From mcpress.mayoclinic.org
If you have been diagnosed with obstructive sleep apnoea (OSA), your care team has likely recommended continuous positive airway pressure therapy, also called CPAP therapy or a CPAP machine.
A CPAP machine works by keeping your upper airway open as you sleep. This helps prevent apnoea — short pauses in breath that reduce your air supply and disrupt your sleep. But even with consistent CPAP use, some people with OSA still experience daytime sleepiness that’s severe enough to get in the way of relationships, work and life.
It can take 2 to 3 months of consistent, nightly CPAP use to see improvements in daytime sleepiness, says Tyler L. Herzog, M.D., a pulmonologist and sleep medicine specialist at Mayo Clinic at Rochester, Minnesota. But if it’s been over three months — and if your care team has already covered the basics by checking your device settings and the fit of your CPAP mask — it may be time to consider adding in a medicine that can help you stay awake during the day. These medicines are called wake-promoting agents.
“All of us can feel sleepy at times during the day, but when it starts to interfere with either the quality of your life or potentially interfere with your own safety or the safety of others that’s when it becomes an issue,” says Dr. Herzog.
Wake-promoting agents can help you manage daytime sleepiness with OSA
Before recommending a wake-promoting agent, your care team will likely want to rule out any other sleep condition or health conditions. Be sure to discuss any other medicines and supplements you take, even if they aren’t related to your OSA.
Dr. Herzog says benzodiazepines, antihistamines, opioid pain medicines, certain antidepressants, anti-seizure medications, hypnotics and even beta blockers also may cause drowsiness. Substances such as alcohol also can be a potential cause, so it’s important to have a frank conversation with your care team about how much you drink.
If other causes have been ruled out, there are three Food and Drug Administration (FDA)-approved medicines that can improve daytime sleepiness in people with OSA who already use a CPAP machine:
Modafinil and armodafinil primarily work by increasing dopamine levels in the brain, which activates regions of the brain responsible for alertness. Both modafinil and armodafinil are taken as a daily, oral pill. Depending on your needs, Dr. Herzog says you may take the medicine once or twice daily. Common side effects include headache, nausea, anxiety and insomnia. Rarely, severe rash can occur. In this situation, call your care team immediately.
In addition, modafinil and armodafinil can make birth control methods, such as oral contraceptives, implants, shots, IUDs or vaginal rings, less effective. You will likely need to use an additional form of birth control, such as a condom or diaphragm, to prevent pregnancy.
Solriamfetol, meanwhile, increases both dopamine and norepinephrine in the brain — which helps improve daytime sleepiness. Solriamfetol is taken as a daily, oral pill. Common side effects include nausea, headache, anxiety and decreased appetite. Less commonly, weight loss or increases in blood pressure may occur. But, in general, Dr. Herzog says lower doses are less likely to cause side effects.
With all three options, tell your care team if you have a history of any mental health conditions, including psychosis, as these medications can worsen a mental health condition. Likewise, tell your care team if you have a history of heart attack, angina, heart disease, hypertension or hyperlipidemia.
Your care team also may recommend pitolisant (Wakix), which Dr. Herzog says has been found effective for daytime sleepiness with OSA. Pitolisant has not been approved by the FDA for use with OSA-related sleepiness in the United States, but it may be prescribed off-label, as it has been approved for other uses.
Which wake-promoting agent is right for me?
Modafinil, armodafinil, solriamfetol and pitolisant can significantly improve your daytime wakefulness — but Dr. Herzog says there aren’t yet any head-to-head studies to show when one option is better or more effective than the other.
“An individual may respond better to one of these medications versus another, so you may have to go through a trial of one or two before you find the one that works for you,” says Dr. Herzog. Typically, it can take about 4 to 6 weeks on a medicine to determine how well you respond.
In very specific circumstances, your care team may recommend other types of stimulants, such as amphetamines or methylphenidate (Ritalin, Concerta). For the most part, Dr. Herzog says these stimulants are an option only if you haven’t responded to other medicines and if there is a considerable safety concern. For example, you may be at risk of falling asleep while driving. But, in general, Dr. Herzog says modafinil, armodafinil and solriamfetol are preferred to other stimulants because they are effective at reducing daytime sleepiness. They also have less severe side effects compared with other types of stimulants.
Don’t forget about sleep hygiene and other lifestyle strategies
If you are taking a wake-promoting agent, Dr. Herzog says it’s still important to use your CPAP machine every night — for at least four hours a night, but ideally all night. Remember, wake-promoting agents can help you feel better and stay alert, but they don’t cure or directly treat your OSA.
Likewise, sticking to a regular nighttime routine is a must.
“Sleep hygiene is easy to say and a lot harder to do,” acknowledges Dr. Herzog. “It often takes weeks or longer to see the benefits of consistent sleep hygiene.”
But Dr. Herzog strongly recommends focusing on the following:
- Have a consistent bedtime and wake time, even on weekends.
- Get at least 7 to 9 hours of sleep every night.
- Get about 30 minutes of natural light when you wake up, ideally outside.
- Exercise regularly.
- Avoid caffeine after noon.
- Avoid alcohol or large meals within three hours of bedtime.
- Limit your screen time at least an hour before bed.
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