Combination Therapy to Treat Sleep Apnea

Combination Therapy for the Treatment of Obstructive Sleep Apnea

In Obstructive sleep apnea (OSA), the upper airway closes over and over again during sleep. This leads to disrupted sleep (waking up during the night), daytime sleepiness, and an increased risk for developing high blood pressure. Currently, the best treatment for obstructive sleep apnea is sleeping with a mask that continuously blows air into the nose (i.e. Continuous positive airway pressure [CPAP] treatment). While CPAP treatment stops the upper airway from closing in most people, many people have difficulty sleeping with the mask in place and therefore do not use the CPAP treatment. This research study is being conducted to learn whether using a combination of therapies (i.e. a sedative and oxygen therapy) will improve OSA severity by altering some of the traits that are responsible for the disorder.

Study Overview

• Status: Completed
• Conditions: Sleep Apnea, Obstructive
• Intervention / Treatment: Drug: Placebo pill; Other: Room air; Drug: Sedative; Other: Oxygen

Detailed Description

Obstructive sleep apnea (OSA) is characterized by repetitive collapse or 'obstruction' of the pharyngeal airway during sleep. These obstructions result in repetitive hypopneas/apneas and intermittent hypoxia/hypercapnia, as well as surges in sympathetic activity. Such processes disturb normal sleep and impair neurocognitive function, often resulting in excessive daytime sleepiness and decreased quality of life. Furthermore, OSA is associated with cardiovascular morbidity and mortality, making OSA a major health concern.

Current evidence suggests that OSA pathogenesis involves the interactions of at least four physiological traits comprising 1) the pharyngeal anatomy and its propensity towards collapse 2) the ability of the upper airway dilator muscles to activate and reopen the airway during sleep (i.e. neuromuscular compensation), 3) the arousal threshold from sleep (i.e. the propensity for hypopneas/apneas to lead to arousal and fragmented sleep) and 4) the stability of the ventilatory feedback loop (i.e. loop gain). Continuous positive airway pressure (CPAP) is the most common treatment for OSA but it is often poorly tolerated; only ~50% of patients diagnosed with OSA continue therapy beyond 3 months. Given this limitation, alternative approaches have been tested and have generally focused on the use of oral appliances, surgery, and more recently pharmacological agents.

However, these alternate therapies, when used alone as monotherapy, rarely abolish OSA completely. This is not that surprising given that these treatments focus primarily on correcting only one trait and ignore the fact that the pathogenesis of OSA is multi-factorial. Thus the investigators hypothesize that some patients could be treated without CPAP if more than one trait is targeted (i.e., the investigators take a multi-factorial treatment approach). Such a multi-factorial approach is not unusual in Medicine. Many disorders such as diabetes, asthma, hypertension, cancer and congestive heart failure are treated with more than one medication or modality. In our view, giving CPAP to all OSA patients is like treating every diabetic with insulin, or every asthmatic with oral steroids - these treatments, like CPAP, are poorly tolerated and ignore the complexity of the underlying biology.

The investigators recently published a technique that measures the four traits using repeated 'drops' in CPAP levels during sleep. Each trait is measured in a way that allows model-based predictions of the presence/absence of OSA. With this technique the investigators demonstrated in a small group of CPAP-treated OSA subjects that decreasing the sensitivity of the ventilatory feedback loop (i.e. reducing loop gain) by approximately 50% with either acetazolamide or oxygen reduces the apnea/hypopnea index (AHI) by half. Interestingly, our model allowed us to make the prediction that if, in addition to an agent that reduces loop gain, the investigators also gave a drug that increases the arousal threshold by at least 25%, then the investigators could potentially abolish OSA (rather than just reduce its severity by 50%). This is of great interest given that the investigators already have shown than eszopiclone increases the arousal threshold by approximately 30% and is associated with an improvement in the AHI. However, to date there has been no study examining the combination of an agent that reduces loop gain (i.e. oxygen) with one that increases the arousal threshold (i.e. eszopiclone) as a treatment for OSA.

To determine the effect of combination therapy on each of the four traits and how they contribute to our model prediction of OSA, as well as on apnea severity. Specifically the investigators will assess:

1. The physiological traits responsible for OSA:

   1. Pharyngeal anatomy and its propensity towards collapse
   2. The ability of the upper airway dilator muscles to activate and reopen the airway during sleep (i.e. neuromuscular compensation)
   3. Arousal threshold from sleep (i.e. the propensity for hypopneas/apneas to lead to arousal and fragmented sleep).
   4. Stability of the ventilatory control system feedback loop (i.e. loop gain)
2. The severity of OSA (apnea-hypopnea index (AHI), percent of time with unstable breathing, sleep quality)

STUDY DESIGN:

A single-blinded randomized control design will be used. Initially, participants will be randomized to either the treatment or placebo arm where they will have both a clinical and research polysomnography (PSG); these initial PSGs constitute what will be referred to as VISIT 1 (see outcome measures). The purpose of the clinical PSG is to determine the severity of OSA (i.e. AHI). The research PSG will measure the 4 physiological OSA traits.

During the treatment arm, in both PSGs (i.e. clinical and research) participants will be given eszopiclone (3mg by mouth) to take before bed and be placed on oxygen throughout the night. During the placebo arm, subjects will be given a placebo to take before bed and placed on room air while they sleep. Participants will then have at least a 1-week washout period and cross over to the other arm of the study whereby the clinical and research PSG will be repeated; these studies constitute what will be referred to asVISIT 2 (see outcome measures).

• Study Type: Interventional
• Enrollment (Actual): 22
• Phase: Not Applicable

Contacts and Locations

Study Locations

• United States
  • Massachusetts
    • Boston, Massachusetts, United States, 02115
      • Brigham and Women's Hospital

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 79 years (Adult, Older Adult)
• Accepts Healthy Volunteers: No
• Genders Eligible for Study: All

Description

Inclusion Criteria:

• Ages 18 - 79 years
• Documented OSA (AHI > 10 events/hr Non rapid eye movement sleep supine)
• If treated then, current CPAP use (>4 hrs CPAP/night for > 2 months)

Exclusion Criteria:

• Any uncontrolled medical condition
• Any other sleep disorder (Periodic leg movement syndrome, restless legs syndrome, insomnia, etc.)
• Use of medications known to affect sleep/arousal, breathing, or muscle physiology
• Allergy to lidocaine or Afrin
• Claustrophobia
• Alcohol consumption within 24 hours of PSG

Study Plan

How is the study designed?

Design Details

• Primary Purpose: Basic Science
• Allocation: Randomized
• Interventional Model: Crossover Assignment
• Masking: Single

Number of Arms

2

Arms and Interventions

Participant Group / Arm	Intervention / Treatment
Placebo Comparator: Placebo; Subjects will receive both a sugar pill and room air during their overnight sleep studies	Drug: Placebo pill; Subjects will receive a sugar pill (in combination with room air) during their placebo arm studies; Other Names: sugar pill; Other: Room air; Subjects will receive room air (in combination with a sugar pill) during their placebo arm studies
Active Comparator: Treatment; Subjects will receive both Lunesta (eszopiclone) and medical grade oxygen during their overnight sleep studies	Drug: Sedative; Subjects will receive eszopiclone (in combination with medical oxygen) during their treatment arm studies; Other Names: Lunesta; Other: Oxygen; Subjects will receive medical grade oxygen (in combination with eszopiclone) during their treatment arm studies

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Model Prediction of Absence/Presence of OSA: Ventilation That Causes an Arousal From Sleep (Varousal)	Our published method estimates 4 important physiological traits causing OSA: 1) pharyngeal anatomy, 2) loop gain, 3) the ability of the upper airway to dilate/stiffen in response to increases in ventilatory drive, and 4) arousal threshold. Each individual's set of traits is then entered into a physiological model of OSA that graphically illustrates the relative importance of each trait in that individual. In this table the investigators report the minimum ventilation that can be tolerated before an arousal from sleep (Varousal). It is calculated by slowly reducing the CPAP level from optimum to the minimum tolerable pressure. This trait is symbolized as Varousal (L/min)	Subjects will be assessed on day 1 (visit 1) and up to 1 month (visit 2)
Model Prediction of Absence/Presence of OSA: Ventilatory Control Sensitivity (Loop Gain)	Our published method estimates 4 important physiological traits causing OSA: 1) pharyngeal anatomy, 2) loop gain, 3) the ability of the upper airway to dilate/stiffen in response to increases in ventilatory drive, and 4) arousal threshold. Each individual's set of traits is then entered into a physiological model of OSA that graphically illustrates the relative importance of each trait in that individual and predicts OSA presence/absence. In this table the investigators report the ventilatory control sensitivity value (Loop Gain). It is calculated dividing the increase in ventilatory drive by the steady state reduction in ventilation. The increase in ventilatory drive is measured as the ventilatory overshoot following a switch to optimal CPAP from the minimum tolerable CPAP. This trait is symbolized as steady state loop gain (LG, adimensional)	Subjects will be assessed on day 1 (visit 1) and up to 1 month (visit 2)
Model Prediction of Absence/Presence of OSA: Passive Collapsibility	Our published method estimates 4 important physiological traits causing OSA: 1) pharyngeal anatomy, 2) loop gain, 3) the ability of the upper airway to dilate/stiffen in response to increases in ventilatory drive, and 4) arousal threshold. Each individual's set of traits is then entered into a physiological model of OSA that graphically illustrates the relative importance of each trait in that individual and predicts OSA presence/absence. The passive collapsibility of the upper airway is quantified as the ventilation on no CPAP (atmospheric pressure) at the eupneic level of ventilatory drive when upper airway dilator muscles are relatively passive. This trait is symbolized as Vpassive (L/min)	Subjects will be assessed on day 1 (visit 1) and up to 1 month (visit 2)
Model Prediction of Absence/Presence of OSA: Active Collapsibility (Vactive)	Our published method estimates 4 important physiological traits causing OSA: 1) pharyngeal anatomy, 2) loop gain, 3) the ability of the upper airway to dilate/stiffen in response to increases in ventilatory drive, and 4) arousal threshold. Each individual's set of traits is then entered into a physiological model of OSA that graphically illustrates the relative importance of each trait in that individual and predicts OSA presence/absence. Active collapsibility is the ventilation on no CPAP when upper airway muscle are maximally activated. It is calculated by slowing reducing CPAP from the optimal to the minimum tolerable level and rapidly dropping the CPAP to 0 for a few breaths. This trait is symbolized as Vactive (L/min)	Subjects will be assessed on day 1 (visit 1) and up to 1 month (visit 2)

Secondary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Apnea-Hypopnea Index	The Apnea-Hypopnea Index (AHI) is an index of sleep apnea severity that encompasses the frequency of apneas (cessations in breathing) and hypopneas (reductions in airflow).	Subjects will be assessed on day 1 (visit 1) and up to 1 month (visit 2)

Collaborators and Investigators

• Sponsor: Brigham and Women's Hospital
• Collaborators: National Heart, Lung, and Blood Institute (NHLBI)
• Investigators: Principal Investigator: David A Wellman, MD, Brigham & Womens Hospital

Publications and helpful links

General Publications

• Landry SA, Joosten SA, Sands SA, White DP, Malhotra A, Wellman A, Hamilton GS, Edwards BA. Response to a combination of oxygen and a hypnotic as treatment for obstructive sleep apnoea is predicted by a patient's therapeutic CPAP requirement. Respirology. 2017 Aug;22(6):1219-1224. doi: 10.1111/resp.13044. Epub 2017 Apr 13.
• Edwards BA, Sands SA, Owens RL, Eckert DJ, Landry S, White DP, Malhotra A, Wellman A. The Combination of Supplemental Oxygen and a Hypnotic Markedly Improves Obstructive Sleep Apnea in Patients with a Mild to Moderate Upper Airway Collapsibility. Sleep. 2016 Nov 1;39(11):1973-1983. doi: 10.5665/sleep.6226.

Study record dates

Study Major Dates

• Study Start: August 1, 2012
• Primary Completion (Actual): December 1, 2014
• Study Completion (Actual): December 1, 2014

Study Registration Dates

• First Submitted: June 25, 2012
• First Submitted That Met QC Criteria: July 2, 2012
• First Posted (Estimate): July 4, 2012

Study Record Updates

• Last Update Posted (Actual): March 3, 2017
• Last Update Submitted That Met QC Criteria: January 11, 2017
• Last Verified: January 1, 2017

More Information

Terms related to this study

• Additional Relevant MeSH Terms: Nervous System Diseases; Respiratory Tract Diseases; Respiration Disorders; Sleep Disorders, Intrinsic; Dyssomnias; Sleep Wake Disorders; Signs and Symptoms, Respiratory; Sleep Apnea Syndromes; Sleep Apnea, Obstructive; Apnea; Physiological Effects of Drugs; Central Nervous System Depressants; Hypnotics and Sedatives
• Other Study ID Numbers: BWH-2012P000956; 5R01HL102321-02 (U.S. NIH Grant/Contract)

Plan for Individual participant data (IPD)

• Plan to Share Individual Participant Data (IPD)?: Undecided