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Neshat SS, Heidari A, Henriquez-Beltran M, Patel K, Colaco B, Arunthari V, Lee Mateus AY, Cheung J, Labarca G. Evaluating pharmacological treatments for excessive daytime sleepiness in obstructive sleep apnea: A comprehensive network meta-analysis and systematic review. Sleep Med Rev 2024; 76:101934. [PMID: 38754208 DOI: 10.1016/j.smrv.2024.101934] [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: 10/07/2023] [Revised: 03/10/2024] [Accepted: 04/02/2024] [Indexed: 05/18/2024]
Abstract
Obstructive sleep apnea (OSA) is associated with excessive daytime sleepiness (EDS). Pharmacotherapy offers a potential treatment approach for EDS in OSA patients. This systematic review and meta-analysis aimed to assess the efficacy and safety of pharmacological interventions for alleviating EDS in patients with OSA. Following PRISMA guidelines, we included randomized controlled trials investigating pharmacological treatments for EDS in adult OSA until August 2023. We conducted meta-analysis, subgroup, and meta-regression analyses using a random effects model. Finally, a network meta-analysis synthesized direct and indirect evidence, followed by a comprehensive safety analysis. We included 32 articles in the meta-analysis (n = 3357). Pharmacotherapy showed a significant improvement in the Epworth Sleepiness Scale (ESS) score (Mean Difference (MD) -2.73, (95 % Confidence Interval (CI) [-3.25, -2.20], p < 0.01) and Maintenance of Wakefulness Test (MWT) score (MD 6.00 (95 % CI [2.66, 9.33] p < 0.01). Solriamfetol, followed by Pitolisant and modafinil, exhibited the greatest ESS reduction, while Danavorexton, followed by Solriamfetol and MK-7288, had the strongest impact on MWT. MK-7288 had the most total adverse events (AEs), followed by Danavorexton and armodafinil. Pharmacological Interventions significantly alleviate EDS in OSA patients but with heterogeneity across medications. Treatment decisions should involve a personalized assessment of patient factors and desired outcomes.
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Affiliation(s)
- Seyed Sina Neshat
- Department of Epidemiology and Statistics, University of California, San Francisco, CA, USA; Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Afshin Heidari
- School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran
| | - Mario Henriquez-Beltran
- Núcleo de Investigación en Ciencias de la Salud, Universidad Adventista de Chile, Chillán, Chile
| | - Kripa Patel
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Brendon Colaco
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Vichaya Arunthari
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Jacksonville, Florida, USA
| | | | - Joseph Cheung
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic Jacksonville, Florida, USA
| | - Gonzalo Labarca
- Division of Pulmonary and Critical Care Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA; Department of Respiratory Diseases, School of Medicine, Pontificia Universidad Católica de Chile, Santiago, Chile.
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Badran M, Puech C, Barrow MB, Runion AR, Gozal D. Recovery Mimicking "Ideal" CPAP Adherence Does Not Improve Wakefulness or Cognition in Chronic Murine Models of OSA: Effect of Wake-Promoting Agents. Arch Bronconeumol 2023; 59:805-812. [PMID: 37783638 DOI: 10.1016/j.arbres.2023.09.007] [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: 07/25/2023] [Revised: 09/07/2023] [Accepted: 09/08/2023] [Indexed: 10/04/2023]
Abstract
INTRODUCTION Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH) and sleep fragmentation (SF). OSA can induce excessive daytime sleepiness (EDS) and is associated with impaired cognition and anxiety. Solriamfetol (SOL) and modafinil (MOD) are widely used wake-promoting agents in OSA patients with EDS. METHODS Male C57Bl/6J mice were exposed to SF along with sleep controls (SC) or to IH and room air (RA) controls during the light (inactive) phase for 4 and 16 weeks, respectively. Both IH and SF exposures were then discontinued to mimic "ideal" continuous positive airway pressure (CPAP) adherence. All groups were then randomly assigned to receive once daily intraperitoneal injections of SOL, MOD, or vehicle (VEH) for 6 days. Sleep/wake activity was assessed along with tests of explicit memory, anxiety and depression were performed before and after treatments. RESULTS IH and SF exposures increased sleep percentage in the dark phase and reduced wake bouts lengths (i.e., EDS), and induced cognitive deficits and impulsivity in mice. Both SOL and MOD treatments effectively mitigated EDS when combined with recovery, while recovery alone did not improve EDS over the 6-day period. Furthermore, improvements explicit memory emerged only after SOL. CONCLUSION Chronic IH and SF induce EDS in young adult mice that is not ameliorated by recovery except when combined with either SOL or MOD. SOL, but not MOD, significantly improves IH-induced cognitive deficits. Thus, SOL emerges as a viable adjuvant medication for residual EDS in OSA along with its positive impact on cognition.
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Affiliation(s)
- Mohammad Badran
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Clementine Puech
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Max B Barrow
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - Alexandra R Runion
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - David Gozal
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA; Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO, USA; Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, USA.
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Hoy SM. Solriamfetol: A Review in Excessive Daytime Sleepiness Associated with Narcolepsy and Obstructive Sleep Apnoea. CNS Drugs 2023; 37:1009-1020. [PMID: 37847434 DOI: 10.1007/s40263-023-01040-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/17/2023] [Indexed: 10/18/2023]
Abstract
Solriamfetol (SUNOSI®) is an oral selective dopamine and norepinephrine reuptake inhibitor approved in the EU and the USA for improving wakefulness in adults with excessive daytime sleepiness (EDS) associated with narcolepsy or obstructive sleep apnoea (OSA). In phase III studies, 12 weeks' therapy with solriamfetol within the recommended dosage range for narcolepsy (75 mg or 150 mg once daily) or OSA (37.5 mg, 75 mg or 150 mg once daily) provided early and sustained reductions in excessive sleepiness and improvements in wakefulness relative to placebo. These effects were generally sustained through 52 weeks. The drug's effectiveness in adults with EDS associated with narcolepsy is supported by results from real-world studies. Solriamfetol demonstrated a consistent safety and tolerability profile across clinical studies, with commonly reported adverse reactions generally occurring within 2 weeks of treatment initiation and mostly resolving within 2 weeks. Thus, solriamfetol represents a useful treatment option for adults with EDS associated with narcolepsy or OSA.
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Affiliation(s)
- Sheridan M Hoy
- Springer Nature, Private Bag 65901, Mairangi Bay, Auckland, 0754, New Zealand.
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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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Badran M, Puech C, Barrow MB, Runion AR, Gozal D. Solriamfetol enhances wakefulness and improves cognition and anxiety in a murine model of OSA. Sleep Med 2023; 107:89-99. [PMID: 37137196 DOI: 10.1016/j.sleep.2023.04.007] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/31/2023] [Accepted: 04/09/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) is a chronic condition characterized by intermittent hypoxia (IH). Excessive daytime sleepiness (EDS) is a common consequence of OSA and is associated with cognitive deficits and anxiety. Modafinil (MOD) and Solriamfetol (SOL) are potent wake-promoting agents clinically used to improve wakefulness in OSA patients with EDS. METHODS Male C57Bl/6J mice were exposed to either IH or room air (RA) controls during the light phase for 16 weeks. Both groups were then randomly assigned to receive once-daily intraperitoneal injections of SOL (200 mg/kg), MOD (200 mg/kg) or vehicle (VEH) for 9 days while continuing IH exposures. Sleep/wake activity was assessed during the dark (active) phase. Novel object recognition (NOR), elevated-plus maze test (EPMT), and forced swim test (FST) were performed before and after drug treatment. RESULTS IH exposure increased dark phase sleep percentage and reduced wake bouts lengths and induced cognitive deficits and anxiogenic effects. Both SOL and MOD treatments decreased sleep propensity under IH conditions, but only SOL promoted improvements in NOR performance (explicit memory) and reduced anxiety-like behaviors. CONCLUSION Chronic IH, a hallmark feature of OSA, induces EDS in young adult mice that is ameliorated by both SOL and MOD. SOL, but not MOD, significantly improves IH-induced cognitive deficits and promotes anxiolytic effects. Thus, SOL could potentially benefit OSA patients beyond EDS management.
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Affiliation(s)
- Mohammad Badran
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Clementine Puech
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA
| | - Max B Barrow
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - Alexandra R Runion
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - David Gozal
- Child Health Research Institute, Department of Child Health, School of Medicine, University of Missouri, Columbia, MO, USA; Department of Medical Pharmacology and Physiology, School of Medicine, University of Missouri, Columbia, MO, USA.
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Puech C, Badran M, Barrow MB, Runion AR, Gozal D. Solriamfetol improves chronic sleep fragmentation-induced increases in sleep propensity and ameliorates explicit memory in male mice. Sleep 2023; 46:zsad057. [PMID: 36866452 PMCID: PMC10413435 DOI: 10.1093/sleep/zsad057] [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: 10/24/2022] [Revised: 02/15/2023] [Indexed: 03/04/2023] Open
Abstract
Obstructive sleep apnea (OSA) is a highly prevalent condition characterized by episodes of partial or complete breath cessation during sleep that induces sleep fragmentation (SF). One of the frequent manifestations of OSA is the presence of excessive daytime sleepiness (EDS) associated with cognitive deficits. Solriamfetol (SOL) and modafinil (MOD) are wake-promoting agents commonly prescribed to improve wakefulness in OSA patients with EDS. This study aimed to assess the effects of SOL and MOD in a murine model of OSA characterized by periodic SF. Male C57Bl/6J mice were exposed to either control sleep (SC) or SF (mimicking OSA) during the light period (06:00 h to 18:00 h) for 4 weeks, which consistently induces sustained excessive sleepiness during the dark phase. Both groups were then randomly assigned to receive once-daily intraperitoneal injections of SOL (200 mg/kg), MOD (200 mg/kg), or vehicle for 1 week while continuing exposures to SF or SC. Sleep/wake activity and sleep propensity were assessed during the dark phase. Novel Object Recognition test, Elevated-Plus Maze Test, and Forced Swim Test were performed before and after treatment. SOL or MOD decreased sleep propensity in SF, but only SOL induced improvements in explicit memory, while MOD exhibited increased anxiety behaviors. Chronic SF, a major hallmark of OSA, induces EDS in young adult mice that is mitigated by both SOL and MOD. SOL, but not MOD, significantly improves SF-induced cognitive deficits. Increased anxiety behaviors are apparent in MOD-treated mice. Further studies aiming to elucidate the beneficial cognitive effects of SOL are warranted.
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Affiliation(s)
- Clementine Puech
- Child Health Research Institute, Department of Child Health, University of Missouri School of Medicine, Columbia, MO, USA
| | - Mohammad Badran
- Child Health Research Institute, Department of Child Health, University of Missouri School of Medicine, Columbia, MO, USA
| | - Max B Barrow
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - Alexandra R Runion
- Undergraduate Student Research Program, University of Missouri, Columbia, MO, USA
| | - David Gozal
- Child Health Research Institute, Department of Child Health, University of Missouri School of Medicine, Columbia, MO, USA
- Department of Medical Pharmacology and Physiology, University of Missouri School of Medicine, Columbia, MO, USA
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Gusman E, Standlee J, Reid KJ, Wolfe LF. Work-Related Sleep Disorders: Causes and Impacts. Semin Respir Crit Care Med 2023; 44:385-395. [PMID: 37072022 DOI: 10.1055/s-0043-1767787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2023]
Abstract
Insufficient sleep syndrome, shift work disorder, and obstructive sleep apnea (OSA) not only significantly impact the health of affected individuals, but also pose a threat to public safety. This article describes the clinical manifestations and impact of these sleep disorders, particularly as they pertain to workers' health and those with safety-sensitive positions. Sleep deprivation, circadian rhythm disruptions, and excessive daytime sleepiness-hallmarks of insufficient sleep, shift work disorder, and OSA, respectively-all lead to a series of cognitive deficits and impaired concentration that affect workers in a wide variety of fields. We describe the health consequences of these disorders along with treatment strategies, with a focus on current regulatory standards and the under-recognition of OSA in commercial drivers. Given its large scale, there is a need for improved guidelines and regulations for the screening, diagnosis, treatment, and long-term follow-up of OSA in commercial motor vehicle drivers. Increased recognition of the ways in which these sleep disorders impact workers will pave the way for significant improvements in occupational health and safety.
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Affiliation(s)
- Elen Gusman
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
| | - Jordan Standlee
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Kathryn J Reid
- Department of Neurology, Division of Sleep Medicine, Northwestern Medicine, Chicago, Illinois
- Center for Circadian and Sleep Medicine, Northwestern Medicine, Chicago, Illinois
| | - Lisa F Wolfe
- Department of Pulmonary and Critical Care Medicine, Northwestern Medicine, Chicago, Illinois
- Department of Neurology, Division of Sleep Medicine, Northwestern Medicine, Chicago, Illinois
- Center for Circadian and Sleep Medicine, Northwestern Medicine, Chicago, Illinois
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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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Bonsignore MR, Lombardi C, Lombardo S, Fanfulla F. Epidemiology, Physiology and Clinical Approach to Sleepiness at the Wheel in OSA Patients: A Narrative Review. J Clin Med 2022; 11:jcm11133691. [PMID: 35806976 PMCID: PMC9267880 DOI: 10.3390/jcm11133691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/22/2022] [Accepted: 06/24/2022] [Indexed: 11/16/2022] Open
Abstract
Sleepiness at the wheel (SW) is recognized as an important factor contributing to road traffic accidents, since up to 30 percent of fatal accidents have been attributed to SW. Sleepiness-related motor vehicle accidents may occur both from falling asleep while driving and from behavior impairment attributable to sleepiness. SW can be caused by various sleep disorders but also by behavioral factors such as sleep deprivation, shift work and non-restorative sleep, as well as chronic disease or the treatment with drugs that negatively affect the level of vigilance. An association between obstructive sleep apnea (OSA) and motor vehicle accidents has been found, with an increasing risk in OSA patients up to sevenfold in comparison to the general population. Regular treatment with continuous positive airway pressure (CPAP) relieves excessive daytime sleepiness and reduces the crash risk. Open questions still remain about the physiological and clinical determinants of SW in OSA patients: the severity of OSA in terms of the frequency of respiratory events (apnea hypopnea index, AHI) or hypoxic load, the severity of daytime sleepiness, concomitant chronic sleep deprivation, comorbidities, the presence of depressive symptoms or chronic fatigue. Herein, we provide a review addressing the epidemiological, physiological and clinical aspects of SW, with a particular focus on the methods to recognize those patients at risk of SW.
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Affiliation(s)
- Maria R. Bonsignore
- PROMISE Department, University of Palermo, 90127 Palermo, Italy
- Sleep Clinic, Division of Respiratory Medicine, Ospedali Riuniti Villa Sofia-Cervello, 90146 Palermo, Italy;
- Institute for Biomedical Research and Innovation (IRIB), National Research Council (CNR), 90146 Palermo, Italy
- Correspondence:
| | - Carolina Lombardi
- Sleep Disorders Center, Department of Cardiology, San Luca Hospital, Istituto Auxologico Italiano, IRCCS, 20145 Milan, Italy;
- Department of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Simone Lombardo
- Sleep Clinic, Division of Respiratory Medicine, Ospedali Riuniti Villa Sofia-Cervello, 90146 Palermo, Italy;
| | - Francesco Fanfulla
- Respiratory Function and Sleep Unit, Maugeri Clinical and Scientific Institute of Pavia and Montescano, 27100 Pavia, Italy;
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Ishikawa O, Hahn S, Greenberg H. Pharmacologic Therapy for Narcolepsy. Neurology 2022. [DOI: 10.17925/usn.2022.18.1.68] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Narcolepsy is a lifelong disorder that adversely affects daytime function and quality of life. Major symptoms include excessive daytime sleepiness with irrepressible sleep attacks and cataplexy. Recent developments in the understanding of the pathobiology of narcolepsy, as well as the neuronal systems involved in the regulation of wakefulness have led to development of new pharmacologic approaches to therapy. In this paper, we review available pharmacologic treatments for narcolepsy as well as agents currently under investigation.
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Panahi L, Udeani G, Ho S, Knox B, Maille J. Review of the Management of Obstructive Sleep Apnea and Pharmacological Symptom Management. Medicina (B Aires) 2021; 57:medicina57111173. [PMID: 34833390 PMCID: PMC8620994 DOI: 10.3390/medicina57111173] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 10/19/2021] [Accepted: 10/26/2021] [Indexed: 11/16/2022] Open
Abstract
Nearly a billion adults around the world are affected by a disease that is characterized by upper airway collapse while sleeping called obstructive sleep apnea or OSA. The progression and lasting effects of untreated OSA include an increased risk of diabetes mellitus, hypertension, stroke, and heart failure. There is often a decrease in quality-of-life scores and an increased rate of mortality in these patients. The most common and effective treatments for OSA include continuous positive airway pressure (CPAP), surgical treatment, behavior modification, changes in lifestyle, and mandibular advancement devices. There are currently no pharmacological options approved for the standard treatment of OSA. There are, however, some pharmacological treatments for daytime sleepiness caused by OSA. Identifying and treating obstructive sleep apnea early is important to reduce the risks of future complications.
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Affiliation(s)
- Ladan Panahi
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (S.H.); (B.K.); (J.M.)
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 59 Reynolds Medical Building, College Station, TX 77843, USA
- Correspondence: (L.P.); (G.U.)
| | - George Udeani
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (S.H.); (B.K.); (J.M.)
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 59 Reynolds Medical Building, College Station, TX 77843, USA
- Correspondence: (L.P.); (G.U.)
| | - Steven Ho
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (S.H.); (B.K.); (J.M.)
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 59 Reynolds Medical Building, College Station, TX 77843, USA
| | - Brett Knox
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (S.H.); (B.K.); (J.M.)
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 59 Reynolds Medical Building, College Station, TX 77843, USA
| | - Jason Maille
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 1010 W Ave B, Kingsville, TX 78363, USA; (S.H.); (B.K.); (J.M.)
- Department of Pharmacy Practice, Texas A&M Rangel College of Pharmacy, 59 Reynolds Medical Building, College Station, TX 77843, USA
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