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White DP, Messineo L, Thompson E, Hughes B, Lannom WD, Hete B, Joshi A, Noah WH. Kairos positive airway pressure (KPAP) equals continuous PAP in effectiveness, and offers superior comfort for obstructive sleep apnea treatment. Sleep Med 2024; 124:268-275. [PMID: 39341027 DOI: 10.1016/j.sleep.2024.09.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2024] [Revised: 09/14/2024] [Accepted: 09/16/2024] [Indexed: 09/30/2024]
Abstract
STUDY OBJECTIVES A recent study challenged the prevailing clinical view that maintaining inspiratory positive airway pressure (IPAP) is necessary for upper airway patency, demonstrating no differences in apnea hypopnea index (AHI) between continuous PAP (CPAP) with and without a resistor to reduce IPAP. In this study, we assessed the effect of Kairos PAP (KPAP), a new algorithm which features multiple drops in IPAP, only returning to therapeutic pressure near the end expiration, on sleep apnea severity and subjective comfort. METHODS Two randomized clinical trials were conducted. In the Efficacy trial, the effect of KPAP vs. CPAP on AHI in PAP-treated OSA patients was examined using a split-night design, adjusting for period, sequence and fraction of supine sleep (mixed models). Unintentional leak differences between treatments were also examined. Exploratory analyses assessed the effect of KPAP vs. CPAP on key polysomnography outcomes. In the Comfort trial, we tested subjective preference for KPAP vs. CPAP at 9 and 13 cmH2O in PAP-naïve OSA patients. RESULTS In the Efficacy trial (N = 48), KPAP reduced AHI more than CPAP (mean difference [95%CI]: -0.5 [-0.8, -0.2] events/h, P = 0.007). Unintentional leak was also reduced by over 50 % (-2.5 [-3.2, -1.7] L/min, P < 0.001). No significant change was observed in the exploratory variables assessed. In the Comfort trial (N = 150), 69 [61, 77] % and 84 [77, 89] % of participants preferred KPAP over CPAP at 9 and 13 cmH2O, respectively (P < 0.001). CONCLUSIONS KPAP is as effective as CPAP in reducing respiratory events, but is more comfortable and potentially better tolerated.
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Affiliation(s)
- David P White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA
| | - Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, MA, USA.
| | | | - Bryan Hughes
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | | | - Bernard Hete
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | - Abinash Joshi
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
| | - William H Noah
- Sleep Centers of Middle Tennessee, Murfreesboro, TN, USA
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Nobre ML, Sarmento ACA, de Oliveira PF, Wanderley FF, Diniz Júnior J, Gonçalves AK. Pharmacological treatment for obstructive sleep apnea: A systematic review and meta-analysis. Clinics (Sao Paulo) 2024; 79:100330. [PMID: 38341903 PMCID: PMC10869242 DOI: 10.1016/j.clinsp.2024.100330] [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: 10/25/2023] [Accepted: 12/21/2023] [Indexed: 02/13/2024] Open
Abstract
OBJECTIVE Summarize the evidence on drug therapies for obstructive sleep apnea. METHODS The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. PubMed, Embase, Scopus, Web of Science, SciELO, LILACS, Scopus, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched on February 17th, 2023. A search strategy retrieved randomized clinical trials comparing the Apnea-Hypopnea Index (AHI) in pharmacotherapies. Studies were selected and data was extracted by two authors independently. The risk of bias was assessed using the Cochrane Risk of Bias tool. RevMan 5.4. was used for data synthesis. RESULTS 4930 articles were obtained, 68 met inclusion criteria, and 29 studies (involving 11 drugs) were combined in a meta-analysis. Atomoxetine plus oxybutynin vs placebo in AHI mean difference of -7.71 (-10.59, -4.83) [Fixed, 95 % CI, I2 = 50 %, overall effect: Z = 5.25, p < 0.001]. Donepezil vs placebo in AHI mean difference of -8.56 (-15.78, -1.33) [Fixed, 95 % CI, I2 = 21 %, overall effect: Z = 2.32, p = 0.02]. Sodium oxybate vs placebo in AHI mean difference of -5.50 (-9.28, -1.73) [Fixed, 95 % CI, I2 = 32 %, overall effect: Z = 2.86, p = 0.004]. Trazodone vs placebo in AHI mean difference of -12.75 (-21.30, -4.19) [Fixed, 95 % CI, I2 = 0 %, overall effect: Z = 2.92, p = 0.003]. CONCLUSION The combination of noradrenergic and antimuscarinic drugs shows promising results. Identifying endotypes may be the key to future drug therapies for obstructive sleep apnea. Moreover, studies with longer follow-up assessing the safety and sustained effects of these treatments are needed. PROSPERO REGISTRATION NUMBER CRD42022362639.
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Affiliation(s)
- Maria Luísa Nobre
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ayane Cristine Alves Sarmento
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Clinical Analysis and Toxicology, Universidade Federal do Rio Grande do Norte, RN, Brazil
| | | | | | - José Diniz Júnior
- Department of Surgery, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil
| | - Ana Katherine Gonçalves
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil; Department of Gynecology and Obstetrics, Universidade Federal do Rio Grande do Norte, Natal, RN, Brazil.
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Sweetman A, Osman A, Lack L, Crawford M, Wallace D. Co-morbid insomnia and sleep apnea (COMISA): recent research and future directions. Curr Opin Pulm Med 2023; 29:567-573. [PMID: 37642477 DOI: 10.1097/mcp.0000000000001007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
PURPOSE OF REVIEW Insomnia and obstructive sleep apnea have previously been viewed as completely independent conditions. However, there is now increasing recognition that insomnia and sleep apnea frequently co-occur. Co-morbid insomnia and sleep apnea (COMISA) is a highly prevalent condition that is associated with impairment of sleep, daytime function, mental health and physical health outcomes, and mortality risk. This review aims to provide an update on COMISA prevalence, consequences, treatment approaches, and future research directions. RECENT FINDINGS People with COMISA experience worse sleep, mental health, physical health, quality of life and longevity compared to people with neither condition, and often compared to those with insomnia alone and sleep apnea alone. Emerging evidence suggests that cognitive behavioral therapy for insomnia is an effective treatment in the presence of treated and untreated sleep apnea, that may also improve manifestations and subsequent management of sleep apnea. Future research is required to understand the etiology of COMISA, and to develop and implement tailored treatment approaches. SUMMARY It is important for sleep and respiratory technicians, researchers and clinicians to be aware of the high co-morbidity rates, consequences, and treatment requirements of patients with co-morbid insomnia and sleep apnea.
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Affiliation(s)
- Alexander Sweetman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Amal Osman
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Leon Lack
- Adelaide Institute for Sleep Health, and FHRMI sleep health, Flinders University, South Australia, Australia
| | - Megan Crawford
- School of Psychological Sciences and Health, University of Strathclyde, Glasgow, UK
| | - Douglas Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine
- Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, Florida, USA
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Thomas E, Micic G, Adams R, Eckert DJ. Pharmacological management of co-morbid obstructive sleep apnoea and insomnia. Expert Opin Pharmacother 2023; 24:1963-1973. [PMID: 38099435 DOI: 10.1080/14656566.2023.2292186] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 12/04/2023] [Indexed: 01/06/2024]
Abstract
INTRODUCTION Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA. AREAS COVERED This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities. EXPERT OPINION There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.
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Affiliation(s)
- Emma Thomas
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Gorica Micic
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Robert Adams
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
- National Centre for Sleep Health Services Research: A NHMRC Centre of Research Excellence, Flinders University, Adelaide, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute (FHMRI) Sleep Health/Adelaide Institute for Sleep Health (AISH), College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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McNicholas WT, Korkalainen H. Translation of obstructive sleep apnea pathophysiology and phenotypes to personalized treatment: a narrative review. Front Neurol 2023; 14:1239016. [PMID: 37693751 PMCID: PMC10483231 DOI: 10.3389/fneur.2023.1239016] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/07/2023] [Indexed: 09/12/2023] Open
Abstract
Obstructive Sleep Apnea (OSA) arises due to periodic blockage of the upper airway (UA) during sleep, as negative pressure generated during inspiration overcomes the force exerted by the UA dilator muscles to maintain patency. This imbalance is primarily seen in individuals with a narrowed UA, attributable to factors such as inherent craniofacial anatomy, neck fat accumulation, and rostral fluid shifts in the supine posture. Sleep-induced attenuation of UA dilating muscle responsiveness, respiratory instability, and high loop gain further exacerbate UA obstruction. The widespread comorbidity profile of OSA, encompassing cardiovascular, metabolic, and neuropsychiatric domains, suggests complex bidirectional relationships with conditions like heart failure, stroke, and metabolic syndrome. Recent advances have delineated distinct OSA phenotypes beyond mere obstruction frequency, showing links with specific symptomatic manifestations. It is vital to bridge the gap between measurable patient characteristics, phenotypes, and underlying pathophysiological traits to enhance our understanding of OSA and its interplay with related outcomes. This knowledge could stimulate the development of tailored therapies targeting specific phenotypic and pathophysiological endotypes. This review aims to elucidate the multifaceted pathophysiology of OSA, focusing on the relationships between UA anatomy, functional traits, clinical manifestations, and comorbidities. The ultimate objective is to pave the way for a more personalized treatment paradigm in OSA, offering alternatives to continuous positive airway pressure therapy for selected patients and thereby optimizing treatment efficacy and adherence. There is an urgent need for personalized treatment strategies in the ever-evolving field of sleep medicine, as we progress from a 'one-size-fits-all' to a 'tailored-therapy' approach.
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Affiliation(s)
- Walter T. McNicholas
- School of Medicine and the Conway Research Institute, University College Dublin, Dublin, Ireland
- Department of Respiratory and Sleep Medicine, St. Vincent’s Hospital Group, Dublin, Ireland
| | - Henri Korkalainen
- Department of Technical Physics, University of Eastern Finland, Kuopio, Finland
- Diagnostic Imaging Center, Kuopio University Hospital, Kuopio, Finland
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Dalkilic O, Turbedaroglu O, Lafzi F, Kilic H. Regioselective C3-H Alkylation of Imidazopyridines with Donor-Acceptor Cyclopropanes. J Org Chem 2023; 88:11834-11846. [PMID: 37535468 PMCID: PMC10443042 DOI: 10.1021/acs.joc.3c01122] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Indexed: 08/05/2023]
Abstract
Alkylated imidazopyridines are crucial structures for medicinal chemistry. Here, an efficient method for the C3-H alkylation of imidazopyridines was devised. Under Lewis acid-catalyzed conditions, reactions of imidazopyridines with different donor-acceptor cyclopropanes were carried out. Finally, 1,3-bisfunctionalizaton of donor-acceptor cyclopropanes was performed. In addition, synthesized C3-alkylated imidazopyridines are amenable for diverse synthetic applications.
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Affiliation(s)
| | | | - Ferruh Lafzi
- Department of Chemistry,
Faculty of Sciences, Atatürk University, Erzurum 25240, Türkiye
| | - Haydar Kilic
- Department of Chemistry,
Faculty of Sciences, Atatürk University, Erzurum 25240, Türkiye
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Horner RL. Targets for obstructive sleep apnea pharmacotherapy: principles, approaches, and emerging strategies. Expert Opin Ther Targets 2023; 27:609-626. [PMID: 37494064 DOI: 10.1080/14728222.2023.2240018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 07/19/2023] [Indexed: 07/27/2023]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a common and serious breathing disorder. Several pathophysiological factors predispose individuals to OSA. These factors are quantifiable, and modifiable pharmacologically. AREAS COVERED Four key pharmacotherapeutic targets are identified and mapped to the major determinants of OSA pathophysiology. PubMed and Clinicaltrials.gov were searched through April 2023. EXPERT OPINION Target #1: Pharyngeal Motor Effectors. Increasing pharyngeal muscle activity and responsivity with noradrenergic-antimuscarinic combination is central to recent breakthrough OSA pharmacotherapy. Assumptions, knowledge gaps, future directions, and other targets are identified. #2: Upper Airway Sensory Afferents. There is translational potential of sensitizing and amplifying reflex pharyngeal dilator muscle responses to negative airway pressure via intranasal delivery of new potassium channel blockers. Rationales, advantages, findings, and potential strategies to enhance effectiveness are identified. #3: Chemosensory Afferents and Ventilatory Control. Strategies to manipulate ventilatory control system sensitivity by carbonic anhydrase inhibitors are supported in theory and initial studies. Intranasal delivery of agents to stimulate central respiratory activity are also introduced. #4: Sleep-Wake Mechanisms. Arousability is the fourth therapeutic target rationalized. Evolving automated tools to measure key pathophysiological factors predisposing to OSA will accelerate pharmacotherapy. Although not currently ready for general clinical settings, the identified targets are of future promise.
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Affiliation(s)
- Richard L Horner
- Departments of Physiology and Medicine, University of Toronto, Toronto, ON, Canada
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Perger E, Bertoli S, Lombardi C. Pharmacotherapy for obstructive sleep apnea: targeting specific pathophysiological traits. Expert Rev Respir Med 2023; 17:663-673. [PMID: 37646222 DOI: 10.1080/17476348.2023.2241353] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 07/24/2023] [Indexed: 09/01/2023]
Abstract
INTRODUCTION The pathophysiology of obstructive sleep apnea (OSA) is multi-factorial and complex. Varying OSA's pathophysiological traits have been identified, including pharyngeal collapsibility, upper airway muscle reactivity, arousal threshold, and regulation of the ventilatory drive. Being CPAP of difficult tolerance and other interventions reserved to specific subpopulations new pharmacological treatments for OSA might be resolutive. AREAS COVERED Several existing and newly developed pharmacological drugs can impact one or more endotypes and could therefore be proposed as treatment options for sleep disordered breathing. With this review we will explore different pathophysiological traits as new targets for OSA therapy. This review will summarize the most promising pharmacological treatment for OSA accordingly with their mechanisms of action on upper airway collapsibility, muscle responsiveness, arousal threshold, and loop gain. EXPERT OPINION Only understanding the pathophysiological traits causing OSA in each patient and placing the disease in the framework of patient comorbidities, we will be able to evolve interventions toward OSA. The development of new drug's combinations will permit different approaches and different choices beside conventional treatments. In the next future, we hope that sleep specialists will select the treatment for a specific patient on the base of its pathophysiology, defining a precision medicine for OSA.
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Affiliation(s)
- Elisa Perger
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
| | - Simona Bertoli
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Food, Environmental and Nutritional Sciences (DeFENS), University of Milan, Milan, Italy
- Lab of Nutrition and Obesity Research, Istituto Auxologico Italiano, IRCCS, Milan, Carolina
| | - Carolina Lombardi
- Sleep Disorders Center & Department of Cardiovascular, Neural and Metabolic Sciences, Istituto Auxologico Italiano, IRCCS, Milan, Italy
- Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
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Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med 2023; 19:1035-1042. [PMID: 36734173 PMCID: PMC10235724 DOI: 10.5664/jcsm.10464] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 12/22/2022] [Accepted: 01/17/2023] [Indexed: 02/04/2023]
Abstract
STUDY OBJECTIVES Pharmacotherapy for obstructive sleep apnea (OSA) regained consideration after the discovery that atomoxetine and oxybutynin greatly reduced OSA severity. However, atomoxetine and oxybutynin reduced the arousal threshold and may therefore be poorly tolerated in patients with OSA and disturbed sleep. As a result, we tested the combination of atomoxetine plus 2 hypnotics in patients with OSA. The effects of atomoxetine plus: (1) trazodone (Ato-Trazo) and (2) lemborexant vs placebo on apnea-hypopnea index, hypoxic burden, arousal threshold, and total sleep time were assessed. Drug safety was also ascertained, together with the effect of the combinations on other OSA traits, self-reported sleep quality, and next-day alertness. METHODS Following a baseline study, 15 patients with mild-to-severe OSA with moderate upper airway collapsibility were administered Ato-Trazo, atomoxetine and lemborexant, and matching placebo according to a double-blind, randomized, crossover design. Apnea-hypopnea index and other objective outcomes were calculated from 3 clinical, in-laboratory polysomnograms. RESULTS Ato-Trazo significantly reduced apnea-hypopnea index from a median [interquartile range] of 18.2 [11.8 to 31.3] on placebo to 7.4 [5.4 to 16.1] events/h, P = .024, and hypoxic burden from 46.3 [25.1 to 88.3] on placebo to 18.7 [14.9 to 43.5], P = .003. This effect was likely driven by an increase in polysomnography-estimated pharyngeal muscle activity during the events (P = .029). Atomoxetine and lemborexant had smaller statistically insignificant effects. Contrary to atomoxetine and oxybutynin, Ato-Trazo and atomoxetine and lemborexant did not reduce the arousal threshold. Both combinations had no effect on total sleep time but worsened self-reported sleep quality. CONCLUSIONS Ato-Trazo has the potential to become a useful drug combination, however, longer trials are needed to determine the best dosage and the subgroup of patients who may benefit most from this combination. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: Crossover Trial of AD182 and AD504 in Obstructive Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/NCT04645524; Identifier: NCT04645524. CITATION Corser B, Eves E, Warren-McCormick J, Rucosky G. Effects of atomoxetine plus a hypnotic on obstructive sleep apnea severity in patients with a moderately collapsible pharyngeal airway. J Clin Sleep Med. 2023;19(6):1035-1042.
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Affiliation(s)
| | - Erica Eves
- Sleep Management Institute, Cincinnati, Ohio
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10
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Yanagimori M, Fernandes MD, Garcia ML, Scudeller PG, Carvalho CRR, Edwards B, Lorenzi-Filho G, Genta PR. Respiratory arousal threshold among patients with isolated sleep apnea and with comorbid insomnia (COMISA). Sci Rep 2023; 13:7638. [PMID: 37169833 PMCID: PMC10175295 DOI: 10.1038/s41598-023-34002-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 04/22/2023] [Indexed: 05/13/2023] Open
Abstract
Insomnia and obstructive sleep apnea (OSA) are common sleep disorders and frequently coexist (COMISA). Arousals from sleep may be a common link explaining the frequent comorbidity of both disorders. Respiratory arousal threshold (AT) is a physiologic measurement of the level of respiratory effort to trigger an arousal from sleep. The impact of COMISA on AT is not known. We hypothesized that a low AT is more common among COMISA than among patients with OSA without insomnia. Participants referred for OSA diagnosis underwent a type 3 sleep study and answered the insomnia severity index (ISI) questionnaire and the Epworth sleepiness scale. Participants with an ISI score ≥ 15 were defined as having insomnia. Sleep apnea was defined as an apnea hypopnea index (AHI) ≥ 15 events/h. Low AT was determined using a previously validated score based on 3 polysomnography variables (AHI, nadir SpO2 and the frequency of hypopneas). OSA-only (n = 51) and COMISA (n = 52) participants had similar age (61[52-68] vs 60[53-65] years), body-mass index (31.3[27.7-36.2] vs 32.2[29.5-38.3] kg/m2) and OSA severity (40.2[27.5-60] vs 37.55[27.9-65.2] events/h): all p = NS. OSA-only group had significantly more males than the COMISA group (58% vs 33%, p = 0.013. The proportion of participants with a low AT among OSA-only and COMISA groups was similar (29 vs 33%, p = NS). The similar proportion of low AT among COMISA and patients with OSA suggests that the respiratory arousal threshold may not be related to the increased arousability of insomnia.
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Affiliation(s)
- Marcela Yanagimori
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil.
| | - Mariana D Fernandes
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Michelle L Garcia
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Paula G Scudeller
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Carlos R R Carvalho
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Bradley Edwards
- Sleep and Circadian Medicine Laboratory, Department of Physiology and School of Psychological Sciences, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Geraldo Lorenzi-Filho
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Pedro R Genta
- Laboratorio do Sono, LIM 63, Divisao de Pneumologia, Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
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11
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Ahmad B, Sankari A, Eshraghi M, Aldwaikat A, Yarandi H, Zeineddine S, Salloum A, Badr MS. Effect of Zolpidem on nocturnal arousals and susceptibility to central sleep apnea. Sleep Breath 2023; 27:173-180. [PMID: 35286569 PMCID: PMC9470768 DOI: 10.1007/s11325-022-02593-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/07/2022] [Accepted: 03/02/2022] [Indexed: 12/19/2022]
Abstract
PURPOSE Arousals may contribute to the pathogenesis of sleep-disordered breathing (SDB) and central sleep apnea (CSA). We aimed to determine the effect of the nonbenzodiazepine hypnotic zolpidem on the frequency of respiratory-related arousals and central apnea in patients with moderate-to-severe SDB. We hypothesized that zolpidem decreases the severity of SDB by decreasing the frequency of respiratory-related arousals. METHODS Patients with apnea-hypopnea index ≥ 15 events/hour and central apnea-hypopnea index ≥ 5 events/hour underwent a sleep study on zolpidem 5 mg and a sleep study with no medication in a randomized order. The respiratory arousal index was compared between the two studies using a randomized crossover design. Sleep, respiratory, and physiologic parameters, including the CO2 reserve and the respiratory arousal threshold, were also compared. RESULTS Eleven participants completed the study. Compared to no treatment, zolpidem reduced the respiratory arousal index (39.7 ± 7.7 vs. 23.3 ± 4.4 events/h, P = 0.031). Zolpidem also lowered the total apnea-hypopnea index (55.6 ± 8.5 vs. 41.3 ± 7.5 events/hour, P = 0.033) but did not affect other clinical and physiologic parameters. Compared to control, zolpidem did not widen CO2 reserve (- 0.44 ± 1.47 vs. - 0.63 ± 0.86 mmHg, P = 0.81). The respiratory arousal threshold did not show a significant change on zolpidem compared to control (- 8.72 ± 2.1 vs. - 8.25 ± 2.81 cmH2O, P = 0.41). CONCLUSION Nocturnal arousals and overall SDB severity were reduced with a single dose of zolpidem in patients with moderate-to-severe sleep-disordered breathing with increased susceptibility for central apnea. Zolpidem did not widen the CO2 reserve or increase the arousal threshold. TRIAL REGISTRATION Clinicaltrials.gov. Sleep and Breathing in the General Population - Chemical Stimuli (NCT04720547).
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Affiliation(s)
- Bachar Ahmad
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Abdulghani Sankari
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA.
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA.
- Department of Medical Education, Ascension Providence Hospital, Southfield, MI, USA.
| | - Mehdi Eshraghi
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Ahmad Aldwaikat
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
| | - Hossein Yarandi
- Department of Biostatistics, Wayne State University School of Medicine, Detroit, MI, USA
| | - Salam Zeineddine
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - Anan Salloum
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
| | - M Safwan Badr
- Department of Internal Medicine, Wayne State University School of Medicine, 4646 John R, Detroit, MI, 48201, USA
- Department of Internal Medicine, John D. Dingell VA Medical Center, Detroit, MI, USA
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12
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Messineo L, Gell L, Calianese N, Sofer T, Vena D, Azarbarzin A, Labarca G, Taranto-Montemurro L, Yang HC, Wang TY, Kim M, Smith H, White D, Sands S, Wellman A. Effect of Pimavanserin on the Respiratory Arousal Threshold from Sleep: A Randomized Trial. Ann Am Thorac Soc 2022; 19:2062-2069. [PMID: 35947827 PMCID: PMC9743476 DOI: 10.1513/annalsats.202205-419oc] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 08/10/2022] [Indexed: 12/15/2022] Open
Abstract
Rationale: A low respiratory arousal threshold is a key endotype responsible for obstructive sleep apnea (OSA) pathogenesis. Pimavanserin is an antiserotoninergic capable of suppressing CO2-mediated arousals without affecting the respiratory motor response in animal models, and thus it holds potential for increasing the arousal threshold in OSA and subsequently reducing OSA severity. Objectives: We measured the effect of pimavanserin on arousal threshold (primary outcome), OSA severity, arousal index, and other OSA endotypes (secondary outcomes). Methods: A total of 18 OSA participants were studied in a randomized, double-blind, crossover study. Patients received a single dose of placebo or pimavanserin 34 mg 4 hours before in-lab polysomnography. Airflow was measured with an oronasal mask attached to a pneumotachograph, and ventilatory drive was recorded with an intraesophageal electromyography catheter. Results are presented as mean or median changes (Δ) and 95% confidence intervals (CIs). Results: Pimavanserin did not increase the arousal threshold, nor did it decrease OSA severity or arousal index. It, however, prolonged total sleep time (Δ[confidence interval (CI)], 39.5 [95%CI, -1.2 to 80.1] min). In an exploratory analysis, a subgroup of seven patients who had a 10% or more increase in arousal threshold on pimavanserin exhibited a decrease in AHI4 (hypopneas associated with 4% desaturation) (Δ[CI], 5.6 [95%CI, 3.6-11.1] events/h) and hypoxic burden (Δ[CI], 22.3 [95%CI, 6.6-32.3] %min/h). Conclusions: A single dose of pimavanserin did not have a significant effect on arousal threshold or OSA severity. However, in a post hoc analysis, a subset of patients who exhibited an increase in arousal threshold on pimavanserin showed a small decrease in OSA severity. Thus, if the arousal threshold could be increased with pimavanserin, perhaps with longer dosing to reach higher drug blood concentrations, then the desired effect on OSA severity might be achievable. Clinical trial registered with ClinicalTrials.gov (NCT04538755).
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Affiliation(s)
| | | | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Tamar Sofer
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Dan Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Hyung Chae Yang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Tsai-Yu Wang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Molly Kim
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Hannah Smith
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - David White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Scott Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
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13
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Comorbid Insomnia and Sleep Apnea. Sleep Med Clin 2022; 17:597-617. [DOI: 10.1016/j.jsmc.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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14
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Choi BY, Kim JK, Cho JH. A Review of a Recent Meta-Analysis Study on Obstructive Sleep Apnea. JOURNAL OF RHINOLOGY 2022. [DOI: 10.18787/jr.2022.00422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
This paper summarizes a recent meta-analysis of various topics in obstructive sleep apnea (OSA). In addition to cardiovascular disease and neurocognitive dysfunction, a wide variety of diseases have been associated with OSA, and associations with cancer have also been reported. Although continuous positive airway pressure is a very effective treatment, the results have shown that it does not reduce the incidence of various complications. It has been reported that uvulopalatopharyngoplasty was effective, and robotic surgery for the tongue root and hypoglossal nerve stimulation were also effective. The effectiveness of various medications to reduce daytime sleepiness has also been demonstrated. Although exercise lowered the apnea-hypopnea index, it was not related to changes in body composition, and it was also reported that exercise combined with weight control were effective. Additionally, interesting and clinically meaningful meta-analysis results were summarized and presented.
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15
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Messineo L, Taranto-Montemurro L, Calianese N, Gell LK, Azarbarzin A, Labarca G, Vena D, Yang HC, Wang TY, Wellman A, Sands SA. Atomoxetine and fesoterodine combination improves obstructive sleep apnoea severity in patients with milder upper airway collapsibility. Respirology 2022; 27:975-982. [PMID: 35811347 PMCID: PMC10041976 DOI: 10.1111/resp.14326] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 06/23/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND OBJECTIVE The combination of the noradrenergic atomoxetine plus the anti-muscarinic oxybutynin acutely increased genioglossus activity and reduced obstructive sleep apnoea (OSA) severity. However, oxybutynin has shorter half-life than atomoxetine and side effects that might discourage long-term usage. Accordingly, we aimed to test the combination of atomoxetine and fesoterodine (Ato-Feso), a newer anti-muscarinic with extended release formulation, on OSA severity and endotypes. METHODS Twelve subjects with OSA underwent a randomized, double-blind, crossover trial comparing one night of atomoxetine plus fesoterodine (80-4 mg) to placebo. Parameters of OSA severity (e.g., apnoea-hypopnoea index [AHI], nadir oxygen desaturation and hypoxic burden) were calculated from two clinical, in-lab polysomnographic studies. OSA endotypes (including collapsibility per VMIN and arousal threshold) were derived from validated algorithms. RESULTS Compared to placebo, Ato-Feso did not reduce the AHI (34.2 ± 19.1 vs. 30.1 ± 28.2 events/h, p = 0.493), but reduced the apnoea index (12.9 [28.8] vs. 1.8 [9.1] events/h, median [interquartile range], p = 0.027) and increased nadir desaturation (76.8 [8.0] vs. 82.2 [8.8] %, p = 0.003); a non-significant trend for improved hypoxic burden was observed (52.4 [50.5] vs. 29.7 [78.9] %min/h, p = 0.093). Ato-Feso lowered collapsibility (raised VMIN ; 43.7 [29.8-55.7] vs. 56.8 [43.8-69.8] %VEUPNOEA , mean [CI], p = 0.002), but reduced the arousal threshold (129.3 [120.1-138.6] vs. 116.7 [107.5-126] %VEUPNOEA , p = 0.038). In post hoc analysis, 6/6 patients with milder collapsibility (VMIN > 43%) exhibited OSA resolution (drop in AHI > 50% and residual AHI < 10 events/h) and improved hypoxaemia. CONCLUSION While inefficacious in unselected patients, Ato-Feso administered for one night suppressed OSA in patients with milder collapsibility. Ato-Feso may hold some promise as an alternative OSA treatment in certain subgroups of individuals.
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Affiliation(s)
- Ludovico Messineo
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Laura K Gell
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Gonzalo Labarca
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Dan Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Hyung Chae Yang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Tsai-Yu Wang
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
| | - Scott A Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women’s Hospital & Harvard Medical School, Boston, Massachusetts
- Department of Allergy Immunology and Respiratory Medicine and Central Clinical School, The Alfred and Monash University, Melbourne, Australia
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16
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Hedner J, Zou D. New pharmacologic agents for obstructive sleep apnoea: what do we know and what can we expect? Curr Opin Pulm Med 2022; 28:522-528. [PMID: 36121301 DOI: 10.1097/mcp.0000000000000920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW This review provides a condensed description of pharmacological remedies explored in patients with obstructive sleep apnoea (OSA) as well as projections of what we might expect in terms of clinical performance of these drugs. RECENT FINDINGS Conventional drug therapies explored in OSA have generally produced disappointing results and there is a shortage of pharmacological treatment alternatives in this disorder. Recent insights into pathophysiological mechanisms potentially involved in OSA suggest that the condition may be divided into distinct subgroups based on clusters or defined by means of unique functional endotypic criteria. In fact, positive outcomes in clinical trials have now resulted in several drug candidates that show a convincing reduction of sleep disordered breathing in both short and intermediate term. Such drugs may be particularly useful in certain variants of OSA but not in others. These insights have also raised the ambition to create personalized therapies in OSA. Another recent development is the insight that OSA-linked conditions such as obesity, daytime somnolence and various forms of cardiovascular/metabolic disease may provide drug-based targets. For instance, pharmacological obesity therapy may provide not only positive metabolic effects but may also be a way to eliminate the anatomic component in obese OSA patients. SUMMARY Recent insights into the pathophysiology of OSA have opened possibilities to develop personalized therapy. Drugs addressing fundamental aspects of the sleep and breathing disorder provide a particularly promising avenue for development of novel forms of treatment in OSA.
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Affiliation(s)
- Jan Hedner
- Center for Sleep and Vigilance Disorders, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
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17
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Huang W, Wang X, Xu C, Xu H, Zhu H, Liu S, Zou J, Guan J, Yi H, Yin S. Prevalence, characteristics, and respiratory arousal threshold of positional obstructive sleep apnea in China: a large scale study from Shanghai Sleep Health Study cohort. Respir Res 2022; 23:240. [PMID: 36096792 PMCID: PMC9465879 DOI: 10.1186/s12931-022-02141-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 08/16/2022] [Indexed: 11/21/2022] Open
Abstract
Purpose To evaluate the prevalence, characteristics, and respiratory arousal threshold (ArTH) of Chinese patients with positional obstructive sleep apnea (POSA) according to the Cartwright Classification (CC) and Amsterdam Positional Obstructive Sleep Apnea Classification (APOC). Methods A large-scale cross-sectional study was conducted in our sleep center from 2007 to 2018 to analyze the clinical and polysomnography (PSG) data of Chinese POSA patients. Low ArTH was defined based on PSG indices. Results Of 5,748 OSA patients, 36.80% met the CC criteria, and 42.88% the APOC criteria, for POSA. The prevalence of POSA was significantly higher in women than men (40.21% and 46.52% vs. 36.13% and 42.18% for CC and APOC, respectively). Chinese POSA patients had a lower apnea hypopnea index (AHI) and lower oxygen desaturation index, shorter duration of oxygen saturation (SaO2) < 90%, and a higher mean SaO2 and higher lowest SaO2 value compared to subjects with non-positional OSA (NPOSA). More than 40% of the POSA patients had a low ArTH; the proportion was extremely high in the supine-isolated-POSA (si-POSA) group and APOC I group. In multivariate logistic regression analyses, higher mean SaO2 and lower AHI during sleep were positive predictors of POSA. Conclusions According to the CC and APOC criteria, more than 1/3 of our Chinese subjects with OSA had POSA. Chinese POSA patients had less severe OSA and nocturnal hypoxia. Compared to NPOSA patients, significantly more patients with POSA had a low ArTH. A low ArTH may be an important endotype in the pathogenesis of POSA, especially in patients with si-POSA and APOC I. Further studies are necessary to develop personalized management strategies for POSA patients. Trial registration: Chinese Clinical Trial Registry; URL: http://www.chictr.org.cn; No. ChiCTR1900025714 (retrospectively registered). Supplementary Information The online version contains supplementary material available at 10.1186/s12931-022-02141-3.
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18
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Verbraecken J, Dieltjens M, Op de Beeck S, Vroegop A, Braem M, Vanderveken O, Randerath W. Non-CPAP therapy for obstructive sleep apnoea. Breathe (Sheff) 2022; 18:220164. [PMID: 36340820 PMCID: PMC9584565 DOI: 10.1183/20734735.0164-2022] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Accepted: 08/12/2022] [Indexed: 11/08/2022] Open
Abstract
Treatment of obstructive sleep apnoea in adults is evolving, from a "one treatment fits all" to a more individualised approach. The spectrum of treatment options is broad and heterogeneous, including conservative, technological and pharmaceutical modalities. This raises the questions of which patients these modalities might be useful for, and if there are specific criteria for single or combined treatment. The most commonly used non-CPAP treatment is a mandibular advancement device. Furthermore, it appears from the available evidence that upper airway surgery, bariatric surgery, and maxillomandibular advancement can be effective in particular patient groups and should be indicated more readily in clinical practice. Technically, a tracheotomy is the most effective surgical treatment, but is not socially acceptable and is associated with major side-effects. Other treatment options are emerging, like positional therapy, hypoglossal nerve stimulation, and myofunctional exercises. Drug therapy is also promising when pathophysiological traits are considered. The range of currently available treatment options will be discussed in this review, with emphasis on the selection of appropriate patients, therapeutic efficacy and compliance, and reference to recent guidelines. In the selection process, routine application of drug-induced sleep endoscopy to assess the site(s) of collapse during sleep can increase the success rate of both surgical interventions and oral appliance therapy. Educational aims To outline recommendations concerning the proper management of obstructive sleep apnoea (OSA) patients that cannot be treated adequately with continuous positive airway pressure (CPAP) due to intolerance, poor adherence or compliance, or CPAP refusal.To provide information about the selection of appropriate patients for alternative non-CPAP treatment options.To better understand the different aspects of OSA treatment with noninvasive approaches, such as oral appliances, positional therapy, drug treatment and myofunctional therapy, including indications, contraindications, and expected short- and long-term results.To discuss the different surgical options for the treatment of OSA and to provide information on the important issue of proper patient selection for surgery, as most OSA surgical outcomes are associated with the pre-operative assessment of the level(s) of upper airway collapse.
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Affiliation(s)
- Johan Verbraecken
- Department of Pulmonary Medicine, Antwerp University Hospital, Edegem (Antwerp), Belgium,Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium,Corresponding author: Johan Verbraecken ()
| | - Marijke Dieltjens
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Sara Op de Beeck
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium
| | - Anneclaire Vroegop
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Marc Braem
- Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium,Special Dentistry Care, Antwerp University Hospital, Edegem, Belgium
| | - Olivier Vanderveken
- Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital, Edegem, Belgium,Faculty of Medicine and Health Sciences, University of Antwerp, Wilrijk, Belgium,Department of Otorhinolaryngology, Head and Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Winfried Randerath
- Bethanien Hospital, Clinic of Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Institute of Pneumology at the University of Cologne, Solingen, Germany
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19
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Abstract
Despite extensive research, there is currently no approved drug for obstructive sleep apnea (OSA) treatment. OSA is a heterogeneous condition that involves multiple dominating pathophysiological traits. Drug development in this field needs to address both pathophysiological mechanisms and associated comorbid conditions in order to meet requirements for long-term therapy in OSA. Several drug candidates have been proposed and ongoing phase II trials that target various forms of sleep-disordered breathing have been initiated. The field is moving toward tailored therapeutic approaches in patients with OSA.
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20
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Nokes B, Cooper J, Cao M. Obstructive sleep apnea: personalizing CPAP alternative therapies to individual physiology. Expert Rev Respir Med 2022; 16:917-929. [PMID: 35949101 DOI: 10.1080/17476348.2022.2112669] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Introduction The recent continuous positive airway pressure (CPAP) crisis has highlighted the need for alternative obstructive sleep apnea (OSA) therapies. This article serves to review OSA pathophysiology and how sleep apnea mechanisms may be utilized to individualize alternative treatment options.Areas covered: The research highlighted below focuses on 1) mechanisms of OSA pathogenesis and 2) CPAP alternative therapies based on mechanism of disease. We reviewed PubMed from inception to July 2022 for relevant articles pertaining to OSA pathogenesis, sleep apnea surgery, as well as sleep apnea alternative therapies.Expert opinion: Although the field of individualized OSA treatment is still in its infancy, much has been learned about OSA traits and how they may be targeted based on a patient's physiology and preferences. While CPAP remains the gold-standard for OSA management, several novel alternatives are emerging. CPAP is a universal treatment approach for all severities of OSA. We believe that a personalized approach to OSA treatment beyond CPAP lies ahead. Additional research is needed with respect to implementation and combination of therapies longitudinally, but we are enthusiastic about the future of OSA treatment based on the data presented here.
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Affiliation(s)
- Brandon Nokes
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, USA.,Section of Sleep Medicine, Veterans Affairs (VA) San Diego Healthcare System, La Jolla, CA, USA
| | - Jessica Cooper
- Division of Pulmonary, Critical Care, and Sleep Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Michelle Cao
- Division of Pulmonary, Allergy, Critical Care Medicine & Division of Sleep Medicine, Stanford University, Palo Alto, CA, USA
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21
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McNicholas WT, Pevernagie D. Obstructive sleep apnea: transition from pathophysiology to an integrative disease model. J Sleep Res 2022; 31:e13616. [PMID: 35609941 PMCID: PMC9539471 DOI: 10.1111/jsr.13616] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 04/07/2022] [Accepted: 04/07/2022] [Indexed: 12/12/2022]
Abstract
Obstructive sleep apnea (OSA) is characterised by recurring episodes of upper airway obstruction during sleep and the fundamental abnormality reflects the inability of the upper airway dilating muscles to withstand the negative forces generated within the upper airway during inspiration. Factors that result in narrowing of the oropharynx such as abnormal craniofacial anatomy, soft tissue accumulation in the neck, and rostral fluid shift in the recumbent position increase the collapsing forces within the airway. The counteracting forces of upper airway dilating muscles, especially the genioglossus, are negatively influenced by sleep onset, inadequacy of the genioglossus responsiveness, ventilatory instability, especially post arousal, and loop gain. OSA is frequently associated with comorbidities that include metabolic, cardiovascular, renal, pulmonary, and neuropsychiatric, and there is growing evidence of bidirectional relationships between OSA and comorbidity, especially for heart failure, metabolic syndrome, and stroke. A detailed understanding of the complex pathophysiology of OSA encourages the development of therapies targeted at pathophysiological endotypes and facilitates a move towards precision medicine as a potential alternative to continuous positive airway pressure therapy in selected patients.
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Affiliation(s)
- Walter T McNicholas
- Department of Respiratory and Sleep Medicine, St Vincent's Hospital Group, School of Medicine, University College Dublin, Dublin, Ireland
| | - Dirk Pevernagie
- Department of Respiratory Medicine, Ghent University Hospital, Ghent, Belgium.,Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
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22
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Overview of the Role of Pharmacological Management of Obstructive Sleep Apnea. Medicina (B Aires) 2022; 58:medicina58020225. [PMID: 35208549 PMCID: PMC8874508 DOI: 10.3390/medicina58020225] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 11/17/2022] Open
Abstract
Obstructive sleep apnea (OSA) remains a prominent disease state characterized by the recurrent collapse of the upper airway while sleeping. To date, current treatment may include continuous positive airway pressure (CPAP), lifestyle changes, behavioral modification, mandibular advancement devices, and surgical treatment. However, due to the desire for a more convenient mode of management, pharmacological treatment has been thoroughly investigated as a means for a potential alternative in OSA treatment. OSA can be distinguished into various endotypic or phenotypic classes, allowing pharmacological treatment to better target the root cause or symptoms of OSA. Some medications available for use include antidepressants, CNS stimulants, nasal decongestants, carbonic anhydrase inhibitors, and potassium channel blockers. This review will cover the findings of currently available and future study medications that could potentially play a role in OSA therapy.
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23
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Messineo L, Eckert DJ, Taranto-Montemurro L, Vena D, Azarbarzin A, Hess LB, Calianese N, White DP, Wellman A, Gell L, Sands SA. Ventilatory Drive Withdrawal Rather Than Reduced Genioglossus Compensation as a Mechanism of Obstructive Sleep Apnea in REM Sleep. Am J Respir Crit Care Med 2022; 205:219-232. [PMID: 34699338 PMCID: PMC8787251 DOI: 10.1164/rccm.202101-0237oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
Rationale: REM sleep is associated with reduced ventilation and greater obstructive sleep apnea (OSA) severity than non-REM (nREM) sleep for reasons that have not been fully elucidated. Objectives: Here, we use direct physiological measurements to determine whether the pharyngeal compromise in REM sleep OSA is most consistent with 1) withdrawal of neural ventilatory drive or 2) deficits in pharyngeal pathophysiology per se (i.e., increased collapsibility and decreased muscle responsiveness). Methods: Sixty-three participants with OSA completed sleep studies with gold standard measurements of ventilatory "drive" (calibrated intraesophageal diaphragm EMG), ventilation (oronasal "ventilation"), and genioglossus EMG activity. Drive withdrawal was assessed by examining these measurements at nadir drive (first decile of drive within a stage). Pharyngeal physiology was assessed by examining collapsibility (lowered ventilation at eupneic drive) and responsiveness (ventilation-drive slope). Mixed-model analysis compared REM sleep with nREM sleep; sensitivity analysis examined phasic REM sleep. Measurements and Main Results: REM sleep (⩾10 min) was obtained in 25 patients. Compared with drive in nREM sleep, drive in REM sleep dipped to markedly lower nadir values (first decile, estimate [95% confidence interval], -21.8% [-31.2% to -12.4%] of eupnea; P < 0.0001), with an accompanying reduction in ventilation (-25.8% [-31.8% to -19.8%] of eupnea; P < 0.0001). However, there was no effect of REM sleep on collapsibility (ventilation at eupneic drive), baseline genioglossus EMG activity, or responsiveness. REM sleep was associated with increased OSA severity (+10.1 [1.8 to 19.8] events/h), but this association was not present after adjusting for nadir drive (+4.3 [-4.2 to 14.6] events/h). Drive withdrawal was exacerbated in phasic REM sleep. Conclusions: In patients with OSA, the pharyngeal compromise characteristic of REM sleep appears to be predominantly explained by ventilatory drive withdrawal rather than by preferential decrements in muscle activity or responsiveness. Preventing drive withdrawal may be the leading target for REM sleep OSA.
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Affiliation(s)
- Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia;,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Danny J. Eckert
- Adelaide Institute for Sleep Health, Flinders University, Bedford Park, Adelaide, South Australia, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Daniel Vena
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Ali Azarbarzin
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Lauren B. Hess
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Nicole Calianese
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - David P. White
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Andrew Wellman
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Laura Gell
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Scott A. Sands
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women’s Hospital and Harvard Medical School, Harvard University, Boston, Massachusetts; and,Department of Allergy Immunology and Respiratory Medicine, Central Clinical School, The Alfred and Monash University, Melbourne, Victoria, Australia
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24
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McNicholas WT. Obstructive Sleep Apnoea: Focus on Pathophysiology. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2022; 1384:31-42. [PMID: 36217077 DOI: 10.1007/978-3-031-06413-5_3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Obstructive sleep apnoea (OSA) is characterized by recurring episodes of upper airway obstruction during sleep and the fundamental abnormality reflects the inability of the upper airway dilating muscles to withstand the negative forces generated within the upper airway during inspiration. Factors that result in narrowing of the oropharynx such as abnormal craniofacial anatomy, soft tissue accumulation in the neck, and rostral fluid shift in the recumbent position increase the collapsing forces within the airway. The counteracting forces of upper airway dilating muscles, especially the genioglossus, are negatively influenced by sleep onset, inadequacy of the genioglossus responsiveness, ventilatory instability, especially post arousal, and loop gain. Recent reports indicate that multiple endotypes reflecting OSA pathophysiology are present in individual patients. A detailed understanding of the complex pathophysiology of OSA encourages the development of therapies targeted at these pathophysiological endotypes and facilitates a move towards precision medicine as a potential alternative to continuous positive airway pressure therapy in selected patients.
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Affiliation(s)
- Walter T McNicholas
- School of Medicine, University College Dublin, Department of Respiratory and Sleep Medicine, St. Vincent's Hospital Group, Dublin, Ireland.
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25
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Baillieul S, Tamisier R, Eckert DJ, Pépin JL. Current knowledge and perspectives for pharmacological treatment in OSA. Arch Bronconeumol 2022; 58:681-684. [DOI: 10.1016/j.arbres.2021.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 12/20/2021] [Indexed: 11/29/2022]
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26
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Messineo L, Loffler K, Chiang A, Osman A, Taranto-Montemurro L, Eckert DJ. The Combination of Betahistine and Oxybutynin Increases Respiratory Control Sensitivity (Loop Gain) in People with Obstructive Sleep Apnea: A Randomized, Placebo-Controlled Trial. Nat Sci Sleep 2022; 14:1063-1074. [PMID: 35698591 PMCID: PMC9188336 DOI: 10.2147/nss.s362205] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 05/16/2022] [Indexed: 12/12/2022] Open
Abstract
RATIONALE There are widespread histaminergic projections throughout the brain, including hypoglossal nuclei, that modulate pharyngeal muscle tone and respiratory control. Hence, histaminergic stimulation pharmacologically may increase pharyngeal muscle tone and stabilize respiratory control (loop gain) to reduce obstructive sleep apnea (OSA) severity. Antimuscarinics also increase REM pharyngeal muscle tone in rats. Thus, a combination of histaminergic and anti-muscarinic drugs may be a novel target for OSA pharmacotherapy. However, this has not been investigated. Accordingly, we aimed to test the effects of betahistine (Beta), an H3-autoreceptor antagonist which thereby increases histamine levels, in combination with the antimuscarinic oxybutynin (Oxy), on OSA severity, OSA endotypes, polysomnography parameters and next-day sleepiness and alertness. METHODS Thirteen adults with OSA received either Beta-Oxy (96-5mg) or placebo according to a randomized, crossover, double-blind design, prior to polysomnography. Participants completed the Karolinska Sleep Scale and Leeds Sleep Evaluation Questionnaire and a driving simulation task to quantify next-day sleepiness and alertness. OSA endotypes were estimated through validated algorithms using polysomnography. RESULTS Compared to placebo, Beta-Oxy increased respiratory control sensitivity (loop gain) (0.52[0.24] vs 0.60[0.34], median [IQR], P = 0.021) without systematically changing OSA severity (34.4±17.2 vs 40.3±27.3 events/h, mean±SD, P = 0.124), sleep efficiency, arousal index or markers of hypoxemia. Beta-Oxy was well tolerated and did not worsen next-day sleepiness/alertness. CONCLUSION Rather than stabilize breathing during sleep, Beta-Oxy increases loop gain, which is likely to be deleterious for most people with OSA. However, in certain conditions characterized by blunted respiratory control (eg, obesity hypoventilation syndrome), interventions to increase loop gain may be beneficial.
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Affiliation(s)
- Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia.,Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Kelly Loffler
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Alan Chiang
- Neuroscience Research Australia, Randwick, NSW, Australia
| | - Amal Osman
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia
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27
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Osteopathic Manipulation of the Sphenopalatine Ganglia Versus Sham Manipulation, in Obstructive Sleep Apnoea Syndrom: A Randomised Controlled Trial. J Clin Med 2021; 11:jcm11010099. [PMID: 35011840 PMCID: PMC8745154 DOI: 10.3390/jcm11010099] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/06/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
(1) Background: osteopathic manipulation of the sphenopalatine ganglia (SPG) blocks the action of postganglionic sensory fibres. This neuromodulation can reduce nasal obstruction and enhance upper airway stability. We investigated the manipulation of the SPG in 31 patients with obstructive sleep apnoea syndrome (OSAS); (2) Methods: Randomised, controlled, double-blind, crossover study. Participants received active (AM), then sham manipulation (SM), or vice versa. The primary endpoint was apnoea-hypopnoea index (AHI). Secondary endpoints were variation of nasal obstruction evaluated by peak nasal inspiratory flow (PNIF) and upper airways stability evaluated by awake critical closing pressure [awake Pcrit]), at 30 min and 24 h. Schirmer’s test and pain were assessed immediately post-manipulation. Tactile/gustatory/olfactory/auditory/nociceptive/visual sensations were recorded. Adverse events were collected throughout. (3) Results: SPG manipulation did not reduce AHI (p = 0.670). PNIF increased post-AM but not post-SM at 30 min (AM-SM: 18 [10; 38] L/min, p = 0.0001) and 24 h (23 [10; 30] L/min, p = 0.001). There was no significant difference on awake Pcrit (AM-SM) at 30 min or 24 h). Sensations were more commonly reported post-AM (100% of patients) than post-SM (37%). Few adverse events and no serious adverse events were reported. (4) Conclusions: SPG manipulation is not supported as a treatment for OSAS but reduced nasal obstruction. This effect remains to be confirmed in a larger sample before using this approach to reduce nasal congestion in CPAP-treated patients or in mild OSAS.
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28
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Pépin JL, Eastwood P, Eckert DJ. Novel avenues to approach non-CPAP therapy and implement comprehensive OSA care. Eur Respir J 2021; 59:13993003.01788-2021. [PMID: 34824053 DOI: 10.1183/13993003.01788-2021] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 09/16/2021] [Indexed: 11/05/2022]
Abstract
Recent advances in obstructive sleep apnoea (OSA) pathophysiology and translational research have opened new lines of investigation for OSA treatment and management. Key goals of such investigations are to provide efficacious, alternative treatment and management pathways that are better tailored to individual risk profiles to move beyond the traditional, continuous positive airway pressure (CPAP)-focused, "one size fits all", trial and error approach which is too frequently inadequate for many patients. Identification of different clinical manifestations of OSA (clinical phenotypes) and underlying pathophysiological phenotypes (endotypes), that contribute to OSA have provided novel insights into underlying mechanisms and have underpinned these efforts. Indeed, this new knowledge has provided the framework for precision medicine for OSA to improve treatment success rates with existing non-CPAP therapies such as mandibular advancement devices and upper airway surgery, and newly developed therapies such as hypoglossal nerve stimulation and emerging therapies such as pharmacotherapies and combination therapy. These concepts have also provided insight into potential physiological barriers to CPAP adherence for certain patients. This review summarises the recent advances in OSA pathogenesis, non-CPAP treatment, clinical management approaches and highlights knowledge gaps for future research. OSA endotyping and clinical phenotyping, risk stratification and personalised treatment allocation approaches are rapidly evolving and will further benefit from the support of recent advances in e-health and artificial intelligence.
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Affiliation(s)
- Jean-Louis Pépin
- HP2 Laboratory, INSERM U1042, University Grenoble Alpes, Grenoble, France .,EFCR Laboratory, Grenoble Alpes University Hospital, Grenoble, France
| | - Peter Eastwood
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Bedford Park, South Australia, Australia
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29
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Lim R, Messineo L, Grunstein RR, Carberry JC, Eckert DJ. The noradrenergic agent reboxetine plus the antimuscarinic hyoscine butylbromide reduces sleep apnoea severity: a double-blind, placebo-controlled, randomised crossover trial. J Physiol 2021; 599:4183-4195. [PMID: 34174090 DOI: 10.1113/jp281912] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2021] [Accepted: 06/23/2021] [Indexed: 11/08/2022] Open
Abstract
KEY POINTS Recent animal and human physiology studies indicate that noradrenergic and muscarinic processes are key mechanisms that mediate pharyngeal muscle control during sleep. The noradrenergic agent reboxetine combined with the anti-muscarinic hyoscine butylbromide has recently been shown to improve upper airway function during sleep in healthy individuals. However, whether these findings translate to the clinically relevant patient population of people with obstructive sleep apnoea (OSA), and the effects of the agents on OSA severity, are unknown. We found that reboxetine plus hyoscine butylbromide reduced OSA severity, including overnight hypoxaemia, via increases in pharyngeal muscle responsiveness, improvements in respiratory control and airway collapsibility without changing the respiratory arousal threshold. These findings provide mechanistic insight into the role of noradrenergic and anti-muscarinic agents on upper airway stability and breathing during sleep and are important for pharmacotherapy development for OSA. ABSTRACT The noradrenergic agent reboxetine combined with the anti-muscarinic hyoscine butylbromide has recently been shown to improve upper airway function during sleep in healthy individuals. However, the effects of this drug combination on obstructive sleep apnoea (OSA) severity are unknown. Accordingly, this study aimed to determine if reboxetine plus hyoscine butylbromide reduces OSA severity. Secondary aims were to investigate the effects on key upper airway physiology and endotypic traits. Twelve people with OSA aged 52 ± 13 years, BMI = 30 ± 5 kg/m2 , completed a double-blind, randomised, placebo-controlled, crossover trial (ACTRN12617001326381). Two in-laboratory sleep studies with nasal mask, pneumotachograph, epiglottic pressure sensor and bipolar fine-wire electrodes into genioglossus and tensor palatini muscles were performed separated by approximately 1 week. Each participant received either reboxetine (4 mg) plus hyoscine butylbromide (20 mg), or placebo immediately prior to sleep. Polysomnography, upper airway physiology and endotypic estimates of OSA were compared between conditions. Reboxetine plus hyoscine butylbromide reduced the apnoea/hypopnoea index by (mean ± SD) 17 ± 17 events/h from 51 ± 30 to 33 ± 22 events/h (P = 0.005) and nadir oxygen saturation increased by 6 ± 5% from 82 ± 5 to 88 ± 2% (P = 0.002). The drug combination increased tonic genioglossus muscle responsiveness during non-REM sleep (median [25th, 75th centiles]: -0.007 [-0.0004, -0.07] vs. -0.12 [-0.02, -0.40] %maxEMG/cmH2 O, P = 0.02), lowered loop gain (0.43 ± 0.06 vs. 0.39 ± 0.07, P = 0.01), and improved airway collapsibility (90 [69, 95] vs. 93 [88, 96] %eupnoea, P = 0.02), without changing the arousal threshold (P = 0.39). These findings highlight the important role that noradrenergic and muscarinic processes have on upper airway function during sleep and the potential for pharmacotherapy to target these mechanisms to treat OSA.
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Affiliation(s)
- Richard Lim
- Neuroscience Research Australia (NeuRA), New South Wales, Sydney, Australia.,School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia
| | - Ludovico Messineo
- Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
| | - Ronald R Grunstein
- Woolcock Institute of Medical Research, Sydney Medical School, the University of Sydney, New South Wales, Glebe, Australia.,Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, New South Wales, Camperdown, Australia
| | - Jayne C Carberry
- Neuroscience Research Australia (NeuRA), New South Wales, Sydney, Australia.,Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia.,UCD School of Medicine, University College Dublin, Belfield, Dublin, Ireland
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA), New South Wales, Sydney, Australia.,School of Medical Sciences, University of New South Wales, New South Wales, Sydney, Australia.,Flinders Health and Medical Research Institute and Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
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30
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Sweetman A, Lack L, McEvoy RD, Smith S, Eckert DJ, Osman A, Carberry JC, Wallace D, Nguyen PD, Catcheside P. Bi-directional relationships between co-morbid insomnia and sleep apnea (COMISA). Sleep Med Rev 2021; 60:101519. [PMID: 34229295 DOI: 10.1016/j.smrv.2021.101519] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 06/06/2021] [Accepted: 06/11/2021] [Indexed: 02/07/2023]
Abstract
Insomnia and obstructive sleep apnea (OSA) commonly co-occur. Approximately 30-50% of patients with OSA report clinically significant insomnia symptoms, and 30-40% of patients with chronic insomnia fulfil diagnostic criteria for OSA. Compared to either insomnia or OSA alone, co-morbid insomnia and sleep apnea (COMISA) is associated with greater morbidity for patients, complex diagnostic decisions for clinicians, and reduced response to otherwise effective treatment approaches. Potential bi-directional causal relationships between the mechanisms and manifestations of insomnia and OSA could play an integral role in the development and management of COMISA. A greater understanding of these relationships is required to guide personalized diagnostic and treatment approaches for COMISA. This review summarizes the available evidence of bi-directional relationships between COMISA, including epidemiological research, case studies, single-arm treatment studies, randomized controlled treatment trials, and objective sleep study data. This evidence is integrated into a conceptual model of COMISA to help refine the understanding of potential bi-directional causal relationships between the two disorders. This theoretical framework is essential to help guide future research, improve diagnostic tools, determine novel therapeutic targets, and guide tailored sequenced and multi-faceted treatment approaches for this common, complex, and debilitating condition.
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Affiliation(s)
- Alexander Sweetman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Leon Lack
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Education Psychology and Social Work, Flinders University, Adelaide, Australia.
| | - R Doug McEvoy
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Simon Smith
- Institute for Social Science Research (ISSR), The University of Queensland, Brisbane, 4027, Australia.
| | - Danny J Eckert
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Amal Osman
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
| | - Jayne C Carberry
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia; University College Dublin, School of Medicine, Dublin, Ireland.
| | - Douglas Wallace
- Department of Neurology, Sleep Medicine Division, University of Miami Miller School of Medicine, Miami, FL, USA; Neurology Service, Bruce W. Carter Department of Veterans Affairs Medical Center, Miami, FL, USA.
| | - Phuc D Nguyen
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Science and Engineering, Flinders University, Adelaide, Australia.
| | - Peter Catcheside
- The Adelaide Institute for Sleep Health: A Centre of Research Excellence, Flinders Health and Medical Research Institute: Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, Australia.
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31
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Messineo L, Carter SG, Taranto-Montemurro L, Chiang A, Vakulin A, Adams RJ, Carberry JC, Eckert DJ. Addition of zolpidem to combination therapy with atomoxetine-oxybutynin increases sleep efficiency and the respiratory arousal threshold in obstructive sleep apnoea: A randomized trial. Respirology 2021; 26:878-886. [PMID: 34164887 DOI: 10.1111/resp.14110] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 05/24/2021] [Accepted: 06/15/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND OBJECTIVE Atomoxetine combined with oxybutynin (Ato-Oxy) has recently been shown to reduce obstructive sleep apnoea (OSA) severity by >60%. However, Ato-Oxy also modestly reduced the respiratory arousal threshold, which may decrease sleep quality/efficiency. We sought to investigate the additional effect of zolpidem with Ato-Oxy on sleep efficiency (primary outcome), the arousal threshold, OSA severity, other standard polysomnography (PSG) parameters, next-day sleepiness and alertness (secondary outcomes). METHODS Twelve participants with OSA received 10 mg zolpidem plus Ato-Oxy (80-5 mg, respectively) or Ato-Oxy plus placebo prior to overnight in-laboratory PSG according to a double-blind, randomized, crossover design (1-week washout). Participants were fitted with an epiglottic catheter, a nasal mask and pneumotachograph to quantify arousal threshold and airflow. Next-day sleepiness and alertness were assessed via the Karolinska Sleepiness Scale and a driving simulation task. RESULTS The addition of zolpidem increased sleep efficiency by 9% ± 13% (80.9% ± 16.9% vs. 88.2% ± 8.2%, p = 0.037) and the respiratory arousal threshold by 17% ± 18% (-26.6 ± 14.5 vs. -33.8 ± 20.3 cm H2 O, p = 0.004) versus Ato-Oxy + placebo. Zolpidem did not systematically change OSA severity. Combination therapy was well tolerated, and zolpidem did not worsen next-day sleepiness. However, median steering deviation during the driving simulator task increased following the zolpidem combination. CONCLUSION Zolpidem improves sleep efficiency via an increase in the respiratory arousal threshold to counteract potential wake-promoting properties of atomoxetine in OSA. These changes occur without altering the rate of respiratory events or overnight hypoxaemia. However, while the addition of zolpidem does not increase next-day perceived sleepiness, caution is warranted given the potential impact on next-morning objective alertness.
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Affiliation(s)
- Ludovico Messineo
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Sophie G Carter
- Neuroscience Research Australia (NeuRA), The University of New South Wales, Sydney, New South Wales, Australia
| | - Luigi Taranto-Montemurro
- Division of Sleep and Circadian Disorders, Departments of Medicine and Neurology, Brigham & Women's Hospital & Harvard Medical School, Boston, Massachusetts, USA
| | - Alan Chiang
- Neuroscience Research Australia (NeuRA), The University of New South Wales, Sydney, New South Wales, Australia
| | - Andrew Vakulin
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Robert J Adams
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Jayne C Carberry
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
| | - Danny J Eckert
- Adelaide Institute for Sleep Health, Flinders Health and Medical Research Institute, Flinders University, Adelaide, South Australia, Australia
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32
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Zinchuk AV, Chu JH, Liang J, Celik Y, Op de Beeck S, Redeker NS, Wellman A, Yaggi HK, Peker Y, Sands SA. Physiological Traits and Adherence to Therapy of Sleep Apnea in Individuals with Coronary Artery Disease. Am J Respir Crit Care Med 2021; 204:703-712. [PMID: 34156917 DOI: 10.1164/rccm.202101-0055oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Untreated obstructive sleep apnea (OSA) is associated with adverse outcomes in patients with coronary artery disease (CAD). Continuous positive airway pressure (CPAP) is the most common treatment, but despite interventions addressing established adherence determinants, CPAP use remains poor. OBJECTIVES To determine whether physiological traits that cause OSA are associated with long-term CPAP adherence in patients with CAD. METHODS Participants in the RICCADSA trial with objective CPAP adherence (hours/night) over 2 years and analyzable raw polysomnography data were included (n=249). The physiological traits -loop gain, arousal threshold (ArTH), collapsibility and muscle compensation- were measured from polysomnography. Linear mixed models assessed the relationship between the traits and adherence. We also compared actual CPAP adherence between physiology-predicted "poor" (lowest quartile of predicted adherence) and "good" (all others) adherers. MEASUREMENTS AND RESULTS Median (IQR) CPAP use declined from 3.2 (1.0, 5.8) to 3.0 (0.0, 5.6) hours/night over 24-mo (p<0.001). In analyses adjusted for demographics, anthropometrics, OSA characteristics and clinical comorbidities, lower ArTH was associated with worse CPAP adherence (0.7 hours/SD ArTH, p=0.021). Both high and low muscle compensation were associated with lower adherence (p=0.008). Predicted "poor" adherers exhibited markedly lower CPAP use compared to "good" adherers for up to 2 years of follow-up (group differences: 2.0 to 3.2 hours/night, p<0.003 for all). CONCLUSIONS A low ArTH as well as a very low and high muscle compensation are associated with worse long-term CPAP adherence in patients with CAD and OSA. Physiological traits, alongside established determinants, may help predict and improve CPAP adherence.
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Affiliation(s)
- Andrey V Zinchuk
- Yale School of Medicine, 12228, Section of Pulmonary and Critical Care Medicine, New Haven, Connecticut, United States;
| | - Jen-Hwa Chu
- Yale School of Medicine, 12228, Pulmonary, Critical Care, & Sleep Medicine, New Haven, Connecticut, United States
| | - Jiasheng Liang
- Yale University School of Medicine, 12228, New Haven, Connecticut, United States
| | - Yeliz Celik
- Koc Universitesi, 52979, Koc University Research Center for Translational Medicine (KUTTAM), Istanbul, Turkey
| | - Sara Op de Beeck
- Universiteit Antwerpen Faculteit geneeskunde en gezondheidswetenschappen, 81844, Translational Neurosciences, Wilrijk, Belgium.,Universitair Ziekenhuis Antwerpen, 60202, Ear Nose Throat, Edegem, Belgium
| | - Nancy S Redeker
- Yale University Yale School of Nursing, 16230, New Haven, Connecticut, United States
| | - Andrew Wellman
- Brigham and Women's Hospital Department of Medicine, 370908, Medicine, Boston, Massachusetts, United States.,Harvard Medical School, 1811, Boston, Massachusetts, United States
| | - H Klar Yaggi
- Yale School of Medicine, 12228, Internal Medicine, New Haven, Connecticut, United States.,VA Connecticut Healthcare System, 19985, Clinical Epidemiology Research Center, West Haven, Connecticut, United States
| | - Yüksel Peker
- Koc Universitesi, 52979, Koc University Research Center for Translational Medicine (KUTTAM) , Istanbul, Turkey.,University of Gothenburg Faculty of Health Sciences, 70712, Molecular and Clinical Medicine/Cardiology, Goteborg, Sweden.,Lund University Faculty of Medicine, 59568, Clinical Sciences, Respiratory Medicine and Allergology, Lund, Sweden.,University of Pittsburgh Medical Center, 6595, Pittsburgh, Pennsylvania, United States
| | - Scott A Sands
- Brigham and Women's Hospital, 1861, Boston, Massachusetts, United States
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33
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Lafzi F, Kilic H. Metal‐ and Additive‐Free C3‐Functionalization of Imidazo[1,2‐
a
]pyridines with
para
‐Quinone Methides. ASIAN J ORG CHEM 2021. [DOI: 10.1002/ajoc.202100313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Ferruh Lafzi
- Department of Chemistry Faculty of Sciences Atatürk University 25240 Erzurum Turkey
| | - Haydar Kilic
- Department of Chemistry Faculty of Sciences Atatürk University 25240 Erzurum Turkey
- Oltu Vocational Training School Atatürk University 25400 Erzurum Turkey
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34
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Hoshino T, Sasanabe R, Murotani K, Hori R, Mano M, Nomura A, Konishi N, Baku M, Nishio Y, Kato C, Kuczynski W, Shiomi T. Estimated respiratory arousal threshold in patients with rapid eye movement obstructive sleep apnea. Sleep Breath 2021; 26:347-353. [PMID: 33999361 PMCID: PMC8857081 DOI: 10.1007/s11325-021-02399-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/20/2022]
Abstract
Purpose Rapid eye movement (REM) obstructive sleep apnea (OSA) is a prevalent clinical phenotype. However, the literature focusing on the pathophysiology of REM OSA is limited. This study compared the proportion of individuals with a low respiratory arousal threshold between patients with REM and non-REM OSA. Methods REM OSA was defined as having an apnea–hypopnea index (AHI) ≥ 5 and AHI during REM (AHI-REM)/AHI during NREM (AHI-NREM) ≥ 2. REM OSA was sub-divided into REM-predominant OSA and REM-isolated OSA. REM-predominant OSA was defined as satisfying the definition of REM OSA and having an AHI-NREM ≥ 5. REM-isolated OSA was defined as satisfying the definition of REM OSA and having an AHI-NREM < 5. Patients with an AHI-REM/AHI-NREM < 2 were defined as having non-REM OSA. A low respiratory arousal threshold was defined as having 2 or more of the following conditions: AHI < 30 events/h, proportion of hypopnea > 58.3%, and nadir SpO2 > 82.5%. Results The proportions of individuals with low respiratory arousal thresholds among individuals with REM-predominant OSA and REM-isolated OSA were significantly higher (77.2% and 93.7%, respectively) than that of patients with non-REM OSA (48.6%). This was also true when the analysis was performed according to sex. Conclusion These results indicate that a low respiratory arousal threshold might be an important endotype that contributes to the pathogenesis of REM OSA, especially in REM-isolated OSA.
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Affiliation(s)
- Tetsuro Hoshino
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan.
| | - Ryujiro Sasanabe
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Kenta Murotani
- Biostatistics Center, Graduate School of Medicine, Kurume University, 67 Asahimachi, Kurume, Fukuoka, 8300011, Japan
| | - Reiko Hori
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Mamiko Mano
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Atsuhiko Nomura
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Noriyuki Konishi
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Masayo Baku
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Yoshitomo Nishio
- Department of Oral and Maxillofacial Surgery, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Chihiro Kato
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
| | - Wojciech Kuczynski
- Department of Sleep Medicine and Metabolic Disorders, Medical University of Lodz, 90-001, Lodz, Poland
| | - Toshiaki Shiomi
- Department of Sleep Medicine and Sleep Disorder Center, Aichi Medical University Hospital, 1-1 Nagakute, Aichi, 4801195, Japan
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A Phenotypic Approach for Personalised Management of Obstructive Sleep Apnoea. CURRENT OTORHINOLARYNGOLOGY REPORTS 2021. [DOI: 10.1007/s40136-021-00346-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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36
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Carter SG, Eckert DJ. Effects of hypnotics on obstructive sleep apnea endotypes and severity: Novel insights into pathophysiology and treatment. Sleep Med Rev 2021; 58:101492. [PMID: 33965721 DOI: 10.1016/j.smrv.2021.101492] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 04/07/2021] [Accepted: 04/07/2021] [Indexed: 02/06/2023]
Abstract
Impaired upper airway anatomy is the main cause of obstructive sleep apnea (OSA). However, there are other important non-anatomical contributors or "endotypes" including ventilatory control instability, poor pharyngeal dilator muscle responsiveness and waking up too easily to minor respiratory events (low arousal threshold). Recent studies have focused on the potential to target specific OSA causes with novel treatments to reduce OSA severity and improve efficacy with existing non-CPAP therapies which are often suboptimal (e.g., mandibular advancement splints). One novel target is pharmacotherapy with hypnotics to increase the threshold for arousal and reduce OSA severity in the approximately 30% of patients who have a low arousal threshold endotype. This increasing body of work has produced varied and at times unexpected findings which have challenged previous knowledge on the effects of hypnotics on upper airway physiology and breathing during sleep in people with OSA. This review provides a concise overview of the latest research that has investigated the effects of common hypnotics/sedative agents on upper airway physiology and OSA severity and potential implications for OSA pathophysiology, treatment and safety. This includes a summary of the latest knowledge on the effects of hypnotics on OSA endotypes. Priorities for future research are also highlighted.
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Affiliation(s)
- Sophie G Carter
- Neuroscience Research Australia (NeuRA) Barker Street and the University of New South Wales, Sydney, NSW, Australia
| | - Danny J Eckert
- Flinders Health and Medical Research Institute, Adelaide Institute for Sleep Health, Flinders University, Adelaide, SA, Australia.
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Chen CY, Chen CL, Yu CC. Trazodone improves obstructive sleep apnea after ischemic stroke: a randomized, double-blind, placebo-controlled, crossover pilot study. J Neurol 2021; 268:2951-2960. [PMID: 33625584 DOI: 10.1007/s00415-021-10480-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 02/15/2021] [Accepted: 02/16/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Low arousal threshold plays a part in the pathogenesis of obstructive sleep apnea (OSA) and may be improved by sedatives. Sedative antidepressants are frequently prescribed for stroke patients due to their high prevalence of insomnia and depression. However, the effect of sedative antidepressants on the severity of OSA in stroke patients has not been studied well. METHODS In a double-blinded randomized crossover pilot study, 22 post-acute ischemic stroke patients (mean age, 61.7 ± 10.6 y) with OSA received 100 mg of trazodone or a placebo just before polysomnography, with approximately 1 week between measures. The study also measured baseline heart rate variability and 24-h ambulatory blood pressure. RESULTS Administration of trazodone significantly increased the percentage time of slow-wave sleep (31.5 ± 13.2 vs. 18.4 ± 8.7%; P < 0.001) and improved almost all the parameters of OSA severity, including the apnea-hypopnea index (AHI, 25.4 ± 15.4 vs. 39.1 ± 18.4 events/h; P < 0.001), the respiratory arousal index (9.8 (5.8-11.95) vs. 14.1 (11.3-18.7) events/h; P < 0.001), and the minimum oxygen saturation (80.2 ± 9.1 vs. 77.1 ± 9.6%; P = 0.016). Responders to therapy (AHI reduced by > 50%; n = 7/22) had predominant OSA during rapid-eye-movement sleep and decreased sympathetic tone, as reflected in significantly lower mean blood pressure, diastolic blood pressure, and normalized low-frequency power. CONCLUSIONS Obstructive sleep apnea with comorbid ischemic stroke may be a distinctive phenotype which responds quite well to trazodone, decreasing OSA severity without increasing nocturnal hypoxia. TRIAL REGISTRATION Clinicaltrials.gov: NCT04162743, 2019/11/10.
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Affiliation(s)
- Chung-Yao Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Keelung, Taiwan. .,School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
| | - Chia-Ling Chen
- Department of Physical Medicine and Rehabilitation, Chang Gung Memorial Hospital, Linkou, Taiwan.,Graduate Institute of Early Intervention, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chieh Yu
- School of Medicine, College of Medicine, Chang Gung University, Taoyuan, Taiwan.,Division of Pulmonary Critical Care and Sleep Medicine, Department of Internal Medicine, Chang Gung Memorial Hospital, Keelung, Taiwan
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