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[News] Persistent Daytime Sleepiness Common Despite Effective CPAP
#1
Persistent Daytime Sleepiness Common Despite Effective CPAP

By: BRUCE JANCIN

NEW ORLEANS – Excessive daytime sleepiness in patients with obstructive sleep apnea remains a common and often debilitating problem, despite optimal use of continuous positive airway pressure treatment, according to Dr. Janine R.E. Vintch.

The two drugs most beneficial as adjunctive therapy for these patients are modafinil (Provigil) and armodafinil (Nuvigil). Both are approved by the Food and Drug Administration for the management of persistent sleepiness and fatigue in patients with sleep apnea who are compliant with their CPAP therapy, Dr. Vintch said at the annual meeting of the American College of Physicians.

In one study, 22% of patients with obstructive sleep apnea using effective CPAP – that is, CPAP for more than 6 hours per night – still had impaired daytime functioning because of excessive daytime sleepiness documented on objective tests, including the Multiple Sleep Latency Test. This persistent daytime somnolence can manifest as cognitive impairment, diminished vigilance, and increased rates of workplace and motor vehicle accidents.

Before turning to drug therapy, however, it’s crucial to rule out other causes of persistent daytime sleepiness. The No. 1 reason is the patient is less adherent to CPAP than claimed. Other possible explanations include an improperly fitting CPAP mask, poor sleep hygiene, depression, and additional sleep disorders, such as restless legs, said Dr. Vintch of the University of California, Los Angeles.

Modafinil is a novel wake-promoting agent approved in 2004 for the management of residual sleepiness in CPAP-compliant patients. In 2006 the American Academy of Sleep Medicine published a practice parameter on the medical therapy of obstructive sleep apnea that endorsed modafinil as a standard recommendation for this indication. It has a low abuse potential. Its mechanism of action remains controversial. Modafinil is cleared by both the liver and kidneys, so lower doses are appropriate in patients with either hepatic or renal dysfunction.

Modafinil has several important interactions with other drugs. These medications include propranolol, diltiazem, phenytoin, carbamazepine, and diazepam; the levels of all these drugs are increased in patients on modafinil. Also, women of childbearing age who are on ethinyl estradiol need to be given an alternative method of contraception, she said.

The most common side effects attributed to modafinil are headache, nausea, and nervousness. The headaches typically disappear after the first 3 days of treatment.

Armodafinil is the R-isomer of modafinil. Its 10- to 15-hour half-life is slightly longer than modafinil’s. It has the same side effects as modafinil.

Long-term studies of both drugs have documented good safety and tolerability along with improved objective and subjective measures of wakefulness and cognition.

fair use from:
http://www.familypracticenews.com/news/m...416da.html

The above post may contain copyrighted material the use of which has not always been specifically authorized by the copyright owner. The material available is intended to advance the understanding of Sleep Apnea treatment and to advance the educational level of Sleep Apnea patients with regard to their health. Sometimes included is the full text of articles and documents rather than a simple link because outside links frequently "go bad" or change over time. This constitutes a "fair use" of any such copyrighted material as provided for in section 107 of the US Copyright Law. In accordance with Title 17 U.S.C. Section 107, the material in this post is distributed without fee or payment of any kind for research and educational purposes. If you wish to use copyrighted material from this post for purposes of your own that go beyond "fair use", you must obtain permission from the copyright owner.
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#2
The article conclude
Dr. Vintch reported having no relevant financial relationships.
Dont-know
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#3
You know what really jumped out at me was the statement that "effective CPAP treatment" is 6 hours of sleep on a PAP! Interesting since most compliance for insurance and such seems to be 4 hours. So compliance is only 2/3 of what you need for effective treatment! Hmmmm....
As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
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#4
(06-12-2012, 02:13 PM)mjbearit Wrote: You know what really jumped out at me was the statement that "effective CPAP treatment" is 6 hours of sleep on a PAP! Interesting since most compliance for insurance and such seems to be 4 hours. So compliance is only 2/3 of what you need for effective treatment! Hmmmm....

Remember the 4 hours is about whether insurance will pay, not really about effective treatment.

I suspect the thinking is that if someone uses it 4 hours a night, they'll eventually use it full time. I think there may also be an idea of "fairness" in terms of 4 hours showing you're really trying unlike the large number of people who give up too easy on CPAP.

There's also the consideration of people who don't sleep that many hours a night anyway.

Unfortunately, a number of doctors do seem to think that 4 hours is somehow effective.

I suspect the truly important number is how many hours you sleep without CPAP, not how many hours you sleep with it.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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#5
It struck me that this study's definition of effective CPAP therapy was only that CPAP was being used six hours per night. As the fourth paragraph mentions, there are several other explanations for the study results, starting with mask leaks along with other factors which apparently were not considered in the "effective CPAP." This appears to be an example of how study results can be skewed to result in a particular conclusion due to how the study was conducted and/or how the results were tabulated.
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#6
I am in one of those 22% and take Provigil. I have been taking it for four years. I had a period shortly after New Years when I didn't need it for a couple of months, but have started having to take it again. I am 100% compliant with my ASV andf have always been 100 % compliant- all sleep time.
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#7
4 Hours?
6 Hours?
I have always thought that a good night of sleep was 8 hours and that this requirement actually increased with age, although sleep escapes us as we grow older.
I find that anything under 8 hours leaves me wanting to nap after dinner.
----------------------------------------------------------------------------
Educate, Advocate, Contemplate.
Herein lies personal opinion, no professional advice, which ALL are well advised to seek.



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#8
(06-13-2012, 11:00 AM)TorontoCPAPguy Wrote: 4 Hours?
6 Hours?
I have always thought that a good night of sleep was 8 hours and that this requirement actually increased with age, although sleep escapes us as we grow older.
I find that anything under 8 hours leaves me wanting to nap after dinner.

Today I want a nap and it is not even lunch time yet! LOL! There are good days and bad days. Just like life! Smile
As always, YMMV! You do not have to agree or disagree, I am not a professional so my mental meanderings are simply recollections of things from my own life.

PRS1 - Auto - A-Flex x2 - 12.50 - 20 - Humid x2 - Swift FX
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#9
This may also be another case where we see the world through CPAP tinted glasses.

Plenty of people without apnea have daytime sleepiness problems.

If you need 8 hours of sleep, and only get 6, CPAP isn't going to fix the deficit. Or if you need 10 and get 8. Plenty of people without apnea don't sleep well even if they get enough hours.
Get the free SleepyHead software here.
Useful links.
Click here for information on the main alternative to CPAP.
If it's midnight and a DME tells you it's dark outside, go and check it yourself.
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