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Gabryelska A, Turkiewicz S, Ditmer M, Gajewski A, Strzelecki D, Białasiewicz P, Chałubiński M, Sochal M. The Complex Relationship between Neuromodulators, Circadian Rhythms, and Insomnia in Patients with Obstructive Sleep Apnea. Int J Mol Sci 2024; 25:8469. [PMID: 39126038 PMCID: PMC11313237 DOI: 10.3390/ijms25158469] [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: 06/28/2024] [Revised: 07/28/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Obstructive sleep apnea (OSA) has been linked to disruptions in circadian rhythm and neurotrophin (NFT) signaling. This study explored the link between neuromodulators, chronotype, and insomnia in OSA. The participants (n = 166) underwent polysomnography (PSG) before being categorized into either the control or the OSA group. The following questionnaires were completed: Insomnia Severity Index (ISI), Epworth Sleepiness Scale, Chronotype Questionnaire (morningness-eveningness (ME), and subjective amplitude (AM). Blood samples were collected post-PSG for protein level assessment using ELISA kits for brain-derived neurotrophic factor (BDNF), proBDNF, glial-cell-line-derived neurotrophic factor, NFT3, and NFT4. Gene expression was analyzed utilizing qRT-PCR. No significant differences were found in neuromodulator levels between OSA patients and controls. The controls with insomnia exhibited elevated neuromodulator gene expression (p < 0.05). In the non-insomnia individuals, BDNF and NTF3 expression was increased in the OSA group compared to controls (p = 0.007 for both); there were no significant differences between the insomnia groups. The ISI scores positively correlated with all gene expressions in both groups, except for NTF4 in OSA (R = 0.127, p = 0.172). AM and ME were predicting factors for the ISI score and clinically significant insomnia (p < 0.05 for both groups). Compromised compensatory mechanisms in OSA may exacerbate insomnia. The correlation between chronotype and NFT expression highlights the role of circadian misalignments in sleep disruptions.
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Affiliation(s)
- Agata Gabryelska
- Department of Sleep Medicine and Metabolic Disorder, Medical University of Lodz, 6/8 Mazowiecka, 92-215 Lodz, Poland; (S.T.); (M.D.); (P.B.); (M.S.)
| | - Szymon Turkiewicz
- Department of Sleep Medicine and Metabolic Disorder, Medical University of Lodz, 6/8 Mazowiecka, 92-215 Lodz, Poland; (S.T.); (M.D.); (P.B.); (M.S.)
| | - Marta Ditmer
- Department of Sleep Medicine and Metabolic Disorder, Medical University of Lodz, 6/8 Mazowiecka, 92-215 Lodz, Poland; (S.T.); (M.D.); (P.B.); (M.S.)
| | - Adrian Gajewski
- Department of Immunology and Allergy, Medical University of Lodz, 251 Pomorska, 92-213 Lodz, Poland; (A.G.); (M.C.)
| | - Dominik Strzelecki
- Department of Affective and Psychotic Disorders, Medical University of Lodz, 251 Pomorska, 92-213 Lodz, Poland;
| | - Piotr Białasiewicz
- Department of Sleep Medicine and Metabolic Disorder, Medical University of Lodz, 6/8 Mazowiecka, 92-215 Lodz, Poland; (S.T.); (M.D.); (P.B.); (M.S.)
| | - Maciej Chałubiński
- Department of Immunology and Allergy, Medical University of Lodz, 251 Pomorska, 92-213 Lodz, Poland; (A.G.); (M.C.)
| | - Marcin Sochal
- Department of Sleep Medicine and Metabolic Disorder, Medical University of Lodz, 6/8 Mazowiecka, 92-215 Lodz, Poland; (S.T.); (M.D.); (P.B.); (M.S.)
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Wang J, Ye Y, Shang Z, Zheng Q, Zhang S, Li L, Liu W. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med 2024; 20:1363-1372. [PMID: 38494994 PMCID: PMC11294128 DOI: 10.5664/jcsm.11130] [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: 10/26/2023] [Revised: 03/13/2024] [Accepted: 03/13/2024] [Indexed: 03/19/2024]
Abstract
STUDY OBJECTIVES Randomized controlled trials have shown that combining norepinephrine reuptake inhibitors and antimuscarinics can ameliorate the severity of obstructive sleep apnea. This article explores whether the effectiveness and safety of combining norepinephrine reuptake inhibitors with antimuscarinic agents surpass monotherapy for treating obstructive sleep apnea. METHODS We searched randomized controlled trials including adult patients with obstructive sleep apnea who received combination therapy and monotherapy in 8 databases from inception until April 5, 2023 and evaluated the studies' quality and conducted a meta-analysis and systematic review. The primary outcome was the apnea-hypopnea index. Secondary outcome measures included loop gain, hypoxic burden, oxygen desaturation index, and ventilation at low ventilatory drive, among other indicators. We assessed the quality of the studies using Cochrane Methods criteria. RESULTS We identified 4 randomized controlled trials for systematic review and 2 for meta-analysis. The results of the meta-analysis showed that norepinephrine reuptake inhibitors combined with antimuscarinic agents in patients with obstructive sleep apnea prolonged total sleep time by a mean of 28.20 minutes [95% confidence interval (5.78, 50.61), P = .01] and increased sleep efficiency by 4.73% [95% confidence interval (0.50, 8.97), P = .03] compared with norepinephrine reuptake inhibitors alone. Other indices and adverse events were of no statistical significance. The systematic reviews revealed that norepinephrine reuptake inhibitors combined with antimuscarinics may be superior to monotherapy in improving apnea-hypopnea index and endotypic traits. CONCLUSIONS This evaluation demonstrated the potential advantages of combining norepinephrine reuptake inhibitors plus antimuscarinics for treating OSA compared with norepinephrine reuptake inhibitors alone and revealed no statistically significant difference in drug safety. CITATION Wang J, Ye Y, Shang Z, et al. Effect of norepinephrine reuptake inhibitors combined with antimuscarinic agents vs monotherapy for OSA: a systematic review and meta-analysis. J Clin Sleep Med. 2024;20(8):1363-1372.
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Affiliation(s)
- Juan Wang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Yucai Ye
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Zhizhong Shang
- Department of Orthopedics, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Qingyong Zheng
- Evidence-Based Medicine Center, School of Basic Medical Sciences, Lanzhou University, Lanzhou, Gansu, China
| | - Sha Zhang
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Leping Li
- Department of Respiratory Medicine, Lanzhou University First Clinical Medical College, Lanzhou, China
| | - Weiying Liu
- Department of Respiratory and Critical Care Medicine, The First Hospital of Lanzhou University, Lanzhou, Gansu, China
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Fauska C, Bastiampillai T, Adams RJ, Wittert G, Eckert DJ, Loffler KA. Effects of the antipsychotic quetiapine on sleep and breathing: a review of clinical findings and potential mechanisms. J Sleep Res 2024; 33:e14051. [PMID: 37833613 DOI: 10.1111/jsr.14051] [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: 06/16/2023] [Revised: 09/04/2023] [Accepted: 09/11/2023] [Indexed: 10/15/2023]
Abstract
Quetiapine is an antipsychotic medication indicated for schizophrenia and bipolar disorder. However, quetiapine also has hypnotic properties and as such is increasingly being prescribed at low doses 'off-label' in people with insomnia symptoms. Pharmacologically, in addition to its dopaminergic properties, quetiapine also modulates multiple other transmitter systems involved in sleep/wake modulation and potentially breathing. However, very little is known about the impact of quetiapine on obstructive sleep apnoea (OSA), OSA endotypes including chemosensitivity, and control of breathing. Given that many people with insomnia also have undiagnosed OSA, it is important to understand the effects of quetiapine on OSA and its mechanisms. Accordingly, this concise review covers the existing knowledge on the effects of quetiapine on sleep and breathing. Further, we highlight the pharmacodynamics of quetiapine and its potential to alter key OSA endotypes to provide potential mechanistic insight. Finally, an agenda for future research priorities is proposed to fill the current key knowledge gaps.
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Affiliation(s)
- Cricket Fauska
- Adelaide Institute for Sleep Health/Flinders Health and Medical Research Institute Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Tarun Bastiampillai
- Discipline of Psychiatry, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Southern Adelaide Local Health Network, Flinders Medical Centre, Adelaide, South Australia, Australia
- Department of Psychiatry, Monash University, Clayton, Victoria, Australia
| | - Robert J Adams
- Adelaide Institute for Sleep Health/Flinders Health and Medical Research Institute Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
- Respiratory, Sleep and Ventilation Service, Southern Adelaide Local Health Network, Adelaide, South Australia, Australia
| | - Gary Wittert
- University of Adelaide, Adelaide, South Australia, Australia
- Freemasons Centre for Male Health and Wellbeing, South Australian Health and Medical Research Institute, University of Adelaide, Adelaide, South Australia, Australia
| | - Danny J Eckert
- Adelaide Institute for Sleep Health/Flinders Health and Medical Research Institute Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
| | - Kelly A Loffler
- Adelaide Institute for Sleep Health/Flinders Health and Medical Research Institute Sleep Health, College of Medicine and Public Health, Flinders University, Adelaide, South Australia, Australia
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Bokov P, Koehl B, Dudoignon B, Benkerrou M, Delclaux C. Case-control study of heart rate variability and sleep apnea in childhood sickle cell disease. J Sleep Res 2024:e14209. [PMID: 38590226 DOI: 10.1111/jsr.14209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 03/07/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
Obstructive sleep apnea (OSA) is common in sickle cell disease (SCD) despite the absence of overweight, suggesting a specific pathophysiology. We previously showed that otherwise healthy children with increased pharyngeal compliance, a main endotype of OSA, exhibited decreased sympathetic modulation. Our objective was to assess whether modifications of heart rate variability (HRV) and compliance are associated in SCD. Cases (children with SCD, African or Caribbean ethnicity) and controls (otherwise healthy children, same ethnicity), aged 4-18 years, were selected from our database of children referred for OSA and matched for sex, age, and obstructive apnea-hypopnoea index (OAHI) score. The children underwent polysomnography and acoustic pharyngometry (to compute compliance). HRV analyses were performed from 5 min ECG recordings in wakeful, NREM, and REM sleep states and from the whole night. Twenty-one pairs were analysed (median age 10.5 years, 24 girls). Children with SCD had lower BMI z-scores and more tonsil hypertrophy than control children. Children with SCD and OSA (OAHI ≥2/hour) were characterised by lower compliance than children with SCD without OSA. An inverse relationship between compliance and SD2 (HRV from whole night, inversely related to sympathetic modulation) was evidenced (negative relationship in SCD: R = -0.63, p = 0.002 vs. positive relationship in controls R = 0.59, p = 0.006). In conclusion, while the decrease in sympathetic modulation in control children may contribute to increasing pharyngeal compliance, its decrease seems protective in children with sickle cell disease, which underlines the specificity of OSAS pathophysiology in SCD that could be due to sickle cell disease related smooth muscle dystonia.
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Affiliation(s)
- Plamen Bokov
- AP-HP, Robert Debré Hospital, Department of Physiology, INSERM NeuroDiderot, Paris University, Paris, France
| | - Bérengère Koehl
- AP-HP, Robert Debré Hospital, Sickle Cell Disease Center, Hematology Unit, Paris University, Paris, France
- UMR_S1134, BIGR, INSERM, Institut National de la Transfusion Sanguine, Laboratoire d'Excellence GR-Ex, Paris, France
| | - Benjamin Dudoignon
- AP-HP, Robert Debré Hospital, Department of Physiology, INSERM NeuroDiderot, Paris University, Paris, France
| | - Malika Benkerrou
- Sickle Cell Disease Center, Hematology Unit, Robert Debré Hospital, Paris, France
- INSERM UMR 1123, ECEVE, Paris, France
| | - Christophe Delclaux
- AP-HP, Robert Debré Hospital, Department of Physiology, INSERM NeuroDiderot, Paris University, Paris, France
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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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Schweitzer PK, Taranto-Montemurro L, Ojile JM, Thein SG, Drake CL, Rosenberg R, Corser B, Abaluck B, Sangal RB, Maynard J. The Combination of Aroxybutynin and Atomoxetine in the Treatment of Obstructive Sleep Apnea (MARIPOSA): A Randomized Controlled Trial. Am J Respir Crit Care Med 2023; 208:1316-1327. [PMID: 37812772 PMCID: PMC10765395 DOI: 10.1164/rccm.202306-1036oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 10/09/2023] [Indexed: 10/11/2023] Open
Abstract
Rationale: Obstructive sleep apnea (OSA) is a common sleep disorder for which the principal treatment option, continuous positive airway pressure, is often poorly tolerated. There is currently no approved pharmacotherapy for OSA. However, recent studies have demonstrated improvement in OSA with combined antimuscarinic and noradrenergic drugs. Objectives: The aim of this study was to evaluate the efficacy and safety of AD109, a combination of the novel antimuscarinic agent aroxybutynin and the norepinephrine reuptake inhibitor atomoxetine, in the treatment of OSA. Methods: Phase II randomized, double-blind, placebo-controlled, parallel-group, 4-week trial comparing AD109 2.5/75 mg, AD109 5/75 mg, atomoxetine 75 mg alone, and placebo (www.clinicaltrials.gov identifier NCT05071612). Measurements and Main Results: Of 211 randomized patients, 181 were included in the prespecified efficacy analyses. Sleep was assessed by two baseline and two treatment polysomnograms. Apnea-hypopnea index with a 4% desaturation criterion (primary outcome) was reduced from a median (IQR) of 20.5 (12.3-27.2) to 10.8 (5.6-18.5) in the AD109 2.5/75 mg arm (-47.1%), from 19.4 (13.7-26.4) to 9.5 (6.1-19.3) in the AD109 5/75 mg arm (-42.9%; both P < 0.0001 vs. placebo), and from 19.0 (11.8-28.8) to 11.8 (5.5-21.5) with atomoxetine alone (-38.8%; P < 0.01 vs. placebo). Apnea-hypopnea index with a 4% desaturation criterion decreased from 20.1 (11.9-25.9) to 16.3 (11.1-28.9) in the placebo arm. Subjectively, there was improvement in fatigue with AD109 2.5/75 mg (P < 0.05 vs. placebo and atomoxetine). Atomoxetine taken alone decreased total sleep time (P < 0.05 vs. AD109 and placebo). The most common adverse events were dry mouth, insomnia, and urinary hesitancy. Conclusions: AD109 showed clinically meaningful improvement in OSA, suggesting that further development of the compound is warranted. Clinical trial registered with www.clinicaltrials.gov (NCT05071612).
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Affiliation(s)
- Paula K. Schweitzer
- Sleep Medicine and Research Center, St. Luke’s Hospital, Chesterfield, Missouri
| | | | | | - Stephen G. Thein
- Pacific Research Network, an Evolution Research Group Portfolio Site, San Diego, California
| | - Christopher L. Drake
- Thomas Roth Sleep Disorders and Research Center, Henry Ford Health System, Detroit, Michigan
| | | | | | - Brian Abaluck
- Sleep Medicine, Brian Abaluck, M.D., Malvern, Pennsylvania
| | - R. Bart Sangal
- Sleep & Attention Disorders Institute, Sterling Heights, Michigan
- Oakland University William Beaumont School of Medicine, Rochester, Michigan; and
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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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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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Šmon J, Kočar E, Pintar T, Dolenc-Grošelj L, Rozman D. Is obstructive sleep apnea a circadian rhythm disorder? J Sleep Res 2023:e13875. [PMID: 36922163 DOI: 10.1111/jsr.13875] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/06/2023] [Accepted: 02/28/2023] [Indexed: 03/17/2023]
Abstract
Obstructive sleep apnea is the most common sleep-related breathing disorder worldwide and remains underdiagnosed. Its multiple associated comorbidities contribute to a decreased quality of life and work performance as well as an increased risk of death. Standard treatment seems to have limited effects on cardiovascular and metabolic aspects of the disease, emphasising the need for early diagnosis and additional therapeutic approaches. Recent evidence suggests that the dysregulation of circadian rhythms, processes with endogenous rhythmicity that are adjusted to the environment through various cues, is involved in the pathogenesis of comorbidities. In patients with obstructive sleep apnea, altered circadian gene expression patterns have been demonstrated. Obstructive respiratory events may promote circadian dysregulation through the effects of sleep disturbance and intermittent hypoxia, with subsequent inflammation and disruption of neural and hormonal homeostasis. In this review, current knowledge on obstructive sleep apnea, circadian rhythm regulation, and circadian rhythm sleep disorders is summarised. Studies that connect obstructive sleep apnea to circadian rhythm abnormalities are critically evaluated. Furthermore, pathogenetic mechanisms that may underlie this association, most notably hypoxia signalling, are presented. A bidirectional relationship between obstructive sleep apnea and circadian rhythm dysregulation is proposed. Approaching obstructive sleep apnea as a circadian rhythm disorder may prove beneficial for the development of new, personalised diagnostic, therapeutic and prognostic tools. However, further studies are needed before the clinical approach to obstructive sleep apnea includes targeting the circadian system.
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Affiliation(s)
- Julija Šmon
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Centre for Functional Genomics and Bio-Chips, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Eva Kočar
- Centre for Functional Genomics and Bio-Chips, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Tadeja Pintar
- Department of Abdominal Surgery, University Medical Centre Ljubljana, Ljubljana, Slovenia
| | - Leja Dolenc-Grošelj
- Institute of Clinical Neurophysiology, University Medical Centre Ljubljana, Ljubljana, Slovenia.,Department of Neurology, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Damjana Rozman
- Centre for Functional Genomics and Bio-Chips, Institute of Biochemistry and Molecular Genetics, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
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