Central Sleep Apnea Medication

  • Author: Kendra Becker, MD, MPH; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jan 22, 2010
 

Medication Summary

Due to the heterogeneity of the central sleep apnea syndromes, different medications have been used under different circumstances. No single medication can be considered a drug of choice.[1] Several different medications aimed at improving central sleep apnea include acetazolamide, theophylline, and sedative-hypnotic agents.

  • Acetazolamide (Diamox): Acetazolamide is a carbonic anhydrase inhibitor that causes bicarbaturia and metabolic acidosis, which presumably shifts the apneic threshold of PaCO2 to a lower level. It has been shown to be effective therapy in primary central sleep apnea and CSB in patients with heart failure and in the treatment of high-altitude periodic breathing.
  • Theophylline: This agent has been studied in patients with heart failure and was found to be effective in attenuating CSB.[34] It may also be effective for high-altitude periodic breathing.
  • Sedative hypnotics: These agents have been used successfully in treating nonhypercapnic central sleep apnea. Temazepam and zolpidem have been shown to be effective under these circumstances and are believed to work by consolidating the sleep pattern, thus minimizing the instability in ventilation induced by sleep-wake transitions. A case series showed zolpidem reduced central apneas, and the overall apnea-hypopnea index, without worsening obstructive events.[35]
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Carbonic Anhydrase Inhibitor

Class Summary

To induce metabolic acidosis and increase baseline ventilation.

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Acetazolamide (Diamox)

 

Carbonic anhydrase inhibitor for acclimatization to altitude in HACE and AMS. Helps prevent AMS in forced rapid ascent or in patients with history of repeated AMS. Improves symptomatic periodic breathing and hypoxia experienced at high altitudes. Not indicated for general prophylaxis of AMS. Treatment of AMS may be discontinued when patient is asymptomatic.

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Benzodiazepines

Class Summary

To promote deeper stages of sleep.

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Temazepam (Restoril)

 

Intermediate rate of absorption and duration of action make this drug useful for treating initial and middle insomnia. Has no active metabolites, which reduce cognitive impairment and grogginess the following day.

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Nonbenzodiazepine sedative hypnotic

Class Summary

To consolidate sleep.

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Zolpidem (Ambien)

 

Rapidly absorbed, with fast onset of action (20-30 min), which makes this a good drug for sleep induction. The ER product (Ambien CR) consists of a coated 2-layer tab and is useful for insomnia characterized by difficulties with sleep onset and/or sleep maintenance. First layer releases drug content immediately to induce sleep, whereas second layer gradually releases additional drug to provide continuous sleep.

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Phosphodiesterase inhibitor

Class Summary

Respiratory stimulant.

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Theophylline (Theo-dur)

 

Has a number of physiological effects, including increases in collateral ventilation, respiratory muscle function, mucociliary clearance, and central respiratory drive. Partially acts by inhibiting phosphodiesterase, elevating cellular cyclic AMP levels, or antagonizing adenosine receptors in bronchi, resulting in relaxation of smooth muscle. However, clinical efficacy is controversial, especially in acute setting

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Contributor Information and Disclosures
Author

Kendra Becker, MD, MPH  Sleep Medicine Department, Kaiser Permanente Fontana Medical Center

Kendra Becker, MD, MPH is a member of the following medical societies: American Academy of Sleep Medicine, American College of Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Jeanne M Wallace, MD, MPH  Professor of Clinical Medicine, University of California at Los Angeles School of Medicine

Jeanne M Wallace, MD, MPH is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Sat Sharma, MD, FRCPC  Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St Boniface General Hospital

Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Daniel R Ouellette, MD, FCCP  Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System

Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society

Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching; Astra Zeneca Honoraria Speaking and teaching

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author, Rahul K Kakkar, MD, FCCP, FAASM, to the development and writing of this article.

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The role of loop gain in determining respiratory instability. A) When loop gain is less than 1, the tendency for an overshoot of the corrective response to an apnea or hypopnea is lessened, and ventilation returns to a steady pattern. B) When loop gain is greater than or equal to 1, the vigorous responses to respiratory disturbances result in continuous oscillation between the events and the corrections, resulting in an unstable periodic breathing pattern. Adapted from White DP Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. Dec 1 2005;172(11):1363-70.
This polysomnogram demonstrates central sleep apnea and Biot respiration in a patient receiving long-term morphine for chronic pain. The Biot pattern may be irregular without any type of periodicity, or it can consist of runs of similar-sized breaths alternating with central apneas.
Obstructive sleep apnea (OSA): This polysomnogram demonstrates typical hypopneas occurring in OSA prior to continuous positive airway pressure titration. In OSA, airflow is absent or reduced, but ventilatory effort persists.
Cheyne Stokes: This polysomnogram represents Cheyne Stokes breathing and occurred subsequent to continuous positive airway pressure titration for OSA in the same patient in the previous media file. Cheyne Stokes breathing has a classic crescendo-decrescendo breathing pattern.
 
 
 
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