Obstructive Sleep Apnea (OSA) Medication

Updated: Mar 22, 2019
  • Author: Himanshu Wickramasinghe, MD, MBBS; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Medication

Medication Summary

Pharmacologic therapy is generally not a part of the primary treatment recommendations. Acetazolamide, medroxyprogesterone, fluoxetine, and protriptyline have been used to treat obstructive sleep apnea (OSA); however, these medications are not recommended. Modafinil is approved by the US Food and Drug Administration (FDA) for use in patients who have residual daytime sleepiness despite optimal use of CPAP. The most improvement has been seen in patients who have taken modafinil at doses of 200-400 mg/d. Armodafinil, the R-enantiomer of modafinil, is also now FDA approved for use in these patients.

Solriamfetol, a dopamine/norepinephrine reuptake inhibitor (DNRI), was approved in 2019 and is indicated to improve wakefulness in patients with excessive daytime sleepiness who have OSA.

The American Academy of Sleep Medicine (AASM), in a practice parameter and review of medical therapies for OSA, [153, 218] listed the use of protriptyline as a guideline (patient care strategy based on level 2 or 3 evidence). [218] The use of modafinil was recommended for the treatment of residual sleepiness in persons with OSA and was considered a standard treatment (generally accepted patient care strategy with level 1 or excellent level 2 evidence).

The parameters state as standards that selective serotonin reuptake inhibitors, methylxanthines, and estrogen replacement therapy should not be considered for the treatment of OSA.

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CNS stimulants

Class Summary

Central nervous system (CNS) stimulants may be used to promote daytime wakefulness in sleep apnea patients who have residual daytime sleepiness despite optimal use of continuous positive airway pressure (CPAP). They treat fatigue without interfering with normal sleep architecture. Modafinil and armodafinil are indicated for OSA.

Modafinil (Provigil)

The mechanism of action of modafinil in wakefulness is unknown. It has wake-promoting actions similar to sympathomimetic agents. It is indicated as adjunctive treatment to standard therapy for OSA/hypopnea syndrome to improve wakefulness in patients with excessive sleepiness.

Armodafinil (Nuvigil)

Armodafinil is the R-enantiomer of modafinil (mixture of R- and S-enantiomers). It elicits wake-promoting actions similar to sympathomimetic agents, although its pharmacologic profile is not identical to those of sympathomimetic amines. In vitro, armodafinil binds dopamine transporters and inhibits dopamine reuptake. It is not a direct- or indirect-acting dopamine receptor agonist. It is indicated to improve wakefulness in individuals with excessive sleepiness associated with narcolepsy, OSA, or shift-work sleep disorder.

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Dopamine/Norepinephrine Reuptake Inhibitors

Class Summary

The mechanism of action by which solriamfetol improves wakefulness in patients with excessive daytime sleepiness associated with narcolepsy is unclear, but is thought to be mediated through its inhibition of dopamine/norepinephrine reuptake. 

Solriamfetol (Sunosi)

Solriamfetol is a dopamine/norepinephrine reuptake inhibitor (DNRI). It is indicated to improve wakefulness in adults with excessive daytime sleepiness associated with OSA.

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