Lack of compliance on the part of CPAP patients continues to remain a key concern for sleep professionals. For this reason, physicians have explored the use of prescription sleep aids in conjunction with CPAP therapy. Now, a new study finds that patients with OSA who were given prescription sleep aids were no more likely to use their CPAP machines than patients with OSA taking a placebo. What’s the best way to help sleep apnea patients stay compliant?

About 42 million sleeping pill prescriptions were filled last year, according to the research company IMS Health, up nearly 60% since 2000. What’s more, the market for branded sleeping pills is currently at about $2 billion a year and could grow to approximately $3.8 billion, say analysts. By all appearances, it seems that prescription sleeping pills are working for Americans. That being the case, it might be tempting for physicians to prescribe a sleeping aid to a sleep apnea patient—especially in a case where the patient is having trouble adjusting to the therapy. But the latest research tells us a sleep drug is unlikely to make much of an impact when it comes to CPAP compliance.

The new study, published in the November issue of CHEST, finds that patients with OSA who were given prescription sleep aids were no more likely to use their CPAP machines than patients with OSA taking a placebo. The study’s lead author is Captain David A. Bradshaw, MD, FCCP, Naval Medical Center based in San Diego.

To determine the effect prescription sleep medications have on CPAP compliance, Bradshaw and colleagues compared CPAP use among 72 newly diagnosed male patients with a mean age of 38 who were referred for CPAP treatment. All patients participated in standardized CPAP training and were randomized to receive the sleeping agent zolpidem (N=24), a placebo pill (N=24), or standard care (N=24) with no sleeping pill or placebo. Patients taking zolpidem or placebo were instructed to take one pill each night, 30 minutes prior to bedtime for the first 14 days of treatment. During the four-week trial, an internal data chip recorded CPAP use.

Compared with the placebo pill and standard care groups, the zolpidem group did not show greater CPAP usage in terms of total days used or average time used per night over the course of four weeks. When the initial 14 days of CPAP treatment were analyzed separately, there was also no difference in number of days used or average nightly use.

Education is the Best Medicine

Bradshaw explained the rationale behind the new study. “CPAP treatment improves daytime alertness and quality of life for most patients with OSA and may prevent some of the long-term complications of this disorder, including heart attacks and strokes,” said Bradshaw. “Yet many people find CPAP difficult to use. People with a good initial experience are more likely to use CPAP regularly. Our hypothesis was that a sleeping pill might help new CPAP users adjust to sleeping with the equipment and promote long-term usage.”

Clearly, that hypothesis did not hold up. So just what is the prescription for successful CPAP compliance? Industry experts from physicians and respiratory therapists to sleep technicians seem to agree: Education. The most compliant patients are the best-educated patients.

“When used consistently, CPAP is a highly effective therapy for patients with obstructive sleep apnea,” said Mark J. Rosen, MD, FCCP, president of the American College of Chest Physicians. “More research is needed to determine interventions that can help optimize the initial experience.”

Indeed, medical equipment providers as well as health professionals insist that patients are more likely to comply with CPAP therapy if they are well informed and comfortable. Experts rely on everything from educational videos to ongoing customer service calls in an effort to increase compliance rates.

A Place for Prescription Sleep Drugs

Despite the results of the study, Bradshaw believes prescription sleep medications, when used correctly, may prove helpful in a subset of patients with OSA. “Studies have shown that almost half of patients with OSA have insomnia complaints,” said Bradshaw. “Our study does not support prescription sleeping pills for all new CPAP users, but OSA patients with insomnia symptoms might benefit.” Still researchers remain cautious regarding the use of prescription sleep medications for patients with OSA.

“We are concerned, however, about the potential risk for worsening sleep apnea if patients intentionally or inadvertently remove the mask before the effects of the sleeping pill have worn off,” said Bradshaw. “Also, sleeping pills sometimes have residual daytime effects, such as sleepiness, and can interfere with cognitive function—both of which are already problems for many patients with OSA, even after treatment with CPAP.”

With sleep apnea on the rise among the younger population, the earlier we teach compliance, the better. Recent research studies show that 10% to 12% of children snore. In another study, scientists studied over 1,014 adolescents between 13 and 16 years of age. They found that 20% of the teens snored at least a few nights per month and 6% snored every or nearly every night. What’s more, apnea-like symptoms affected from 2.5% to 6.1% of the adolescents studied.

The health care community must continue to provide sleep apnea patients the kind of care, training, education and understanding to help them stay compliant. For now, that appears to be the best medicine available.

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