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Foster K, Anholm JD, Foster G, Thapamagar S, Subedi P. Effects of Naltrexone on Sleep Quality and Periodic Breathing at High Altitude. High Alt Med Biol 2024. [PMID: 38966963 DOI: 10.1089/ham.2024.0023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/06/2024] Open
Abstract
Foster, Katharine, James D. Anholm, Gary Foster, Suman Thapamagar, and Prajan Subedi. Effects of naltrexone on sleep quality and periodic breathing at high altitude. High Alt Med Biol. 00:000-000, 2024. Objective: This study examined the effects of naltrexone on breathing and sleep at high altitude. Mu-opioid receptor (MOR) agonists have a depressive effect on respiration. Naltrexone is known to block the MOR. We hypothesized that MOR blockade with naltrexone would result in higher nocturnal oxygen saturations, fewer apneas, and improved sleep at high altitude. Methods: This double-blind, placebo-controlled, crossover study included nine healthy volunteers (four females, five males) aged 27.9 (4.6) (mean [standard deviation]) years. Two overnight trips spaced at least 2 weeks apart took participants from Loma Linda, CA (355 m) to the Barcroft Laboratory, CA (3,810 m) for each arm. Participants ingested either 50 mg naltrexone or matching placebo at bedtime. Sleep metrics were recorded using an ambulatory physiological sleep monitor (APSM). Subjective data were measured with the Groningen Sleep Quality Scale, Stanford Sleepiness Scale, and the 2018 Lake Louise Score (LLS) for acute mountain sickness (AMS). Results: Mean overnight SpO2 was lower after taking naltrexone, 81% (6) versus 83% (4) (mean difference 1.9% [2.1, 95% confidence interval or CI = 0.1-3.6, p = 0.040]). The lowest overnight SpO2 (nadir) was lower on naltrexone 70% (6) versus 74% (4) (dif. 4.6% [4.3], CI = 1.0-8.2, p = 0.020). Total sleep time and total apnea-hypopnea index were unchanged. Subjective sleep quality was significantly worse on naltrexone measured via the Groningen Sleep Quality Scale (p = 0.033) and Stanford Sleepiness Scale (p = 0.038). AMS measured via LLS was significantly worse while taking naltrexone (p = 0.025). Conclusion: Contrary to our hypothesis, this study demonstrated a significant decrease in nocturnal oxygen saturation, worse sleep quality, and AMS scores. Further characterization of the MOR's effects on sleep and AMS is needed to evaluate potential exacerbating mechanisms for AMS and poor sleep quality at altitude.
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Affiliation(s)
- Katharine Foster
- Department of Emergency Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - James D Anholm
- Pulmonary & Critical Care, VA Loma Linda Healthcare System, Loma Linda, California, USA
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
| | - Gary Foster
- Cardiology, St. Charles Health System, Bend, Oregon, USA
| | - Suman Thapamagar
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
- Riverside University Healthcare System Medical Center, Moreno Valley, California, USA
| | - Prajan Subedi
- Pulmonary & Critical Care, VA Loma Linda Healthcare System, Loma Linda, California, USA
- Department of Medicine, Loma Linda University School of Medicine, Loma Linda, California, USA
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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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Guglielmi V, Bettini S, Sbraccia P, Busetto L, Pellegrini M, Yumuk V, Colao AM, El Ghoch M, Muscogiuri G. Beyond Weight Loss: Added Benefits Could Guide the Choice of Anti-Obesity Medications. Curr Obes Rep 2023:10.1007/s13679-023-00502-7. [PMID: 37209215 DOI: 10.1007/s13679-023-00502-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 05/22/2023]
Abstract
PURPOSE OF REVIEW To highlight the added benefits of approved and upcoming, centrally-acting, anti-obesity drugs, focusing not only on the most common metabolic and cardiovascular effects but also on their less explored clinical benefits and drawbacks, in order to provide clinicians with a tool for more comprehensive, pharmacological management of obesity. RECENT FINDINGS Obesity is increasingly prevalent worldwide and has become a challenge for healthcare systems and societies. Reduced life expectancy and cardiometabolic complications are some of the consequences of this complex disease. Recent insights into the pathophysiology of obesity have led to the development of several promising pharmacologic targets, so that even more effective drugs are on the horizon. The perspective of having a wider range of treatments increases the chance to personalize therapy. This primarily has the potential to take advantage of the long-term use of anti-obesity medication for safe, effective and sustainable weight loss, and to concomitantly address obesity complications/comorbidities when already established. The evolving scenario of the availability of anti-obesity drugs and the increasing knowledge of their added effects on obesity complications will allow clinicians to move into a new era of precision medicine.
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Affiliation(s)
- Valeria Guglielmi
- Dept. of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Internal Medicine Unit - Obesity Center, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Silvia Bettini
- Center for the Study and the Integrated Treatment of Obesity, Internal Medicine 3, Padua University Hospital, Padua, Italy
| | - Paolo Sbraccia
- Dept. of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
- Internal Medicine Unit - Obesity Center, University Hospital Policlinico Tor Vergata, Rome, Italy
| | - Luca Busetto
- Center for the Study and the Integrated Treatment of Obesity, Internal Medicine 3, Padua University Hospital, Padua, Italy
| | - Massimo Pellegrini
- Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, 41121, Modena, Italy
| | - Volkan Yumuk
- Division of Endocrinology, Metabolism & Diabetes Istanbul University Cerrahpaşa Medical Faculty, Istanbul, Türkiye
| | - Anna Maria Colao
- Italian Centre for the Care and Well-Being of Patients With Obesity (C.I.B.O), Dipartimento Di Medicina Clinica E Chirurgia, Università Federico II, 80131, Naples, Italy
- Dipartimento Di Medicina Clinica E Chirurgia, Diabetologia E Andrologia, Unità Di Endocrinologia, Università Degli Studi Di Napoli Federico II, Via Sergio Pansini 5, 80131, Naples, Italy
- Cattedra Unesco "Educazione Alla Salute E Allo Sviluppo Sostenibile", University Federico II, Naples, Italy
| | - Marwan El Ghoch
- Department of Nutrition and Dietetics, Faculty of Health Sciences, Beirut Arab University, P.O. Box 11-5020, Riad El Solh, Beirut, Lebanon
| | - Giovanna Muscogiuri
- Dipartimento Di Medicina Clinica E Chirurgia, Diabetologia E Andrologia, Unità Di Endocrinologia, Università Degli Studi Di Napoli Federico II, Via Sergio Pansini 5, 80131, Naples, Italy.
- Cattedra Unesco "Educazione Alla Salute E Allo Sviluppo Sostenibile", University Federico II, Naples, Italy.
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Kim JI, Park H, Min B, Oh S, Lee JH, Kim JH. The mediation effect of depression and alcohol use disorders on the association between post-traumatic stress disorder and obstructive sleep apnea risk in 51,149 Korean firefighters: PTSD and OSA in Korean firefighters. J Affect Disord 2021; 292:189-196. [PMID: 34126310 DOI: 10.1016/j.jad.2021.05.077] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 04/19/2021] [Accepted: 05/31/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Post-traumatic stress disorder (PTSD) is shown to be linked to a higher risk of obstructive sleep apnea (OSA). Firefighters are at high risk for PTSD given the increased exposure to trauma. However, the relationship between PTSD and OSA remains unclear in firefighters. Moreover, alcohol use disorders (AUDs) and depression - also common in firefighters - show a high comorbidity rate with both PTSD and OSA. The purpose of this study was to investigate the association of PTSD, depression, and AUDs with OSA in a national sample of Korean firefighters. METHODS A total of 51,149 Korean firefighters completed self-reported questionnaires, assessing the severity of PTSD, OSA, depression, and alcohol misuse. Multivariable logistic regression and mediation analyses were performed. RESULTS PTSD, depression, and AUDs were significantly associated with OSA. In the mediation analyses, PTSD had both direct and indirect effects mediated by depression and AUDs on OSA. Depression had both direct and indirect effects on OSA, with the latter mediated by AUDs. LIMITATIONS First, high-risk of OSA was measured using the Berlin Questionnaire. Second, other medical comorbidities or mediation use were not considered. Third, self-report questionnaires were used for assessment, which are prone to subjectivity and recollection bias. Finally, the majority of the study population were male and all Korean, limiting generalizability. CONCLUSIONS PTSD had both direct and indirect effects on OSA, mediated by depression and AUDs. In patients with both PTSD and OSA, depression and AUD symptoms should be screened routinely.
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Affiliation(s)
- Johanna Inhyang Kim
- Department of Psychiatry, Hanyang University Medical Center, 222-1 Wangsimni-ro, Seongdong-gu, Seoul 04763, Republic of Korea
| | - Heyeon Park
- Division of General Studies & Teaching Profession, Dongduk Women's University, 60, Hwarang-ro 13-gil, Seongbuk-gu, Seoul 02748, Republic of Korea
| | - Beomjun Min
- Department of Public Health Medical Services, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea
| | - Sohee Oh
- Department of Biostatistics, Seoul Metropolitan Government Seoul National University Boramae Medical Center, 20 5 gil, Boramae-ro, Dongjak-gu, Seoul 07061, Republic of Korea
| | - Ji-Hye Lee
- Department of Public Health Medical Services, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea
| | - Jeong-Hyun Kim
- Department of Public Health Medical Services, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea; Department of Psychiatry, Seoul National University Bundang Hospital, 82, Gumi-ro 173 beon-gil, Bundang-gu, Seongnam-si, Gyeonggi-do 13620, Republic of Korea.
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Targeting Endotypic Traits with Medications for the Pharmacological Treatment of Obstructive Sleep Apnea. A Review of the Current Literature. J Clin Med 2019; 8:jcm8111846. [PMID: 31684047 PMCID: PMC6912255 DOI: 10.3390/jcm8111846] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/28/2022] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition with few therapeutic options. To date there is no approved pharmacotherapy for this disorder, but several attempts have been made in the past and are currently ongoing to find one. The recent identification of multiple endotypes underlying this disorder has oriented the pharmacological research towards tailored therapies targeting specific pathophysiological traits that contribute differently to cause OSA in each patient. In this review we retrospectively analyze the literature on OSA pharmacotherapy dividing the medications tested on the basis of the four main endotypes: anatomy, upper airway muscle activity, arousal threshold and ventilatory instability (loop gain). We show how recently introduced drugs for weight loss that modify upper airway anatomy may play an important role in the management of OSA in the near future, and promising results have been obtained with drugs that increase upper airway muscle activity during sleep and reduce loop gain. The lack of a medication that can effectively increase the arousal threshold makes this strategy less encouraging, although recent studies have shown that the use of certain sedatives do not worsen OSA severity and could actually improve patients' sleep quality.
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6
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Efficacy of pharmacotherapy for OSA in adults: A systematic review and network meta-analysis. Sleep Med Rev 2019; 46:74-86. [DOI: 10.1016/j.smrv.2019.04.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 04/11/2019] [Accepted: 04/16/2019] [Indexed: 01/08/2023]
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Roy K, Chauhan G, Kumari P, Wadhwa M, Alam S, Ray K, Panjwani U, Kishore K. Phosphorylated delta sleep inducing peptide restores spatial memory and p-CREB expression by improving sleep architecture at high altitude. Life Sci 2018; 209:282-290. [PMID: 30107169 DOI: 10.1016/j.lfs.2018.08.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Revised: 08/07/2018] [Accepted: 08/10/2018] [Indexed: 12/27/2022]
Abstract
AIMS Sleep loss at high altitude (HA) play major role in worsening of neuropsychological functions, such as attention, memory and decision making. This study investigates the role of phosphorylated delta sleep inducing peptide (p-DSIP) in improving sleep architecture during chronic hypobaric hypoxia (HH) exposure and restoration of spatial navigational memory. METHODS Morris water maze (MWM) trained rats were exposed to HH at 7620 m. p-DSIP was injected intra-peritoneally (10 μg/Kg bw) during HH exposure as an intervention against sleep alteration. Sleep architecture was recorded telemetrically before and during HH exposure. Monoamines were estimated by high performance liquid chromatography from brain stem (BS) and hypothalamus. CREB and p-CREB level in hippocampus was studied by western blotting and expression of different monoamine regulatory enzymes in BS was measured by flow cytometry. Naloxone (1 mg/kg bw), a μ opioid receptor antagonist of sleep inducing effect of DSIP was also studied. KEY FINDINGS p-DSIP injection daily in circadian active period (18.30 h) during chronic HH enhanced non rapid eye movement sleep, rapid eye movement sleep as well as improved MWM performance of rats. p-DSIP treatment showed lower monoamine level and tyrosine hydroxylase (TH) expression and increased monoamine oxidase A (MAO A), glutamic acid decarboxylase (GAD) and Choline acetyltransferase (ChAT) expression. Further, naloxone altered navigational memory by decreasing the CREB and p-CREB level in hippocampus suggesting suppression of sleep inducing effect of p-DSIP. SIGNIFICANCE Our study demonstrates that improvement of sleep quality by p-DSIP restores spatial memory by up regulating CREB phosphorylation during simulated high altitude hypoxia.
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Affiliation(s)
- Koustav Roy
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Garima Chauhan
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Punita Kumari
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Meetu Wadhwa
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Shahnawaz Alam
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Koushik Ray
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Usha Panjwani
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India
| | - Krishna Kishore
- Defence Institute of Physiology and Allied Sciences (DIPAS), Defence Research and Development Organization (DRDO), Lucknow Road, Timarpur, Delhi 110 054, India.
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Khouri C, Arbib F, Revol B, Pepin JL, Tamisier R. Severe central sleep apnoea associated with nalmefene: a case report. Br J Clin Pharmacol 2018; 84:1075-1076. [DOI: 10.1111/bcp.13547] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2017] [Revised: 01/10/2018] [Accepted: 01/28/2018] [Indexed: 12/01/2022] Open
Affiliation(s)
- Charles Khouri
- Pharmacovigilance Unit; Grenoble Alps University Hospital; Grenoble France
- Clinical Pharmacology Department, INSERM CIC1406; Grenoble Alps University Hospital; Grenoble France
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
| | - François Arbib
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
| | - Bruno Revol
- Pharmacovigilance Unit; Grenoble Alps University Hospital; Grenoble France
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
| | - Jean-Louis Pepin
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042; Grenoble Alps University; Grenoble France
- Thorax and Vessel Division; Grenoble Alps University Hospital; Grenoble France
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Shick V, Lebovitz EE, Conrad E. The benefits of ultrasound-guided continuous sensory nerve blockade in the setting of burn injury: a case report of bilateral continuous superficial peroneal nerve blockade in a patient with severe sleep apnea. J Clin Anesth 2017; 36:62-66. [PMID: 28183576 DOI: 10.1016/j.jclinane.2016.10.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Revised: 12/17/2015] [Accepted: 10/04/2016] [Indexed: 11/25/2022]
Abstract
The management of pain after burn injuries is a clinical challenge magnified in patients with significant comorbidities. Presently, burn pain is treated via a wide variety of modalities, including systemic pharmacotherapy and regional analgesia. Although the latter can provide effective pain control in patients with burn injuries, it is relatively underused. Furthermore, the development of ultrasound guidance has allowed for novel approaches and sparing of motor nerve blockade with preference toward sensory-specific analgesia that has not been possible previously. This can result in decreased opiate use and shorter latency to initiation of rehabilitation. In this report, we describe a patient with chronic pain, morbid obesity, and severe sleep apnea who presented with uncontrolled pain resulting from a burn injury to the dorsum of his feet. The treatment consisted of multimodal analgesia and placement of bilateral continuous superficial peroneal nerve catheters, as he underwent skin grafting and postprocedural hydrotherapy. This novel approach allowed for sparing of postprocedural opiates with positive clinical results.
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Affiliation(s)
- Vladislav Shick
- University of Pittsburgh Medical Center Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219.
| | - Evan E Lebovitz
- University of Pittsburgh Medical Center Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219
| | - Emerson Conrad
- University of Pittsburgh Medical Center Mercy Hospital, 1400 Locust St, Pittsburgh, PA 15219
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Jullian-Desayes I, Revol B, Chareyre E, Camus P, Villier C, Borel JC, Pepin JL, Joyeux-Faure M. Impact of concomitant medications on obstructive sleep apnoea. Br J Clin Pharmacol 2016; 83:688-708. [PMID: 27735059 DOI: 10.1111/bcp.13153] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2016] [Revised: 10/07/2016] [Accepted: 10/10/2016] [Indexed: 01/11/2023] Open
Abstract
Obstructive sleep apnoea (OSA) is characterized by repeated episodes of apnoea and hypopnoea during sleep. Little is known about the potential impact of therapy drugs on the underlying respiratory disorder. Any influence should be taken into account and appropriate action taken, including drug withdrawal if necessary. Here, we review drugs in terms of their possible impact on OSA; drugs which (1) may worsen OSA; (2) are unlikely to have an impact on OSA; (3) those for which data are scarce or contradictory; and (4) drugs with a potentially improving effect. The level of evidence is ranked according to three grades: A - randomized controlled trials (RCTs) with high statistical power; B - RCTs with lower power, non-randomized comparative studies and observational studies; C - retrospective studies and case reports. Our review enabled us to propose clinical recommendations. Briefly, agents worsening OSA or inducing weight gain, that must be avoided, are clearly identified. Drugs such as 'Z drugs' and sodium oxybate should be used with caution as the literature contains conflicting results. Finally, larger trials are needed to clarify the potential positive impact of certain drugs on OSA. In the meantime, some, such as diuretics or other antihypertensive medications, are helpful in reducing OSA-associated cardiovascular morbidity.
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Affiliation(s)
- Ingrid Jullian-Desayes
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Bruno Revol
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France.,Pharmacovigilance Department, Grenoble Alps University Hospital, Grenoble, France
| | - Elisa Chareyre
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Philippe Camus
- Pneumology Department, Dijon Bourgogne University Hospital, Dijon, France
| | - Céline Villier
- Pharmacovigilance Department, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Christian Borel
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Jean-Louis Pepin
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
| | - Marie Joyeux-Faure
- HP2 Laboratory, Inserm U1042 Unit, University Grenoble Alps, Grenoble, France.,EFCR Laboratory, Thorax and Vessels, Grenoble Alps University Hospital, Grenoble, France
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Abstract
Sleep respiration is regulated by circadian, endocrine, mechanical and chemical factors, and characterized by diminished ventilatory drive and changes in Pao2 and Paco2 thresholds. Hypoxemia and hypercapnia are more pronounced during rapid eye movement. Breathing is influenced by sleep stage and airway muscle tone. Patient factors include medical comorbidities and body habitus. Medications partially improve obstructive sleep apnea and stabilize periodic breathing at altitude. Potential adverse consequences of medications include precipitation or worsening of disorders. Risk factors for adverse medication effects include aging, medical disorders, and use of multiple medications that affect respiration.
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Affiliation(s)
- Gilbert Seda
- Department of Pulmonary and Sleep Medicine, Naval Medical Center San Diego, 34730 Bob Wilson Drive, Building 3-3, Suite 301, San Diego, CA 92134, USA.
| | - Sheila Tsai
- Division of Pulmonary, Critical Care and Sleep Medicine, National Jewish Health, 1400 Jackson Street, Denver, CO 80206, USA
| | - Teofilo Lee-Chiong
- Division of Pulmonary and Critical Care Medicine, National Jewish Health, University of Colorado, 1400 Jackson Street, Denver, CO 80206, USA
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14
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Abstract
BACKGROUND The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) applied via a mask during sleep. However, this is not tolerated by all individuals and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of rapid eye movement (REM) sleep, an increase in cholinergic tone during sleep, an increase in arousal threshold, a reduction in airway resistance and a reduction in surface tension in the upper airway. OBJECTIVES To determine the efficacy of drug therapies in the specific treatment of sleep apnoea. SEARCH METHODS We searched the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2012. SELECTION CRITERIA Randomised, placebo controlled trials involving adult patients with confirmed OSA. We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. We excluded studies investigating treatment of associated conditions such as excessive sleepiness, hypertension, gastro-oesophageal reflux disease and obesity. DATA COLLECTION AND ANALYSIS We used standard methodological procedures recommended by The Cochrane Collaboration. MAIN RESULTS Thirty trials of 25 drugs, involving 516 participants, contributed data to the review. Drugs had several different proposed modes of action and the results were grouped accordingly in the review. Each of the studies stated that the participants had OSA but diagnostic criteria were not always explicit and it was possible that some patients with central apnoeas may have been recruited.Acetazolamide, eszopiclone, naltrexone, nasal lubricant (phosphocholinamine) and physiostigmine were administered for one to two nights only. Donepezil in patients with and without Alzheimer's disease, fluticasone in patients with allergic rhinitis, combinations of ondansetrone and fluoxetine and paroxetine were trials of one to three months duration, however most of the studies were small and had methodological limitations. The overall quality of the available evidence was low.The primary outcomes for the systematic review were the apnoea hypopnoea index (AHI) and the level of sleepiness associated with OSA, estimated by the Epworth Sleepiness Scale (ESS). AHI was reported in 25 studies and of these 10 showed statistically significant reductions in AHI.Fluticasone in patients with allergic rhinitis was well tolerated and reduced the severity of sleep apnoea compared with placebo (AHI 23.3 versus 30.3; P < 0.05) and improved subjective daytime alertness. Excessive sleepiness was reported to be altered in four studies, however the only clinically and statistically significant change in ESS of -2.9 (SD 2.9; P = 0.04) along with a small but statistically significant reduction in AHI of -9.4 (SD 17.2; P = 0.03) was seen in patients without Alzheimer's disease receiving donepezil for one month. In 23 patients with mild to moderate Alzheimer's disease donepezil led to a significant reduction in AHI (donepezil 20 (SD 15) to 9.9 (SD 11.5) versus placebo 23.2 (SD 26.4) to 22.9 (SD 28.8); P = 0.035) after three months of treatment but no reduction in sleepiness was reported. High dose combined treatment with ondansetron 24 mg and fluoxetine 10 mg showed a 40.5% decrease in AHI from the baseline at treatment day 28. Paroxetine was shown to reduce AHI compared to placebo (-6.10 events/hour; 95% CI -11.00 to -1.20) but failed to improve daytime symptoms.Promising results from the preliminary mirtazapine study failed to be reproduced in the two more recent multicentre trials and, moreover, the use of mirtazapine was associated with significant weight gain and sleepiness. Few data were presented on the long-term tolerability of any of the compounds used. AUTHORS' CONCLUSIONS There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcomes. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24% and 45%. For donepezil and fluticasone, studies of longer duration with a larger population and better matching of groups are required to establish whether the change in AHI and impact on daytime symptoms are reproducible. Individual patients had more complete responses to particular drugs. It is possible that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.
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Affiliation(s)
- Martina Mason
- Respiratory Support and Sleep Centre, Papworth Hospital, Cambridge, UK
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Kohler M, Stradling JR. Pitfalls of clinical trials on pharmacological treatment for obstructive sleep apnoea: future directions. Expert Opin Investig Drugs 2011; 20:1033-7. [DOI: 10.1517/13543784.2011.590473] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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17
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Therapeutics for Sleep-disordered Breathing. Sleep Med Clin 2010. [DOI: 10.1016/j.jsmc.2010.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Kohler M, Bloch KE, Stradling JR. Pharmacological approaches to the treatment of obstructive sleep apnoea. Expert Opin Investig Drugs 2009; 18:647-56. [DOI: 10.1517/13543780902877674] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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Schwartz JR, Hughes RJ, Roth T. Pharmacologic therapy for sleep-related breathing disorders. Expert Rev Clin Pharmacol 2008; 1:441-55. [PMID: 24422697 DOI: 10.1586/17512433.1.3.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Rl Schwartz
- Integris Sleep Disorders Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK 73109, USA.
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Hedner J, Grote L, Zou D. Pharmacological treatment of sleep apnea: Current situation and future strategies. Sleep Med Rev 2008; 12:33-47. [DOI: 10.1016/j.smrv.2007.06.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
BACKGROUND The treatment of choice for moderate to severe obstructive sleep apnoea (OSA) is continuous positive airways pressure (CPAP) via a mask during sleep. However this is not tolerated by all patients and its role in mild OSA is not proven. Drug therapy has been proposed as an alternative to CPAP in some patients with mild to moderate sleep apnoea and could be of value in patients intolerant of CPAP. A number of mechanisms have been proposed by which drugs could reduce the severity of OSA. These include an increase in tone in the upper airway dilator muscles, an increase in ventilatory drive, a reduction in the proportion of REM sleep, an increase in cholinergic tone during sleep, a reduction in airway resistance and a reduction in surface tension in the upper airway. OBJECTIVES To determine the efficacy of drug therapies in the treatment of sleep apnoea. SEARCH STRATEGY We carried out searches on the Cochrane Airways Group Specialised Register of trials. Searches were current as of July 2005. SELECTION CRITERIA Randomised, placebo controlled trials involving adult patients with confirmed OSA . We excluded trials if continuous positive airways pressure, mandibular devices or oxygen therapy were used. No restriction was placed upon publication language or trial duration. DATA COLLECTION AND ANALYSIS Two reviewers independently assessed studies for inclusion, undertook data extraction according to pre-specified entry criteria, and quality assessment of studies. No response for further information was forthcoming from study authors. Results were expressed as mean differences and 95% Confidence Intervals (CI). MAIN RESULTS Twenty-six trials of 21 drugs, involving 394 participants contributed data to the review. Most of the studies were small and many trials had methodological limitations. Each of the studies states that the subjects had OSA but diagnostic criteria were not always explicit and it is possible that some patients with central apnoeas may have been recruited. Six drugs had some impact on OSA severity and two altered daytime symptoms. One study reported that apnoea hypopnea index (AHI) was lower following treatment with intranasal fluticasone compared with placebo (23.3 versus 30.3) in 24 participants with sleep apnoea and rhinitis. Subjective alertness in the daytime also improved. Physostigmine gave an AHI of 41 compared to 54 on placebo (10 participants) and in a similar study Mirtazipine 15 mg produced an AHI of 13 compared to 23.7 for placebo (10 participants). Topical nasal lubricant given twice overnight resulted in an AHI of 14 compared to 24 with placebo (10 participants). These three latter studies were of single night crossover design and so there are no data on the acceptability of these treatments or their effect on symptoms. Paroxetine was shown to reduce AHI to 23.3 compared to 30.3 for placebo, most of the 20 participants tolerated the treatment but there was no improvement in daytime symptoms. Acetazolamide also reduced the AHI (one crossover trial of nine patients, mean difference 24 (95% CI 4 to 44). However there was no symptomatic benefit from the drug and it was poorly tolerated in the long term. Protriptyline led to a symptomatic improvement (improved versus not improved) in two out of three crossover trials (13 participants, Peto Odds Ratio 29.2 (95% CI 2.8 to 301.1) but there was no change in the apnoea frequency. In one trial naltrexone did reduce AHI, but total sleep time favoured placebo. No significant beneficial effects were found for medroxy progesterone, clonidine, mibefradil, cilazapril, buspirone, aminophylline, theophylline doxapram, ondansetron or sabeluzole. AUTHORS' CONCLUSIONS There is insufficient evidence to recommend the use of drug therapy in the treatment of OSA. Small studies have reported positive effects of certain agents on short-term outcome. Certain agents have been shown to reduce the AHI in largely unselected populations with OSA by between 24 and 45%. For fluticasone, mirtazipine, physostigmine and nasal lubricant, studies of longer duration are required to establish whether this has an impact on daytime symptoms. Individual patients had more complete responses to particular drugs. It is likely that better matching of drugs to patients according to the dominant mechanism of their OSA will lead to better results and this also needs further study.
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Affiliation(s)
- I Smith
- Papworth Hospital, Respiratory Support and Sleep Centre,Papworth Everard, Cambridge, UK, CB3 8RE.
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Abstract
Obstructive sleep apnoea poses a significant health hazard that is associated with leading causes of mortality and morbidity. Nasal continuous positive airway pressure is the primary treatment modality, with surgical treatments as alternatives. Oral appliances and pharmacological therapy remain adjunctive modalities. Non-specific treatments include weight loss, postural therapy and behavioural measures. Pharmacotherapy goals include the reduction of risk factors for sleep apnoea; correction of underlying predisposing metabolic diseases, such as hypothyroidism or acromegaly; treatment of associated symptoms, including excessive daytime sleepiness; and prevention of apnoeas/hypopnoeas. This paper reviews data supporting the treatment of sleep apnoea with various pharmacological agents, including intranasal corticosteroids, decongestant sprays, nicotine therapy, opiate antagonists, methylxanthine derivatives, oestrogen and progesterone, testosterone, thyroid hormone, growth hormone therapy for acromegaly, beta-blockers, alpha-adrenergic agonists, angiotensin-converting enzyme inhibitors, glutamate antagonists, acetazolamide, selective serotonin re-uptake inhibitors, tricyclic antidepressants, physostigmine, modafinil and TNF-alpha antagonists, in addition to supplemental oxygen, and carbon dioxide inhalation. Some of these drugs have received very little testing and are the subject of few research articles.
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Affiliation(s)
- Vivien C Abad
- Clinical Monitoring Sleep Disorders Center, Camino Medical Group, Palo Alto Medical Foundation, Cupertino, CA, USA
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Ayappa I, Berger KI, Norman RG, Oppenheimer BW, Rapoport DM, Goldring RM. Hypercapnia and ventilatory periodicity in obstructive sleep apnea syndrome. Am J Respir Crit Care Med 2002; 166:1112-5. [PMID: 12379556 DOI: 10.1164/rccm.200203-212oc] [Citation(s) in RCA: 94] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
Prevention of acute hypercapnia during obstructive events in obstructive sleep apnea requires a balance between carbon dioxide (CO(2)) loading during the event and CO(2) unloading in the interevent period. Earlier studies have demonstrated that acute CO(2) retention may occur despite high interevent ventilation when the interevent duration is short relative to the duration of the preceding event. The present study examines the relationship between apnea and interapnea durations and relates this assessment of ventilatory periodicity to the degree of chronic hypercapnia in subjects with severe sleep apnea. A total of 18 subjects with sleep apnea (> 40 apnea/hour; chronic awake Pa(CO2) 36-62 mm Hg) and without underlying lung disease underwent polysomnography. For each event, apnea duration, interapnea duration, and apnea/interapnea duration ratio were determined. No relationship was observed between chronic Pa(CO2) and mean apnea or interapnea duration (p > 0.1). However, Pa(CO2) was directly related to apnea/interapnea duration ratio (r = 0.48; p < 0.05) such that with increasing chronic hypercapnia the interapnea duration shortens relative to the apnea duration. The present study suggests that control of the interapnea ventilatory duration relative to the duration of the preceding apnea, is an important component of the integrated ventilatory response to CO(2) loading during apnea and may contribute toward the development and/or maintenance of chronic hypercapnia in obstructive sleep apnea/hypopnea syndrome.
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Affiliation(s)
- Indu Ayappa
- Division of Pulmonary and Critical Care Medicine and Bellevue Hospital Chest Service, Department of Medicine, New York University School of Medicine, New York, New York 10016, USA.
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Abstract
This paper is the sixteenth installment of our annual review of research concerning the opiate system. It is restricted to papers published during 1993 that concern the behavioral effects of the endogenous opiate peptides, and does not include papers dealing only with their analgesic properties. The specific topics this year include stress; tolerance and dependence; eating; drinking; gastrointestinal, renal, and hepatic function; mental illness and mood; learning, memory, and reward; cardiovascular responses; respiration and thermoregulation; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; development; immunological responses; and other behaviors.
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Affiliation(s)
- G A Olson
- Department of Psychology, University of New Orleans, LA 70148
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