Numerous pharmacotherapeutic approaches have been investigated for the treatment of OSA but none have proven to prevent or overcome upper-airway obstruction enough to justify this approach as a primary treatment for OSA.1,7 Thus, pharmacologic treatment is considered adjunctive rather than primary therapy. An example is the use of pharmacologic therapy for residual symptoms of excessive daytime sleepiness that persists despite the patient’s use of CPAP at night.24
Before prescribing any form of adjunctive pharmacotherapy for OSA, the clinician should determine whether the patient has indeed been compliant with primary therapy. The clinician also should assess the patient for additional factors that can contribute to poor sleep before considering pharmacotherapy, including having one or more of the following:7,24
- ill-fitting PAP mask
- poor sleep hygiene
- thyroid disease
- other sleep disorders (e.g., restless leg syndrome, narcolepsy).
Only two drugs are FDA-approved for the treatment of residual daytime somnolence: modafinil24,25 and armodafinil.26 Both of these wakefulness-promoting agents are oral medications that have properties similar to amphetamines and other sympathomimetic agents, but their mechanisms of action are unknown. Modafinil and armodafinil should be used in conjunction with PAP therapy.7
In addition to considering the patient’s cardiovascular health and other medical conditions that might preclude the use of modafinil or armodafinil,25,26 providers should also know that these medications may affect the user’s judgment and cognitive abilities. Persons taking these medications should be cautioned not to drive and not to engage in other potentially dangerous activities until they can determine how the drug affects them.25,26 Both agents may be habit-forming as well. Clinicians should inform female patients of childbearing age that modafinil and armodafinil may also reduce the effectiveness of hormonal contraceptives.
Supplemental oxygen is not recommended as a primary treatment for OSA, but may have an adjunctive role in treating hypoxemia.7,27 This treatment can help overcome oxygen desaturation and may reduce the frequency of apnea episodes, but also may increase episode duration.7,27 In addition, the use of supplemental oxygen used alone can worsen nocturnal hypercapnia in individuals who have comorbid respiratory disease.7