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Pıhtılı A, Gündüz Gürkan C, Ali Habeşoğlu M, Öztürk Ö, Özsancak Uğurlu A, Sezai Taşbakan M, Peker Y. A Narrative Review of the Clinical Trials in Sleep-Related Breathing Disorders from 2022 to Present. THORACIC RESEARCH AND PRACTICE 2023; 25. [PMID: 38015164 PMCID: PMC11160422 DOI: 10.5152/thoracrespract.2023.23104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Accepted: 09/25/2023] [Indexed: 11/29/2023]
Abstract
Sleep-related breathing disorders (SRBD) comprise obstructive sleep apnea (OSA), central sleep apnea (CSA), obesity-hypoventilation syndrome (OHS), as well as isolated sleep-related hypoxemia (ISRH), according to the recent International Classification of Sleep Disorders 3. During the last decades, there have been cumulative research reports indicating an association between the SRBD and increased cardiometabolic illness and death, as well as decreased quality of life. Notwithstanding, the results have been inconclusive, and the evidence level was not high regarding the effect of treatment for the SRBD on adverse outcomes. In the current work, we aim to give a comprehensive review of the clinical trials published from January 2022 to August 31, 2023. We highlight the heterogeneity of cardiometabolic disorders among adults with SRBD and particularly emphasize OSA management, drug therapy for OSA, positive airway pressure (PAP) therapy and cardiovascular outcomes, other effects of PAP in pregnancy and neurocognitive function, as well as the effects of surgical treatment and oral appliances. We also underline future directions in OSA management, telemonitoring, and druginduced sleep endoscopy in managing the SRBD, especially OSA. We ascertain that more studies are needed within the CSA, OHS, and ISRH research fields.
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Affiliation(s)
- Aylin Pıhtılı
- Department of Pulmonary Medicine, İstanbul University İstanbul Faculty of Medicine, İstanbul, Turkey
| | - Canan Gündüz Gürkan
- Department of Pulmonary Medicine, Süreyyapaşa Chest Diseases Research and Training Hospital, İstanbul, Turkey
| | - Mehmet Ali Habeşoğlu
- Department of Pulmonary Medicine, Başkent University Faculty of Medicine, Ankara, Turkey
| | - Önder Öztürk
- Department of Pulmonary Medicine, Süleyman Demirel University Faculty of Medicine, Isparta, Turkey
| | - Aylin Özsancak Uğurlu
- Department of Pulmonary Medicine, Başkent University Faculty of Medicine, Ankara, Turkey
| | | | - Yüksel Peker
- Department of Pulmonary Medicine, Ege University Faculty of Medicine, İzmir, Turkey
- Department of Pulmonary Medicine, Koç University Faculty of Medicine, İstanbul, Turkey
- Division of Sleep and Circadian Disorders, Brigham and Women’s Hospital, Boston, MA, USA
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Li B, Zhang J, Dong H, Feng X, Yu L, Zhu J, Zhang J. Systematic analysis of various RNA transcripts and construction of biological regulatory networks at the post-transcriptional level for chronic obstructive pulmonary disease. J Transl Med 2023; 21:790. [PMID: 37936118 PMCID: PMC10631086 DOI: 10.1186/s12967-023-04674-7] [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: 05/26/2023] [Accepted: 10/29/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Although chronic inflammation, oxidative stress, airway remodeling, and protease-antiprotease imbalance have been implicated in chronic obstructive pulmonary disease (COPD), the exact pathogenesis is still obscure. Gene transcription and post-transcriptional regulation have been taken into account as key regulators of COPD occurrence and development. Identifying the hub genes and constructing biological regulatory networks at the post-transcriptional level will help extend current knowledge on COPD pathogenesis and develop potential drugs. METHODS All lung tissues from non-smokers (n = 6), smokers without COPD (smokers, n = 7), and smokers with COPD (COPD, n = 7) were collected to detect messenger RNA (mRNA), microRNA (miRNA), circular RNA (circRNA), and long non-coding RNA (lncRNA) expression and identify the hub genes. Biological regulatory networks were constructed at the post-transcriptional level, including the RNA-binding protein (RBP)-hub gene interaction network and the competitive endogenous RNA (ceRNA) network. In addition, we assessed the composition and abundance of immune cells in COPD lung tissue and predicted potential therapeutic drugs for COPD. Finally, the hub genes were confirmed at both the RNA and protein levels. RESULTS Among the 20 participants, a total of 121169 mRNA transcripts, 1871 miRNA transcripts, 4244 circRNA transcripts, and 122130 lncRNA transcripts were detected. There were differences in the expression of 1561 mRNAs, 48 miRNAs, 33 circRNAs, and 545 lncRNAs between smokers and non-smokers, as well as 1289 mRNAs, 69 miRNAs, 32 circRNAs, and 433 lncRNAs between smokers and COPD patients. 18 hub genes were identified in COPD. TGF-β signaling and Wnt/β-catenin signaling may be involved in the development of COPD. Furthermore, the circRNA/lncRNA-miRNA-mRNA ceRNA networks and the RBP-hub gene interaction network were also constructed. Analysis of the immune cell infiltration level revealed that M2 macrophages and activated NK cells were increased in COPD lung tissues. Finally, we identified that the ITK inhibitor and oxybutynin chloride may be effective in treating COPD. CONCLUSIONS We identified several novel hub genes involved in COPD pathogenesis. TGF-β signaling and Wnt/β-catenin signaling were the most dysregulated pathways in COPD patients. Our study constructed post-transcriptional biological regulatory networks and predicted small-molecule drugs for the treatment of COPD, which enhanced the existing understanding of COPD pathogenesis and suggested an innovative direction for the therapeutic intervention of the disease.
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Affiliation(s)
- Beibei Li
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Jiajun Zhang
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Hui Dong
- Center of Research Equipment Management, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Xueyan Feng
- School of Clinical Medicine, Ningxia Medical University, Yinchuan, 750004, China
| | - Liang Yu
- Department of Thoracic Surgery, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Jinyuan Zhu
- Department of Critical Care Medicine, General Hospital of Ningxia Medical University, Yinchuan, 750004, China
| | - Jin Zhang
- Department of Respiratory and Critical Care Medicine, General Hospital of Ningxia Medical University, 804 Shengli South Street, Xingqing District, Yinchuan, 750004, China.
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Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med 2023; 19:1183-1190. [PMID: 36805833 PMCID: PMC10315604 DOI: 10.5664/jcsm.10528] [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: 11/22/2022] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 02/23/2023]
Abstract
STUDY OBJECTIVES The potential sedative effect of dronabinol and the high expression of cannabinoid receptors on the hypoglossal motor nuclei makes this agent a good candidate for obstructive sleep apnea (OSA) pharmacotherapy to be tested with atomoxetine, a noradrenergic reuptake inhibitor that reduced OSA severity in combination with oxybutynin. Here we tested the effect of atomoxetine 80 mg plus dronabinol (Ato-Dro) at 2 different doses (5 and 10 mg) vs. baseline and atomoxetine alone in a 2-center, open-label, dose-escalating trial. The primary outcome was the effect of Ato-Dro vs. baseline on OSA severity (apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation). Safety of the combination and self-reported outcomes were also assessed. METHODS Fifteen patients with OSA received progressively increasing Ato-Dro doses (dose escalation was performed every week, starting from Ato-Dro 40-2.5 mg, then 80-5 mg and finally 80-10 mg). A clinical, in-lab polysomnography was performed at baseline, on Ato-Dro 80-5 and Ato-Dro 80-10 mg. RESULTS Ato-Dro 80-10 mg did not significantly reduce apnea-hypopnea index, hypopneas associated with 4% oxygen desaturation, and hypoxic burden and yielded limited clinical benefit vs. baseline and atomoxetine alone. However, Ato-Dro 80-5 mg did improve OSA severity (Δapnea-hypopnea index = 8.3[0.3, 16.3] events/h; mean [confidence interval]; Δhypoxic burden = 37.7[12.5, 62.7] %min/h) and multiple self-reported outcomes vs. baseline and/or atomoxetine alone. Ato-Dro administration was characterized by several potentially harmful side effects and treatment discontinuation in 1/3 of cases. CONCLUSIONS Ato-Dro 80-5 mg might be useful to reduce OSA severity and lead to self-reported improvement in those who could tolerate the combination. However, given the numerous side effects and the exploratory nature of this open-label study, our results warrant further validation in larger trials. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Study for Efficacy and Dose Escalation of AD313 + Atomoxetine (SEED) (SEED); URL: https://clinicaltrials.gov/ct2/show/NCT05101122; Identifier: NCT05101122. CITATION Messineo L, Norman D, Ojile J. The combination of atomoxetine and dronabinol for the treatment of obstructive sleep apnea: a dose-escalating, open-label trial. J Clin Sleep Med. 2023;19(7):1183-1190.
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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
| | - Daniel Norman
- Santa Monica Clinical Trials, Los Angeles, California
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Altree TJ, Aishah A, Loffler KA, Grunstein RR, Eckert DJ. The norepinephrine reuptake inhibitor reboxetine alone reduces obstructive sleep apnea severity: a double-blind, placebo-controlled, randomized crossover trial. J Clin Sleep Med 2023; 19:85-96. [PMID: 36004739 PMCID: PMC9806793 DOI: 10.5664/jcsm.10256] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/16/2022] [Accepted: 08/17/2022] [Indexed: 01/07/2023]
Abstract
STUDY OBJECTIVES Recent findings indicate that noradrenergic and muscarinic processes are crucial for pharyngeal muscle control during sleep. However, to date, reductions in obstructive sleep apnea (OSA) severity have only been detected when noradrenergic agents are combined with an antimuscarinic. Accordingly, this study aimed to determine if reboxetine alone and combined with oxybutynin reduces OSA severity. The pathophysiological mechanisms underpinning the effects of these agents were also investigated via endotyping analysis. METHODS Sixteen people (6 women) with OSA completed 3 polysomnograms (∼1-week washout) according to a double-blind, placebo-controlled, three-way crossover design across 2 sites. Single doses of 4 mg reboxetine, placebo, or 4 mg reboxetine + 5 mg oxybutynin were administered before sleep (order randomized). RESULTS Reboxetine reduced the apnea-hypopnea index (primary outcome) by 5.4 (95% confidence interval -10.4 to -0.3) events/h, P = .03 (-24 ± 27% in men; -0.7 ± 32% in women). Oxybutynin did not cause additional reductions in apnea-hypopnea index. Reboxetine alone reduced the 4% oxygen desaturation index by (mean ± standard deviation) 5.2 ± 7.2 events/h and reboxetine+oxybutynin by 5.1 ± 10.6 events/h vs placebo, P = .02. Nadir oxygen saturation also increased by 7 ± 11% with reboxetine and 5 ± 9% with reboxetine+oxybutynin vs placebo, P = .01. Mechanistically, reboxetine and reboxetine+oxybutynin improved pharyngeal collapsibility and respiratory control (loop gain). Larger reductions in apnea-hypopnea index with reboxetine in men were associated with higher baseline loop gain. CONCLUSIONS These findings show the first evidence that reboxetine alone reduces OSA severity. The data provide novel insight into the role of norepinephrine reuptake inhibitors on upper airway stability during sleep and are important to inform future pharmacotherapy development for OSA. CLINICAL TRIAL REGISTRATION Registry: Australian New Zealand Clinical Trials Registry; Name: Reboxetine and Combination Therapy with AD128 in Sleep Apnoea Trial: A Double-Blind, 3-Way Cross-Over Study; URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374614&isReview=true; Identifier: ACTRN12620000662965. CITATION Altree TJ, Aishah A, Loffler KA, Grunstein RR, Eckert DJ. The norepinephrine reuptake inhibitor reboxetine alone reduces obstructive sleep apnea severity: a double-blind, placebo-controlled, randomized crossover trial. J Clin Sleep Med. 2023;19(1):85-96.
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Affiliation(s)
- Thomas J. Altree
- Flinders Health and Medical Research Institute/Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
| | - Atqiya Aishah
- Flinders Health and Medical Research Institute/Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
- Neuroscience Research Australia (NeuRA), University of New South Wales (UNSW), Randwick, Sydney, New South Wales, Australia
| | - Kelly A. Loffler
- Flinders Health and Medical Research Institute/Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
| | - Ronald R. Grunstein
- Centre for Sleep and Chronobiology, The Woolcock Institute of Medical Research, The University of Sydney and Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Danny J. Eckert
- Flinders Health and Medical Research Institute/Adelaide Institute for Sleep Health, Flinders University, Bedford Park, South Australia, Australia
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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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