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Sleep Disorders

Severe obstructive sleep apnea and medication

01/30/2008

Question:

I have severe obstructive sleep apnea. I cannot wear the mask because it makes me nervous, so I discontinued using it. I went to a sleep disorder psychiatrist and he said NO SLEEPING MEDS will work because I have Psychophysiological Insomnia. Is this true? Also, he prescribed Neurontin 600mg and this was the first time I slept. Do you think this is too many milligrams? In fact, I could use 800mg. But the Neurontin really works. Will anyting happen because I am not using the mask? ANd taking Neurontin really helps. Neurontin won`t hurt me, will it? How many milligrams does it go up to?

Answer:

You have a number of questions that need to be addressed, and I’ll try to take them in order. It sounds as though you want to know the following:

1. What are the consequences of untreated obstructive sleep apnea (OSA)?

OSA is a condition where the airway partially or completely collapses during sleep. This results in fragmentation of sleep and, in some individuals, low oxygen level during sleep. The consequences of this condition can be serious and range from a poor quality of life (morning headaches, disabling sleepiness, poor concentration, irritability, etc) to increasing problems with blood pressure control, heart disease and strokes. Due to these significant medical problems, it appears that those with moderate to severe OSA may be at increased risk for premature death if their OSA remains untreated. As such, I would strongly recommend you pursue treatment of your sleep apnea.

2. Are there treatment options for OSA other than CPAP?

There are a number of different treatments available for OSA. Which treatment is best for a given individual depends on a number of factors, including the severity of the sleep apnea, the patient’s size and airway anatomy, the patient’s co-morbid conditions and the patient’s willingness to accept a given treatment.

The primary treatment for OSA is the use of CPAP, which is very effective at keeping the airway open during sleep. It does this by “pressurizing” the airway to prevent it from collapsing. In a large number of well-done studies, CPAP therapy has been shown to be very effective at improving a number of measures of quality of life, including daytime alertness, improved concentration and improved mood. Individuals with OSA who can successfully use CPAP generally feel better! In addition, growing data suggest that CPAP may reduce some of the medical consequences associated with sleep apnea. The main problem with CPAP is that many individuals, such as yourself, have trouble adapting to sleeping with this type of device. Most times, with patience, perseverance, and appropriate trouble-shooting, individuals can learn to sleep with CPAP (or one of it’s versions) and do quite well. Despite best efforts, some individuals are unable to use CPAP and thus alternative therapies must be considered.

Alternative treatments for OSA really fall into 2 main categories: oral appliances and surgery. Oral appliances generally work to advance the lower jaw, hoping to open space in the back of the throat. They tend to work best in individuals with more mild to moderate OSA and in those who may have a small or more posterior sitting jaw. Individuals who use oral appliances during sleep often tolerate them, though they can have some annoying side effects (jaw achiness, pain with chewing in the morning, headaches, drooling). In addition, if there is a history of temporomandibular joint (TMJ) disease, then these devices should be used with great caution as they put considerable stress on the TMJ and can worsen problems.

For some individuals, surgery is a reasonable option. Surgery tends to be most effective in those with clear anatomic problems that are amenable to surgery (such as large tonsils, deviated septum), more mild to moderate sleep apnea and who are not obese. There are a variety of surgeries that can be considered, though they are generally tailored based upon an individual’s anatomy. A tracheotomy (surgical tube placed in the neck) is usually curative for OSA, but because it is somewhat disfiguring, is reserved for severe cases that fail other treatments.

3. Do medications work for OSA?

Other treatments that have been mentioned in the literature included weight loss for those who are overweight (in some cases, this can be curative), positional therapy (avoiding sleep on your back) and medications. Unfortunately, aside from treatment to help alleviate nasal congestion, almost all other medications hoped to significantly impact OSA have failed when well-studied (this includes the serotonin active agents). Primary medication treatment for OSA is not recommended at this time.

4. What are the treatment options for psychophysiological insomnia?

Insomnia has multiple underlying causes. Identifying the underlying factors that are contributing to insomnia is extremely important to ensure appropriate treatment. Insomnia can usually be divided into two broad categories: trouble falling asleep at the start of the night (also known as sleep onset insomnia) and difficulty staying asleep during the night (also known as sleep maintenance insomnia). Some individuals may experience problems with both. Factors affecting one’s ability to fall asleep at the start of the night are quite varied and may include one or more of the following; a poor sleep environment (i.e. the bedroom is too noisy, too bright or too warm), learned poor sleep habits (i.e. watching TV to fall asleep), excessive use of stimulants (both medications and common substances such as caffeine and nicotine), certain medications, stress or anxiety, pain, medical conditions that may make it uncomfortable or difficult to breathe well when lying down, heartburn, restless legs syndrome (an irresistible need to move the legs when awake at night) and circadian rhythm disturbances (when the body’s biologic rhythms are out of synchrony or delayed). Occasionally some individuals will not have any of these underlying causes contributing to their insomnia and their condition is often labeled as “idiopathic insomnia” or insomnia for which a cause can not be found.

The workup of insomnia requires a detailed evaluation to help sort out the important underlying factors that may need to be addressed. While many individuals can have their insomnia successfully managed with simple lifestyle changes, others may require more intensive therapy that may include counseling and/or medication use. Details in your specific history should help to determine what treatment options are best for you.

5. What are the risks to taking Neurontin?

Neurontin (gabapentin) is an antiseizure medication that has been found to be useful in a variety of other conditions ranging from helping with chronic pain control to working as mood stabilizer to the treatment of restless legs syndrome. While it is generally well-tolerated, it has potential side effects (like any medication). One of these side effects is sleepiness and thus it may be useful for some cases of insomnia. Other common side effects include leg swelling, muscle aches, dizziness, trouble walking, tremors, mood swings and fatigue. Neurontin will not worsen your underlying sleep apnea.

The 600 mg dose is at the lower end of the dosing of this medication and higher doses can be used under appropriate supervision. You should not adjust your dosing without speaking to your doctor first.

I strongly recommend you discuss your problems with your Sleep Specialist. There are a number of potential options for you and you have hope that your problems can be treated successfully.

To learn more about sleep apnea, insomnia, or other sleep disorders, please visit the American Academy of Sleep Medicine website. In addition to information, the website contains a list of Sleep Centers across the country so that you may locate one near you. The website Sleep Education.com also contains plenty of consumer friendly information about sleep and sleep apnea. Good luck and here's to better sleep!

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University