Discov Today 2019; 24:1398-1404. [PMID: 31100209 DOI: 10.1016/j.drudis.2019.05.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 03/27/2019] [Accepted: 05/09/2019] [Indexed: 12/13/2022]
Abstract
Treatment options for multiple sclerosis (MS) have improved in the past 20 years, with new oral disease-modifying drugs and monoclonal antibodies becoming available. The success seen with these drugs in MS, and their various mechanisms of action, has led to them being investigated in other neurological and psychiatric disorders. This review article summarises the ongoing and completed studies of MS drugs in neurological and psychiatric conditions other than MS. The most promising results are for interferon beta in human T cell leukaemia virus 1 associated myelopathy/tropical spastic paraparesis and glioma, and for fingolimod in acute ischaemic stroke and intracerebral haemorrhage. The coming years could see the arrival of exciting new therapies for disorders that neurologists have historically found difficult to treat and that represent a significant unmet clinical need.
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Affiliation(s)
| | - Johann Sellner
- Department of Neurology, Christian Doppler Medical Center, Paracelsus Medical University, Salzburg, Austria
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