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Hi everyone, my name is Neomi Shah. I'm the System Vice Chair of Medicine and Professor of Medicine at the Icahn School of Medicine at Mount Sinai in New York City. And today I'm going to be discussing the Algorithm for Assessing Excessive Daytime Sleepiness in Obstructive Sleep Apnea patients, and also some of the medications that you may be able to use for these patients.
So the first thing that we are doing in all patients that are treated for obstructive sleep apnea in our clinical consultation is that we're recognizing patient complaints that suggest sleepiness, such as they're napping, they’re feeling tired, they are not able to stay awake at work. And then of course, we administered the Epworth Sleepiness Scale, which is a scale that goes from 0 to 24, indicating excessive sleepiness when it's greater than 10. And at that point, you want to evaluate their sleep habits, you want to look for optimization of CPAP or other OSA therapies that they may be on such as oral appliance, and also assess lifestyles such as diet, exercise, and anything that may potentially interfere with their ability to get a restful night of sleep. You want to also eliminate competing etiology such as comorbidities, any medications or substances that may interfere with someone's ability to sleep at night and resulting in daytime sleepiness. So nicotine or caffeine, and then of course, differential diagnosis of residual excessive daytime sleepiness can be made once you have sort of gone through this process and then you can consider pharmacotherapy.
In terms of the drugs you have available, the ones that are currently approved for use in EDS and OSA are Modafinil, solriamfetol, and pitolisant. Modafinil and solriamfetol are similar in the sense that they both are dopamine reuptake inhibitors, with solriamfetol having additional norepinephrine reuptake inhibition, slightly stronger in its ability to suppress sleepiness. Pitolisant works differently, it's a histamine receptor antagonist.
In terms of FDA approved medications for obstructive sleep apnea, these are the three medications. Pitolisant is approved primarily for narcolepsy, but will most likely be approved for OSA in the future as we do studies that have investigated its efficacy. Modafinil is a medication that's been around for a long time, it is very well tolerated. The main issue that I have with the drug is that you can't use it in individuals that are on oral contraceptives, because it will reduce the efficacy, as similarly with armodafinil, that is a concern. And they're both, you know, there is a serious rash, such as Stevens-Johnson Syndrome that can happen, so you have to watch out for that. Solriamfetol, it isn't really - that's not really a concern. Especially it can be used in individuals with OCPs. But you do want to be careful about it in individuals with cardiovascular disease, because it can elevate blood pressure. Pitolisant is really not indicated for OSA yet, but you can consider it if the other medications aren't working, and it's pretty well tolerated for the most part.
For pharmacokinetics, what you'll notice is Modafinil has the longest half-life of 15 hours, and solriamfetol has the shortest. So just something to keep in mind when you have patient, especially when they have trouble falling asleep in the evening hours.
And finally, in terms of how you want to potentially use these therapies in your clinical practice. Here's just a quick example of it. And it's showing you pitolisant or solriamfetol, but you can easily substitute Modafinil wherever it says pitolisant, because that is approved for sleepiness.
So you know, assess the patient and you take the sleep history, and then you ask whether they're using their CPAP. Of course, if they're not using their CPAP, they have obstructive sleep apnea, and they are sleepy, you want to emphasize that they go home and they try to use their CPAP. And in your clinic, you want to troubleshoot any issues they're having with their CPAP.
If they're using their CPAP and you check compliance, you ensure that the download shows that there isn't any residual sleepiness, that they're using it for the entire night. And once you've done that, you'll again want to go through the same checklist as we went through on slide 1 for concomitant sleep disorders, other comorbidities, medications, and once all of that has really been addressed and no other sleep disorders found you can consider the diagnosis of EDS, and you can use the three drugs that I mentioned. If you have a high-risk cardiovascular patient, you don’t want to use solriamfetol because it can increase blood pressure in patients, and some of the data shows that so you want to use Modafinil. If you have a patient that's on an oral contraceptive, you may want to not use Modafinil, and use solriamfetol. So again, you want to tailor the medications based on the patients you're treating.
So I hope this was helpful. Thank you so much for your time and attention.
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