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1.
Sleep Breath ; 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31478126

RESUMO

PURPOSE: To examine the craniofacial and airway morphology as well as the quality of life before and after passive myofunctional therapy (PMFT) for 1 year in children with obstructive sleep apnea (OSA). METHODS: Forty children with OSA wearing an oral device nightly (treatment group) and seventeen without the device (control group) were followed up for 1 year. Lateral cephalometric radiography, polysomnography (without participants wearing the oral device), and quality of life survey (OSA-18) were performed before and after the study period. RESULTS: The apnea-hypopnea index (AHI) during sleep, REM AHI, hypopnea count, and desaturation count in the treatment group dropped significantly, compared with the control group. The craniofacial linear measurements increased significantly in both groups, while the length of mandible (Co-Gn) and anterior facial height (N-Me) became significantly larger in the treatment group. For the airway morphology, the intergroup comparison showed that OPha-Ophp (distance between anterior and posterior sides of oropharynx) increased significantly in the treatment group. For quality of life, the intergroup comparison found statistically significant improvements in the following in the treatment group, based on the OSA-18 survey: loud snoring, dysphagia, mood swings, discipline problems, difficulty awakening, total score for the emotional distress portion, and total survey score. CONCLUSIONS: Preliminary evidence is substantiated for the benefits of 1-year PMFT using an oral device with a built-in tongue bead, including improvements in nasal breathing during sleep, mandible linear growth (Co-Gn and N-Me), airway morphology (OPha-Ophp), and patients' quality of life.

2.
J Nurs Res ; 27(3): e23, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31107773

RESUMO

BACKGROUND: Although people who sleep poorly may attempt to relieve anxiety for better sleep quality, whether daily alcohol consumption is a factor that moderates anxiety and sleep disturbance is not known. PURPOSE: The aim of the study was to explore (a) the association between anxiety and sleep quality and (b) whether daily alcohol consumption acted as a moderator between anxiety and sleep quality in those who reported sleeping poorly. METHODS: Eighty-four participants aged 20-80 years who reported poor sleep (Pittsburgh Sleep Quality Index > 5) in northern Taiwan were enrolled in this cross-sectional study. A structured questionnaire covering demographics (including daily alcohol consumption), level of anxiety, level of depression, and perceived sleep quality was used to collect data. RESULTS: The participants were mostly women (72.6%). The mean age was 41.81 (SD = 12.62) years; 51.2%, 19.0%, 13.1%, and 14.3%, respectively, had minimal, mild, moderate, and severe anxiety. After adjusting for factors related to sleep quality using multiple regression analysis, receiving sleep therapy, consuming alcohol on a daily basis, and having anxiety were found to be predictors of poor sleep quality. Moreover, daily alcohol consumption was found to moderate the relationship between anxiety and sleep quality. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: People who sleep poorly should avoid misusing alcohol to self-treat poor sleep quality or anxiety and should instead utilize sleep hygiene education and mental healthcare. Daily alcohol consumption may be a moderator between anxiety status and sleep quality.

3.
Intern Med ; 58(15): 2151-2157, 2019 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-30996185

RESUMO

Objective The association between narcolepsy and rapid eye movement (REM)-related obstructive sleep apnea (OSA) has not been reported. This study aimed to examine the prevalence of REM-related OSA in narcolepsy patients. Methods From January 2013 to April 2018, 141 adult patients were diagnosed with narcolepsy using nocturnal polysomnography and the multiple sleep latency test. The prevalence of REM-related OSA in narcolepsy patients was retrospectively reviewed. Three criteria were used to determine REM-related OSA: Definition #1, an overall apnea-hypopnea index (AHI) ≥5 and AHI during REM (AHIREM)/AHI during non-rapid eye movement (NREM) (AHINREM) ≥2; Definition #2, an overall AHI ≥5 and AHIREM/AHINREM≥2 and AHINREM <15; and Definition #3, an overall AHI ≥5 and AHIREM/AHINREM≥2 and AHINREM <8 plus an REM sleep duration >10.5 minutes. Results Of the 141 narcolepsy patients, 26 were diagnosed with narcolepsy with cataplexy (NA-CA) and 115 with narcolepsy without cataplexy (NA w/o CA). Seventeen patients with NA-CA and 39 with NA w/o CA had OSA. According to Definition #1, the prevalence of REM-related OSA was 47.1% and 41.0%, respectively, in OSA patients with NA-CA and NA w/o CA; according to Definition #2, the respective prevalence was 47.1% and 38.5%, while that according to Definition #3 was 41.2% and 25.6%. No significant differences were found in the prevalence of REM-related OSA for each definition. Conclusion A high prevalence of REM-related OSA was confirmed in adult narcolepsy patients with OSA. Compared to previous reports, we noted a high frequency of REM-related OSA satisfying the relatively strict Definition #3. These results might reflect the pathophysiological characteristics of narcolepsy.

5.
Sleep Med Clin ; 14(1): 13-20, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30709527

RESUMO

Abnormal breathing during sleep is related to intrinsic and extrinsic factors that are present early in life. Investigation of fetal development and early-in-life orofacial growth allows recognition of risk factors that lead to change in upper airway patency, which leads to abnormal upper airway resistance, abnormal inspiratory efforts, and further increase in resistance and progressive narrowing of the collapsible upper airway. Such evolution can be recognized by appropriate clinical evaluation, specific polysomnographic patterns, and orofacial imaging. Recognition of the problems should lead to appropriate treatments and prevention of obstructive sleep apnea and its comorbidities.


Assuntos
Síndromes da Apneia do Sono/fisiopatologia , Apneia Obstrutiva do Sono/prevenção & controle , Humanos , Sono , Apneia Obstrutiva do Sono/complicações , Apneia Obstrutiva do Sono/fisiopatologia
6.
Sleep Med Clin ; 14(1): 135-142, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30709528

RESUMO

Myofunctional therapy (MFT) has been reported to be an alternative treatment to obstructive sleep apnea (OSA), but compliance and long-term outcome in the children were considered as an issue. A prospective study was performed on age-matched children submitted to MFT or to a functional oral device used during sleep (passive MFT) and compared with no-treatment control group. Compliance is a major problem of MFT, and MFT will have to take into consideration the absolute need to have continuous parental involvement in the procedure for pediatric OSA.


Assuntos
Terapia Miofuncional , Apneia Obstrutiva do Sono/terapia , Adolescente , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Polissonografia , Estudos Prospectivos , Sono , Resultado do Tratamento
7.
Physiol Meas ; 40(2): 025008, 2019 Feb 26.
Artigo em Inglês | MEDLINE | ID: mdl-30736016

RESUMO

OBJECTIVE: Obstructive sleep-disordered breathing (SDB) events, unlike central events, are associated with increased respiratory effort. Esophageal pressure (P es) monitoring is the gold standard for measuring respiratory effort, but it is typically poorly tolerated because of its invasive nature. The objective was to investigate whether machine learning can be applied to routinely collected non-invasive, polysomnography (PSG) measures to accurately model peak negative P es. APPROACH: One thousand one hundred and nineteen patients from the Stanford Sleep Clinic with PSGs containing P es served as the sample. The selected non-invasive PSG signals included nasal pressure, oral airflow, thoracoabdominal effort, and snoring. A long short-term memory neural network was implemented to achieve a context-based mapping between the non-invasive features and the P es values. A hold-out dataset served as a prospective validation of the algorithm without needing to undertake a costly new study with the impractically invasive P es. MAIN RESULTS: The median difference between the measured and predicted P es was 0.61 cmH2O with an interquartile range (IQR) of 2.99 cmH2O and 5th and 95th percentiles of -5.85 cmH2O and 5.47 cmH2O, respectively. The model performed well when compared to actual esophageal pressure signal (ρ median = 0.581, p  = 0.01; IQR = 0.298; ρ 5% = 0.106; ρ 95% = 0.843). SIGNIFICANCE: A significant difference in predicted P es was shown between normal breathing and all obstructive SDB events; whereas, central apneas did not significantly differ from normal breathing. The developed system may be used as a tool for quantifying respiratory effort from the existing clinical practice of PSG without the need for P es, improving characterization of SDB events as obstructive or not.

9.
Sleep Breath ; 23(3): 849-856, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30690676

RESUMO

PURPOSE: Patients with obstructive sleep apnea syndrome (OSAS) have difficulties in compliance with continuous positive airway pressure (CPAP) and the treatment outcome is heterogeneous. We proposed a proof-of-concept study of a novel intermittent negative air pressure (iNAP®) device for physicians to apply on patients who have failed or refused to use CPAP. METHODS: The iNAP® device retains the tongue and the soft palate in a forward position to decrease airway obstruction. A full nightly usage with the device was evaluated with polysomnography. Subgrouping by baseline apnea-hypopnea index (AHI) and body mass index (BMI) with different treatment response criteria was applied to characterize the responder group of this novel device. RESULTS: Thirty-five patients were enrolled: age 41.9 ± 12.2 years (mean ± standard deviation), BMI 26.6 ± 4.3 kg/m2, AHI 41.4 ± 24.3 events/h, and oxygen desaturation index (ODI) 40.9 ± 24.4 events/h at baseline. AHI and ODI were significantly decreased (p < 0.001) by the device. Patients with moderate OSAS, with baseline AHI between 15 to 30 events/h, achieved 64% response rate; and non-obese patients, with BMI below 25 kg/m2, achieved 57% response rate, with response rate defined as 50% reduction in AHI from baseline and treated AHI lower than 20. There were minimal side effects reported. CONCLUSIONS: In a proof-of-concept study, the device attained response to treatment as defined, in more than half of the moderate and non-obese OSAS patients, with minimal side effects.

10.
Sleep Med ; 60: 75-80, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30630675

RESUMO

OBJECTIVE: The objective of this study was to evaluate the skeletal effects of rapid maxillary expansion (RME) therapy performed using teeth as anchors, in obstructive sleep apnea (OSA) children, by low-dose computed tomography (CT) of the midpalatal suture opening, maxillary base width, nasal cavities width, first molar angulation and, unlike most studies in the literature, on the pterygoid processes distance. METHODS: Fourteen children (mean age 8.68 years) with OSA presenting a malocclusion characterized by upper-jaw contraction had 16-Multislice CT (MSCT) scans taken before (T0) and after (T1) RME. All exams were performed using a rigid protocol to ensure reproducibility of image collection over time, with a 16-row MSCT scanner equipped with a Dentascan reconstruction program. Scanning parameters were as follows: scout view in the anteroposterior (AP) and laterolateral (LL); 1.25-mm slice thickness with 0.6-mm collimation from the dentoalveolar and basal areas of the maxilla up to the nasal cavity, parallel to the palatal plane; 80 kV, 100 mA with an 11.25-mm table speed/rotation, rotation time 0.6 s. Matrix size was 512 × 512. RESULTS: Opening of the midpalatal suture was demonstrated in all cases. The results showed statistically significant T0 to T1 increments in all treated cases and clear imaging findings. CONCLUSION: Use of three-dimensional (3D)-CT for follow-up studies requires a very rigid protocol to maintain reproducible positions in the scanner over time. The images confirm the real remodeling of craniofacial structure. However, to be valid such an imaging approach needs great attention to reproducibility of anatomic images over time. The changes in volume of the UA, even with a rigid protocol, cannot be affirmed with 3D-CT. There is a need to improve the definition of markers using this imaging approach when performing longitudinal studies; currently this issue is unresolved.

11.
Sleep Med ; 60: 60-68, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30642692

RESUMO

INTRODUCTION: Midface retrusion creates a size deficiency problem in the upper airway that has been improved in children using surgical midface advancement and orthopedic protraction of the maxilla. The results of these treatments have been mostly promising at enlarging the pharyngeal airway. Recently introduced bone anchored maxillary protraction (BAMP) uses implant inserted devices in the jaws to pull the maxilla forward against a backward pressure to the lower jaw. This is a pilot study that examines the use of BAMP as a strategy to treat maxillary retrusion, malocclusion and children with obstructive sleep apnea. METHODS: 15 children, ages 9-16 years with maxillary retrusion creating a skeletal malocclusion were treated with bone anchored maxillary protraction (BAMP) and the results were compared against an untreated control group. 8 children in the treatment group also had sleep disordered breathing/obstructive sleep apnea. All subjects had lateral cephalograms before and after BAMP therapy. The OSA cohort completed the pediatric sleep questionnaire (PSQ) and polysomnography prior to and at the end of BAMP. RESULTS: The majority of the OSA children (n = 5) showed improvement in their apnea-hypopnea index (AHI) and OSA symptoms after BAMP. Preliminary results of BAMP therapy show improvement in respiratory and airway parameters in OSA children with a highly significant change in the forward position of the upper jaw and enlargement in the nasopharyngeal to oropharyngeal junction as compared to an age and sex matched untreated control group. The outcomes were dependent on the age of treatment initiation and patient compliance. CONCLUSIONS: This preliminary work suggests that bone anchored maxillary protraction may be considered as an adjunctive treatment option in adolescents for improving midface retrusion and sleep apnea, but further work is needed to explore this therapy.

12.
Otolaryngol Head Neck Surg ; 160(4): 580-593, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30598047

RESUMO

OBJECTIVE: To examine outcomes in the intermediate term (1 to <4 years), long term (4 to <8 years), and very long term (≥8 years) for maxillomandibular advancement (MMA) as treatment for obstructive sleep apnea (OSA). DATA SOURCES: The Cochrane Library, Google Scholar, Embase, Cumulative Index to Nursing and Allied Health, and PubMed/MEDLINE. REVIEW METHODS: Three authors systematically reviewed the international literature through July 26, 2018. RESULTS: A total of 445 studies were screened, and 6 met criteria (120 patients). Thirty-one patients showed a reduction in apnea-hypopnea index (AHI) from a mean 48.3 events/h (95% CI, 42.1-54.5) pre-MMA to 8.4 (95% CI 5.6, 11.2) in the intermediate term. Fifty-four patients showed a reduction in AHI from a mean 65.8 events/h (95% CI, 58.8-72.8) pre-MMA to 7.7 (95% CI 5.9, 9.5) in the long term. Thirty-five showed a reduction in AHI from a mean 53.2 events/h (95% CI 45, 61.4) pre-MMA to 23.1 (95% CI 16.3, 29.9) in the very long term. Improvement in sleepiness was maintained at all follow-up periods. Lowest oxygen saturation improvement was maintained in the long term. CONCLUSION: The current international literature shows that patients with OSA who were treated with MMA maintained improvements in AHI, sleepiness, and lowest oxygen saturation in the long term; however, the mean AHI increased to moderate OSA in the very long term. Definitive generalizations cannot be made, and additional research providing individual patient data for the intermediate term, long term, and very long term is needed.

13.
Expert Rev Respir Med ; 13(4): 317-326, 2019 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-30689957

RESUMO

INTRODUCTION: Upper airway resistance syndrome (UARS) as obstructive sleep apnea syndrome (OSAS) has been described as abnormal breathing during sleep, based on the recording technologies and knowledge of the time. These terms have advanced the field, but are they still useful? Area Covered: Historically, the definition of UARS syndrome was aimed at recognizing pathology not covered by 'OSAS' and to prompt specialists to go further than the obvious. It aimed at pushing specialists to recognize pathologies earlier and to elicit research in the developmental features of sleep-disordered-breathing (SDB). The technology used to monitor SDB changed over-time, allowing recognition of SDB differently but not necessarily better. Expert Commentary: Currently, we have a better understanding of the development of SDB, and its evolution with aging, leading to co-morbid-OSA. However, the real issue is to recognize the problems much earlier, and to understand what can be done to prevent its development. The notions of OSA, UARS, apnea hypopnea index are only historical. There is enough knowledge to date to go beyond these definitions, to recognize problems differently and to lead to the prevention of the factors leading to SDB. The recognition of non-hypoxic sleep-disordered breathing is a step in this direction.

14.
Sleep Med ; 60: 31-44, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-30578113

RESUMO

OBJECTIVE: To characterize sleep-disordered breathing patterns not related to hypoxia resulting in fragmented sleep in children. METHODS: We reviewed the polysomnogram (PSG) data of children with sleep complaints who were being evaluated for sleep-disordered breathing and had an apnea-hypopnea-index ≤ 3. These data were compared to the recordings of the same children with nasal CPAP administered for one night and to 60 control subjects (children without any sleep complaints). A subgroup of children was monitored with esophageal manometry, but nasal cannula flow data was recorded in all cases. RESULTS: Abnormal breathing patterns, particularly flow limitation, could be seen with more severity and frequency compared to apnea or hypopnea. The observed abnormal breathing patterns were associated with EEG disturbances. CONCLUSIONS: Patterns such as flow-limitation, mouth-breathing, changes in inspiratory and expiratory time, rib-cage and expiratory muscle activity, transcutaneous CO2 electrode changes and snoring noises are all variables that should be systematically reviewed when analyzing nocturnal PSG. Current scoring guidelines emphasizes apnea-hypopnea and hypoxic-sleep disordered breathing and therefore treatment is often much delayed in this population of children with evidence of abnormal breathing patterns. Analysis of the various patterns of abnormal breathing noted above allows recognition of "non-hypoxic" sleep-disordered-breathing (SDB).

15.
J Nurs Res ; 2018 Nov 28.
Artigo em Inglês | MEDLINE | ID: mdl-30499833

RESUMO

BACKGROUND: Although people who sleep poorly may attempt to relieve anxiety for better sleep quality, whether daily alcohol consumption is a factor that moderates anxiety and sleep disturbance is not known. PURPOSE: The aim of the study was to explore (a) the association between anxiety and sleep quality and (b) whether daily alcohol consumption acted as a moderator between anxiety and sleep quality in those who reported sleeping poorly. METHODS: Eighty-four participants aged 20-80 years who reported poor sleep (Pittsburgh Sleep Quality Index > 5) in northern Taiwan were enrolled in this cross-sectional study. A structured questionnaire covering demographics (including daily alcohol consumption), level of anxiety, level of depression, and perceived sleep quality was used to collect data. RESULTS: The participants were mostly women (72.6%). The mean age was 41.81 (SD = 12.62) years; 51.2%, 19.0%, 13.1%, and 14.3%, respectively, had minimal, mild, moderate, and severe anxiety. After adjusting for factors related to sleep quality using multiple regression analysis, receiving sleep therapy, consuming alcohol on a daily basis, and having anxiety were found to be predictors of poor sleep quality. Moreover, daily alcohol consumption was found to moderate the relationship between anxiety and sleep quality. CONCLUSIONS/IMPLICATIONS FOR PRACTICE: People who sleep poorly should avoid misusing alcohol to self-treat poor sleep quality or anxiety and should instead utilize sleep hygiene education and mental healthcare. Daily alcohol consumption may be a moderator between anxiety status and sleep quality.

16.
Sleep Med ; 2018 Oct 29.
Artigo em Inglês | MEDLINE | ID: mdl-30466820

RESUMO

INTRODUCTION: Sleep problems, neuro-developmental development, and sleep-disordered-breathing (SDB), are reported as more prevalent in premature infants than in full-term infants. We investigated the relationship between neuro-development, and SDB in preterm infants at 24 months corrected age (CA) with a narrow palatal presentation over time. METHODS: We enrolled infants 40 weeks or younger at birth collecting obstetric and birth data. Participants were followed up at 6, 12, 18, and 24 months CA. We evaluated craniofacial development by inspecting and photo documenting hard palate; sleep using sleep diary, actigraphy and night-time polysomnography-PSG-; and development using Bayley- Scales-of-Infant-Development and Denver-Developmental-Screening-Test (DDST) at each visit and comparing results at six months and two years. RESULTS: 244 premature infants [139 (57.0%) boys, [at birth: mean gestational age-GA- 31.5 ± 3.2 weeks, 1691.9 ± 593.9 g, 40.2 ± 5.2 cm], and 30 full term infants (50% boys), [mean GA 39.3 ± 1.0 weeks, 3131.0 ± 390.0 g, and 49.38 ± 2.0 cm] were enrolled in the study. At 6 and 24 months, 65.2% premature infants had a narrow hard palate (NHP). At 24 months, 79% had an apnea-hypopnea- index (AHI) > 1 events/hour at PSG, with a mean AHI of 3.00 ± 2.95. Only 10% of full term infants had NHP at birth and the mean AHI was 0.5 ± 0.2 event/hour at 24 months. CONCLUSION: Preterm infants have a higher occurrence of NHP at birth. At two years of age they have more sleep problems, most commonly associated with obstructive-SDB, and a higher rate of development delays. Frequency of NHP is still abnormally high, suggesting not only abnormal orofacial growth over-time, but also impact of this abnormal growth in the genesis of the obstructive-SDB.

17.
Sleep Med ; 2018 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-30393018

RESUMO

OBJECTIVE: The aim of this retrospective study was to evaluate the results of an outpatient surgical procedure known as endoscopically-assisted surgical expansion (EASE) in expanding the maxilla to treat obstructive sleep apnea (OSA) in adolescent and adults. METHODS: Thirty-three patients (18 males), aged 15-61 years, underwent EASE of the maxilla. All patients completed pre- and post-operative clinical evaluations, polysomnography, questionnaires (Epworth Sleepiness Scale [ESS] and Nasal Obstruction Septoplasty Questionnaire [NOSE]) as well as cone beam computed tomography (CBCT). RESULTS: With EASE, the overall apnea hypopnea index (AHI) improved from 31.6 ± 11.3 to 10.1 ± 6.3. The oxygen desaturation index (ODI) improved from 11.8 ± 9.6 to 1.8 ± 3.7, with reduction of ESS scores from 13.4 ± 4.0 to 6.7 ± 3.1. Nasal breathing improved as demonstrated by reduction of the NOSE scores from 57.8 ± 12.9 to 15.6 ± 5.7. Expansion of the airway from widening of the nasal floor was consistently evident on all postoperative CBCT; the anterior nasal floor expanded 4.9 ± 1.2 mm, posterior nasal floor expanded 5.6 ± 1.2 mm, and the dental diastema created was 2.3 ± 0.8 mm. Mean operative time was 54.0 ± 6.0 min. All patients with mild to moderate OSA were discharged the same day; patients with severe OSA were observed overnight. All patients returned to school or work and regular activities within three days. CONCLUSIONS: EASE is an outpatient procedure that improves nasal breathing and OSA by widening the nasal floor in adolescents and adults. Compared to current surgical approaches for maxillary expansion, EASE is considerably less invasive and consistently achieves enlargement of the airway with minimal complications.

18.
Sleep Med ; 2018 Sep 29.
Artigo em Inglês | MEDLINE | ID: mdl-30448089

RESUMO

BACKGROUNDS: Myofunctional therapy has been reported to be a valid adjunct treatment to OSA, but compliance was mentioned as an issue. We performed a prospective study on age matched randomized children submitted to myofunctional therapy (MFT) or to a functional device used during sleep (passive MFT). METHODS: 110 children 4 to 16 were recruited for the study, 54 children were in the MFT group [A] while 56 were in the "nocturnal device" group [B]. Clinical evaluation, polysomnography and cephalometric X-Rays were performed at baseline, 6 months and 12 months, with clinical follow-up at 3 months. RESULTS: MFT group show very important absence of compliance, at six months only 23 subjects participated and only 10/23 had been compliant with treatment. None came back for research investigation at 12 months. 48/56 of passive MFT children ended the research protocol at 12 months. Comparison of baseline to 6 and 12 months data showed that all children with passive MFT improved (PSG and cephalometrics) and had nasal breathing during sleep at 1 year, and no negative effect of device were noted. The 10 children compliant with MFT showed clear improvement of sleep related breathing with also changes at cephalometric -X-rays. CONCLUSION: Compliance is a major problem of MFT, and MFT will have to take into consideration the absolute need to have continuous parental involvement in the procedure. Passive MFT gives many more positive results, but potential negative effects of device on other jaw will have to be continuously evaluated.

19.
Expert Rev Respir Med ; : 1-13, 2018 Nov 02.
Artigo em Inglês | MEDLINE | ID: mdl-30365900

RESUMO

INTRODUCTION: Obstructive sleep apnea (OSA) is highly prevalent and constitutes a major health hazard. Current pharmacotherapy is ineffective in correcting sleep-disordered breathing and is used adjunctively to address residual sleepiness. A new drug, solriamfetol, a selective norepinephrine-dopamine reuptake inhibitor, is the first drug of its class that is being considered by the US Food and Drug Administration (FDA) to treat excessive sleepiness in OSA and narcolepsy patients. Areas covered: This review covers drug chemistry, pharmacodynamics, pharmacokinetics, and metabolism of solriamfetol. Results of three Phase 3 trials, Treatment of OSA and Narcolepsy Excessive Sleepiness (TONES 3, 4, 5), relevant to OSA patients are summarized. Published abstracts/articles and a 2017 Jazz Investor Presentation provided data. Databases searched included PubMed, Google Scholar, Lexi-Comp, Scopus, Science, and Ovid. Expert commentary: Solriamfetol shows promise as adjunctive therapy in OSA. It is well tolerated and effective in reducing sleepiness and is an alternative to modafinil or armodafinil. Unlike stimulants like methylphenidate or dextroamphetamine, it does not have cardiac effects, rebound hypersomnia, or withdrawal effects.

20.
Drugs Aging ; 35(9): 791-817, 2018 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30058034

RESUMO

Chronic insomnia affects 57% of the elderly in the United States, with impairment of quality of life, function, and health. Chronic insomnia burdens society with billions of dollars in direct and indirect costs of care. The main modalities in the treatment of insomnia in the elderly are psychological/behavioral therapies, pharmacological treatment, or a combination of both. Various specialty societies view psychological/behavioral therapies as the initial treatment intervention. Pharmacotherapy plays an adjunctive role when insomnia symptoms persist or when patients are unable to pursue cognitive behavioral therapies. Current drugs for insomnia fall into different classes: orexin agonists, histamine receptor antagonists, non-benzodiazepine gamma aminobutyric acid receptor agonists, and benzodiazepines. This review focuses on Food and Drug Administration (FDA)-approved drugs for insomnia, including suvorexant, low-dose doxepin, Z-drugs (eszopiclone, zolpidem, zaleplon), benzodiazepines (triazolam, temazepam), and ramelteon. We review the indications, dosing, efficacy, benefits, and harms of these drugs in the elderly, and discuss data on drugs that are commonly used off-label to treat insomnia, and those that are in clinical development. The choice of a hypnotic agent in the elderly is symptom-based. Ramelteon or short-acting Z-drugs can treat sleep-onset insomnia. Suvorexant or low-dose doxepin can improve sleep maintenance. Eszopiclone or zolpidem extended release can be utilized for both sleep onset and sleep maintenance. Low-dose zolpidem sublingual tablets or zaleplon can alleviate middle-of-the-night awakenings. Benzodiazepines should not be used routinely. Trazodone, a commonly used off-label drug for insomnia, improves sleep quality and sleep continuity but carries significant risks. Tiagabine, sometimes used off-label for insomnia, is not effective and should not be utilized. Non-FDA-approved hypnotic agents that are commonly used include melatonin, diphenhydramine, tryptophan, and valerian, despite limited data on benefits and harms. Melatonin slightly improves sleep onset and sleep duration, but product quality and efficacy may vary. Tryptophan decreases sleep onset in adults, but data in the elderly are not available. Valerian is relatively safe but has equivocal benefits on sleep quality. Phase II studies of dual orexin receptor antagonists (almorexant, lemborexant, and filorexant) have shown some improvement in sleep maintenance and sleep continuity. Piromelatine may improve sleep maintenance. Histamine receptor inverse agonists (APD-125, eplivanserin, and LY2624803) improve slow-wave sleep but, for various reasons, the drug companies withdrew their products.


Assuntos
Distúrbios do Início e da Manutenção do Sono/tratamento farmacológico , Idoso , Humanos , Uso Off-Label , Qualidade de Vida , Segurança
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