Home' Australian Pharmacist : Australian Pharmacist February 2015 Contents Australian Pharmacist February 2015 I ©Pharmaceutical Society of Australia Ltd.
CONTINUING PROFESSIONAL DEVELOPMENT
(CPAP) delivered via a nasal or oro-nasal
mask, during sleep.
CPAP has significant
benefits for the patient, including an
improvement in daytime sleepiness for
most patients.9 It also improves quality
of life, reduces driving risk and reduces
cardiovascular risk factors associated
It is believed that CPAP works
by maintaining a positive transmural
pressure (splinting open the airway walls)
which acts to increase end-expiratory
lung volume leading to a stabilised
Adherence to CPAP
therapy is approximately 60–70%.
In addition, lifestyle modifications are
extremely important for patients with OSA.
In overweight patients, weight loss can
assist with symptom control, and alcohol
consumption should be restricted to less
than two units per evening (alcohol can
relax the pharyngeal muscles, increasing
the chances of airway collapse).
In addition, smoking cessation can reduce
the irritant effects of cigarette smoke, which
can cause swelling of the pharyngeal space
and worsen OSA, and associated snoring.
Other treatment options which are used
for OSA include mandibular advancement
splints (MAS) which work to hold the
mandible (and hence tongue) forward to
reduce it from falling to the back of the
throat causing an airway obstruction.
Surgery is an option in some cases, but
is not likely to cure OSA.
therapy with modafinil is indicated for the
treatment of sleepiness associated with
OSA, in combination with CPAP therapy.9,11
The mode of action of modafinil for this
indication is not well defined.
One month later, Simon returns to the
pharmacy with an update. He visited
his doctor, who arranged for some
tests to be conducted. Simon stayed
at a sleep clinic over night, and he was
subsequently diagnosed with OSA.
He has started to use CPAP and although
it is taking some time to get used to
this new therapy, it has significantly
improved his sleep quality, and his
daytime sleepiness has subsided. He has
also been referred to a dietitian for some
weight loss advice, and he is continuing
the nicotine replacement therapy you
provided him previously. Simon thanks
you for taking the time to investigate his
symptoms so thoroughly.
KEY LEARNING POINTS
• There are various potential causes of
excessive daytime sleepiness. In the
presence of other symptoms, such as
nocturnal gasping, morning headache
and depression, pharmacists should
refer patients to their doctor for
• OSA is a very common condition,
and can be easily overlooked in shift
workers, due to the assumption of
circadian rhythm sleep disorders.
1. Kallweit U, Siccoli M, Poryazova R, et al. Excessive
daytime sleepiness in idiopathic restless legs syndrome:
characteristics and evolution under dopaminergic
treatment. Eur Neurol 2009;62:176–9.
2. Nagandla K, De S. Restless legs syndrome:
pathophysiology and modern management. Postgrad
Med J 2013;89:402–10.
3. Garber J, Cobin R, Gharib H, et al. Clinical practice
guidelines for hypothyroidism in adults: cosponsored
by the American association of clinical endocrinologists
and the American thyroid association. Endocr Pract
4. Sleep health foundation. Narcolepsy. 2011. At: http://
5. De la Herran-Arita A, Garcia-Garcia F. Current emerging
opinions for the drug treatment of narcolepsy. Drugs
6. Billard M. Narcolepsy: current treatment options
and future approaches. Neuropsychiatr Dis Treat
7. Roehrs T, Roth T. Sleep, sleepiness and alcohol use. Alcohol
Res Health 2001;25(2):101–9 .
8. Chakravorty S, Jackson N, Chaudhary N, et al. Daytime
sleepiness: associations with alcohol use and sleep
duration in Americans. Sleep Disorders. 2014. At: http://
9. Pagel J. Excessive daytime sleepiness. Am Fam Phys
10. Guilleminault C, Brooks S. Excessive daytime sleepiness:
a challenge for the practising neurologist. Brain
11. Rossi S, ed. Australian medicines handbook. Adelaide:
Australian Medicines Handbook; 2015. At: www.amh.net.
12. Zisapel N. Circadian rhythm sleep disorders. CNS Drugs
13. Jordan A, McSHarry D, Malhotra A. Adult obstructive sleep
apnoea. Lancet 2014;383:736–47 .
14. Australasian sleep association. Obstructive sleep apnoea.
15. Greenstone M, Hack M. Obstructive sleep apnoea. BMJ
16. Jacobsen J, Shi L, Mokhlesi B. Factors associated with
excessive daytime sleepiness in patients with severe
obstructive sleep apnea. Sleep Breath 2013;17:629–35.
17. Chapman J, Kempler L, Chang C, et al. Modafinil improves
daytime sleepiness in patients with mild to moderate
obstructive sleep apnoea not using standard treatments:
a randomised placebo-controlled cross over trial. Thorax
18. Epworth Sleepiness Scale. At: http://
1. A patient presents to the pharmacy
with excessive daytime sleepiness
and cataplexy. They are most likely
a) Restless leg syndrome.
b) Circadian rhythm disorder.
c) Obstructive sleep apnoea.
2. Risk factors of obstructive sleep
a) BMI >25 kg/m2
b) Female gender.
c) Small sized tonsils.
d) Cigarette smoking.
3. Centrally acting medicine which can
cause daytime sedation include:
4. Restless legs syndrome:
a) Only occurs during the day time.
b) Occurs in the absence of any sensory
c) Is not associated with daytime
d) May cause daytime sleepiness due to
serotonin neurotransmitter dysfunction.
5. Alcohol consumption can worsen
obstructive sleep apnoea due to:
a) Irritant effects on the airways leading to
b) Relaxant effects on the pharyngeal
muscles increasing the chance of airway
c) Swelling of the pharyngeal space
leading to apnoea.
d) An unknown cause.
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