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What's new in sleep medicine

What's new in sleep medicine
Authors:
April F Eichler, MD, MPH
Geraldine Finlay, MD
Alison G Hoppin, MD
Literature review current through: Feb 2022. | This topic last updated: Jan 27, 2022.

The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.

SLEEP-RELATED BREATHING DISORDERS

Positive airway pressure devices and risk of cancer (January 2022)

Most Philips positive airway pressure (PAP) devices have been recalled due to potential cancer and other health risks related to polyester-based polyurethane (PE-PUR) foam. However, limited human data support this claim. In a recent retrospective study, the risk of cancer (including lung cancer) was no different among those who had Philips or non-Philips devices (adjusted hazard ratio [HR] 0.94; 95% CI 0.71-1.25) [1]. However, several confounding variables were not included, and the duration of follow-up may not have been long enough to detect an increase in the risk of cancer. Although encouraging, further data are necessary before making firm conclusions regarding the risk of cancer or other adverse effects from PE-PUR-containing devices. (See "Management of obstructive sleep apnea in adults", section on 'Positive airway pressure therapy'.)

American Academy of Sleep Medicine guidance for surgical referral in obstructive sleep apnea (January 2022)

Guidance has been issued by the American Academy of Sleep Medicine (AASM) regarding when referral for surgery (eg, bariatric or upper airway) is appropriate among patents with obstructive sleep apnea (OSA). We agree with the AASM that while early discussion is encouraged, surgery for OSA should only be considered when positive airway pressure is declined, not tolerated, or ineffective for at least three months or longer [2,3]. (See "Management of obstructive sleep apnea in adults", section on 'Upper airway surgery'.)

Nonbenzodiazepine sedatives and adherence to CPAP (September 2021)

Nonadherence to continuous positive airway pressure (CPAP) therapy for patients with obstructive sleep apnea (OSA) is common. Whether sedatives should be used to encourage adherence was the subject of a recent meta-analysis of eight studies in >1000 patients with OSA [4]. Patients who were treated with nonbenzodiazepine sedatives had higher rates of adherence than those who did not receive sedatives (eg, 0.6 hour greater use per night, 12 percent increase in number of nights used). However, results were heavily influenced by trials that used one drug, eszopiclone, and data are conflicting. We do not suggest routine use of a sedative-hypnotic at the time of CPAP initiation and reserve this approach for patients who fail other interventions to address adherence. (See "Assessing and managing nonadherence with continuous positive airway pressure (CPAP) for adults with obstructive sleep apnea", section on 'Pharmacological therapy'.)

INSOMNIA

Daridorexant for treatment of insomnia in adults (January 2022)

Daridorexant, a dual orexin receptor antagonist (DORA), has been approved by the US Food and Drug Administration (FDA) for treatment of insomnia in adults [5]. Like lemborexant and suvorexant, daridorexant improves both subjective and objective measures of sleep onset and sleep maintenance compared with placebo [6]. Among the three DORAs, daridorexant has the shortest half-life (approximately eight hours) (table 1). For adults who fail or do not have access to cognitive behavioral therapy, we consider DORAs to be an acceptable first-line option for sleep maintenance insomnia, along with benzodiazepine receptor agonists (BZRAs) and low-dose doxepin (algorithm 1); for sleep-onset insomnia, we prefer trying medications with shorter half-lives first. (See "Pharmacotherapy for insomnia in adults", section on 'Dual orexin receptor antagonists'.)

CENTRAL DISORDERS OF HYPERSOMNOLENCE

Updated AASM guidelines for treatment of central disorders of hypersomnolence (November 2021)

Updated American Academy of Sleep Medicine (AASM) clinical practice guidelines for treatment of central disorders of hypersomnolence include treatment recommendations for adult and pediatric narcolepsy, idiopathic hypersomnia, Kleine-Levin syndrome, and medical disorders resulting in excessive daytime sleepiness [7]. A companion systematic review summarizes supporting data for specific medications [8]. There are now numerous effective medications for hypersomnia yet few comparative trials; treatment selection is therefore individualized based on symptom severity, medication efficacy and side effects, and patient comorbidities. (See "Treatment of narcolepsy in adults", section on 'Approach to pharmacotherapy' and "Management and prognosis of narcolepsy in children", section on 'Overview of approach' and "Idiopathic hypersomnia", section on 'Pharmacotherapy' and "Kleine-Levin syndrome (recurrent hypersomnia)", section on 'Symptom-based pharmacotherapy'.)

Mixed oxybate salts approved for idiopathic hypersomnia (August 2021)

Mixed oxybate salts (Xywav) have received US Food and Drug Administration (FDA) approval for treatment of adults with idiopathic hypersomnia [9]. Approval was based on results of a randomized discontinuation trial in 154 patients with idiopathic hypersomnia, in which mixed oxybate salts were more effective than placebo as measured by Epworth Sleepiness Scale (ESS) scores [10]. Side effects were consistent with those observed in patients with narcolepsy, most commonly nausea, headache, anxiety, and dizziness. Oxybates have potential for misuse and abuse and are regulated in the United States by the Risk Evaluation and Mitigation Strategies program. Although modafinil/armodafinil and stimulants remain our preferred first-line options based on safety, availability, and cost, oxybates are reasonable to offer as second-line therapy. (See "Idiopathic hypersomnia", section on 'Pharmacotherapy'.)

CIRCADIAN RHYTHM SLEEP-WAKE DISORDERS

Effects of rotating work shift direction on sleep and performance (November 2021)

Sleep duration and sleep quality are commonly affected in shift workers, and certain patterns of shift rotation may be more difficult than others. In a cohort study of 144 nurses working shifts that were either forward-rotating (ie, morning, then afternoon, then overnight) or backward-rotating, both schedules were associated with adverse performance, but levels of sleepiness and decrements in vigilance and reaction time were greater among those on a backward-rotating schedule [11]. These data confirm previous impressions that individuals may find it easier to adjust to forward-rotating shift schedules, particularly if the speed of rotation is slow (eg, >4 days per shift assignment). (See "Sleep-wake disturbances in shift workers", section on 'Sleep disturbances'.)

PARASOMNIAS AND SLEEP-RELATED MOVEMENT DISORDERS

Updated guidelines for management of restless legs syndrome (October 2021)

Updated consensus-based guidelines for the management of restless legs syndrome (RLS) have been published by the RLS Foundation [12]. For chronic persistent RLS in adults despite appropriate iron supplementation, the guideline suggests first-line therapy with an alpha-2-delta calcium channel ligand (gabapentin, gabapentin enacarbil, or pregabalin), except when certain comorbidities are present (eg, obesity, moderate to severe depression, gait instability, respiratory disease, or a history of substance use disorder). In such cases, a non-ergot dopamine agonist (pramipexole, ropinirole, rotigotine) is preferred initially, with monitoring for complications such as augmentation and impulse control disorders. Our approach is consistent with these guidelines (algorithm 2). (See "Management of restless legs syndrome and periodic limb movement disorder in adults", section on 'Choice of therapy'.)

PEDIATRIC SLEEP MEDICINE

Intravenous iron in pediatric restless legs syndrome (October 2021)

Oral iron supplementation is considered first-line therapy for children with restless legs syndrome (RLS) who have a low serum ferritin. For those who fail to absorb or do not tolerate oral iron, intravenous (IV) iron is an option, but supporting evidence in this setting is limited. In a retrospective study of 39 children with RLS or periodic limb movement disorder (PLMD) treated with a single dose of IV iron, clinical symptoms were much or very much improved in all but one patient; laboratory parameters also improved, and there were few adverse events [13]. Although randomized trials are needed, these data support selective use of IV iron in children with RLS who have low iron stores and fail oral iron. (See "Restless legs syndrome and periodic limb movement disorder in children", section on 'Iron supplementation'.)

Sleep problems in children with ADHD during the COVID-19 pandemic (September 2021)

Sleep disturbances are common in children with attention deficit hyperactivity disorder (ADHD), and home confinement associated with the COVID-19 pandemic has exacerbated prepandemic problems. In a survey study of nearly 1000 parents of children aged 5 to 18 years with ADHD, 60 to 70 percent of children had a change in bedtime during confinement, and the frequency of bedtimes later than 11 PM substantially increased [14]. Sleep duration changes were bidirectional, with more children sleeping less than 6 hours or between 10 and 11 hours per night. Management of sleep problems in children with ADHD begins with setting consistent sleep-wake schedules and treating behavioral contributors such as excess screen time near bedtime and anxiety (table 2A-B). (See "Sleep in children and adolescents with attention deficit hyperactivity disorder", section on 'Common sleep complaints'.)

GENERAL SLEEP MEDICINE

Updated protocol guidance for quantifying sleepiness (October 2021)

The American Academy of Sleep Medicine (AASM) has released updated protocol recommendations for the Multiple Sleep Latency Test (MSLT) and Maintenance of Wakefulness Test (MWT) [15]. The guidance covers patient preparation and sleep prior to testing, management of medications and substances that may interfere with test results, optimum testing conditions, and specific testing procedures. For both tests, patients should have adequate sleep documented by sleep diary or actigraphy for two weeks leading up to testing, and medications and substances with alerting, sedating, and/or rapid eye movement (REM)-modulating properties should be discontinued at least two weeks before the MSLT. (See "Quantifying sleepiness", section on 'Protocol'.)

REFERENCES

  1. Kendzerska T, Leung RS, Boulos MI, et al. An Association between Positive Airway Pressure Device Manufacturer and Incident Cancer? A Secondary Data Analysis. Am J Respir Crit Care Med 2021; 204:1484.
  2. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021; 17:2499.
  3. Kent D, Stanley J, Aurora RN, et al. Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:2507.
  4. Wang D, Tang Y, Chen Y, et al. The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis. Sleep 2021; 44.
  5. Quviviq (daridorexant) prescribing information. https://www.idorsia.us/documents/us/label/Quviviq_PI.pdf.
  6. Mignot E, Mayleben D, Fietze I, et al. Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials. Lancet Neurol 2022; 21:125.
  7. Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med 2021; published online April 23, 2021.
  8. Maski K, Trotti LM, Kotagal S, et al. Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment. J Clin Sleep Med 2021; 17:1895.
  9. https://pp.jazzpharma.com/pi/xywav.en.USPI.pdf (Accessed on August 17, 2021).
  10. Dauvilliers Y, Arnulf I, Foldvary-Schaefer N, et al. Safety and efficacy of lower-sodium oxybate in adults with idiopathic hypersomnia: a phase 3, placebo-controlled, double-blind, randomised withdrawal study. Lancet Neurol 2022; 21:53.
  11. Di Muzio M, Diella G, Di Simone E, et al. Comparison of Sleep and Attention Metrics Among Nurses Working Shifts on a Forward- vs Backward-Rotating Schedule. JAMA Netw Open 2021; 4:e2129906.
  12. Silber MH, Buchfuhrer MJ, Earley CJ, et al. The Management of Restless Legs Syndrome: An Updated Algorithm. Mayo Clin Proc 2021; 96:1921.
  13. DelRosso LM, Ferri R, Chen ML, et al. Clinical efficacy and safety of intravenous ferric carboxymaltose treatment of pediatric restless legs syndrome and periodic limb movement disorder. Sleep Med 2021; 87:114.
  14. Bruni O, Giallonardo M, Sacco R, et al. The impact of lockdown on sleep patterns of children and adolescents with ADHD. J Clin Sleep Med 2021; 17:1759.
  15. Krahn LE, Arand DL, Avidan AY, et al. Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine. J Clin Sleep Med 2021; 17:2489.
Topic 107235 Version 10977.0

References

1 : An Association between Positive Airway Pressure Device Manufacturer and Incident Cancer? A Secondary Data Analysis.

2 : Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine clinical practice guideline.

3 : Referral of adults with obstructive sleep apnea for surgical consultation: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

4 : The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis.

5 : The effect of non-benzodiazepine sedative hypnotics on CPAP adherence in patients with OSA: a systematic review and meta-analysis.

6 : Safety and efficacy of daridorexant in patients with insomnia disorder: results from two multicentre, randomised, double-blind, placebo-controlled, phase 3 trials.

7 : Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine clinical practice guideline

8 : Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

9 : Treatment of central disorders of hypersomnolence: an American Academy of Sleep Medicine systematic review, meta-analysis, and GRADE assessment.

10 : Safety and efficacy of lower-sodium oxybate in adults with idiopathic hypersomnia: a phase 3, placebo-controlled, double-blind, randomised withdrawal study.

11 : Comparison of Sleep and Attention Metrics Among Nurses Working Shifts on a Forward- vs Backward-Rotating Schedule.

12 : The Management of Restless Legs Syndrome: An Updated Algorithm.

13 : Clinical efficacy and safety of intravenous ferric carboxymaltose treatment of pediatric restless legs syndrome and periodic limb movement disorder.

14 : The impact of lockdown on sleep patterns of children and adolescents with ADHD.

15 : Recommended protocols for the Multiple Sleep Latency Test and Maintenance of Wakefulness Test in adults: guidance from the American Academy of Sleep Medicine.