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We read with interest the responses to our recent review of the diagnosis and treatment of obstructive sleep apnea (OSA)[1]. We agree that challenges with current therapies for OSA necessitate the study of newer and personalized treatments to improve clinical outcomes, treatment adherence and patient satisfaction. As indicated by Dr. Pupko, the use of dronabinol in the treatment of OSA[2] is one of several such approaches to improve OSA severity and sleepiness. The PACE study demonstrated early but promising results of cannabimimetics, which should be validated through comparisons to established OSA treatments over a longer duration of follow-up in larger patient cohorts.
Highlighting the difficulties that some patients with OSA experience tolerating CPAP therapy, Drs. Rotenberg and Pang stress the importance of surgical treatments to improve patient outcomes. We did not find a strong body of high quality literature to justify the use of upper airway surgery as a first line treatment for OSA. Specifically, there is limited data on disease recurrence and the existing literature suggests that complications are not infrequent. Our conclusions are supported by a recent large meta-analysis by the Canadian Agency for Drugs and Technology for Health (CADTH), which also found insufficient evidence to support upper airway surgery as first line therapy for OSA except in highly selected patients for whom other therapies (CPAP or oral appliances) are intolerable or unacceptable[3]. We look forward to higher quality studies, including robust comparisons to currently accepted treatments for OSA, that will help to clarify the role of surgery in the management of OSA. In the meantime, while CPAP intolerance and nonadherence are recognized limitations of therapy, the current body of evidence provides support for its positive effects on sleep quality and longer-term health outcomes. Furthermore, as discussed in Appendix 2 of our review, there are several evidence-based strategies that clinicians can use to support patients who are struggling with CPAP use.
The use of wakefulness promoting medications such as modafinil to treat persistent hypersomnolence despite adequate treatment of OSA is supported by several randomized trials[4]. Prior to initiating stimulants or wakefulness promoting agents, it is important to review other reasons for an incomplete clinical response to therapy as described in our review. The clinical evaluation of these patients may include ensuring treatment efficacy and ruling out other primary disorders of sleep, mood disorders, chronic pain, or medical conditions or medications that worsen sleep. A formal sleep specialist assessment may be of value in this situation.
References:
1. Laratta, CR, Ayas NT, Povitz M, Pendharkar SR. Diagnosis and treatment of obstructive sleep apnea in adults. Canadian Medical Association Journal. 2017;189(48):e1481-1488.
2. Carley DW, Prasad B, Reid KJ, Malkani R, Attarian H, Abbott SM, et al. Pharmacotherapy of apnea by cannabimimetic enhancement, the PACE clinical trial: Effects of dronabinol in obstructive sleep apnea. Sleep. 2018;41(1):zsx1814.
3. Interventions for the treatment of obstructive sleep apnea in adults: a health technology assessment. Ottawa (ON): Canadian Agency for Drugs and Technologies in Health; 2017 Mar. (CADTH optimal use report; vol.6, no1b).
4. Chapman JL, Vakulin A, Hedner J, Yee BJ, Marshall NS. Modafinil/armodafinil in obstructive sleep apnoea: a systematic review and meta-analysis. European Respiratory Journal. 2016;47(5):1420-8.