Pharmacological management of co-morbid obstructive sleep apnoea and insomnia

ABSTRACT

Introduction

Clinical presentation of both insomnia and obstructive sleep apnea (COMISA) is common. Approximately 30% of clinical cohorts with OSA have insomnia symptoms and vice versa. The underlying pathophysiology of COMISA is multifactorial. This poses a complex clinical challenge. Currently, there are no clinical guidelines or recommendations outside of continuous positive airway pressure (CPAP) therapy and cognitive behavioral therapy for insomnia (CBTi). Clinically translatable precision medicine approaches to characterize individual causes or endotypes may help optimize future pharmacological management of COMISA.

Areas covered

This review article provides an up-to-date account of COMISA and its consequences, the underlying pathophysiology of sleep apnea, insomnia and COMISA, current treatment approaches and limitations, pharmacotherapy targets and future priorities.

Expert opinion

There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are lacking. This is a priority for future investigation to inform development of evidence-based guidelines. Pharmacotherapies, particularly for insomnia, do not target the underlying causes of the disorder thus, are indicated for short-term use only and should remain second line. Future multidisciplinary research should be directed toward the multifactorial nature of COMISA and the challenges of adapting COMISA treatment in clinical practice and overcoming the practical barriers that health-care providers and consumers encounter.

KEYWORDS:

• Sleep disordered breathing
• pharmacotherapy
• pathophysiology
• treatment
• sleep disturbance
• precision medicine

Article highlights

• Comorbid insomnia with sleep apnea (COMISA) is common and associated with worse health outcomes than either condition alone and as such, presents a complex clinical challenge.

• Current clinical guidelines focus on existing therapies for each condition alone rather than evidence-based, COMISA-specific solutions.

• Clinically translatable precision medicine approaches to characterize individual causes of COMISA may help optimize future pharmacological management.

• There are multiple promising emerging therapies, but clinical trial data specifically in COMISA populations are currently lacking.

• There are currently no targeted drug therapies approved for COMISA, but a rapidly growing body of evidence suggests that it is both feasible and necessary.

Declaration of interest

D J Eckert reports research grant funding from Apnimed, Bayer, Takeda, Invicta Medical, Eli Lilly, Withings and has served as a consultant/advisor for Bayer, Invicta Medical, Apnimed, and Mosanna. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Acknowledgments

The authors thank Dr Duc Phuc Nguyen for his assistance in preparing the figure for this article.

Additional information

Funding

D J Eckert is funded by a National Health and Medical Research Council of Australia Leadership Fellowship [1196261].