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Am Fam Physician. 2010;81(9):1156

Background: Continuous positive airway pressure (CPAP) is considered first-line therapy for patients with obstructive sleep apnea (OSA); however, about one half of patients stop therapy within one year. Initial CPAP use has been shown to predict long-term adherence, and strategies to maximize initial use could reduce the eventual abandonment of therapy. Prescribing a short-term course of a nonbenzodiazepine sedative-hypnotic when initiating CPAP therapy is one potential strategy. Lettieri and colleagues conducted a randomized controlled trial to determine if an initial short course of eszopiclone (Lunesta) would improve long-term CPAP adherence.

The Study: The authors recruited patients newly diagnosed with OSA who were initiating CPAP therapy. All patients received formal mask-fitting, and were randomized to receive 3 mg of eszopiclone or a placebo nightly for the first 14 nights of CPAP therapy. During the next six months, CPAP use was monitored by a smart card adherence-monitoring device that was integrated into the CPAP units. Patients were excluded if they had a long-term history of taking hypnotic medications, drank more than two alcoholic beverages per night, were pregnant, or had been diagnosed with a hepatic disease or a psychiatric condition that would preclude completion of the study.

Results: A total of 154 patients with similar baseline traits were randomized to receive eszopiclone or placebo. The eszopiclone group used their CPAP machines more often than the control group (64.4 versus 45.2 percent of nights), and for a longer period on average (4.05 versus 3.02 hours per night. Patients using placebo were nearly twice as likely to discontinue CPAP therapy (hazard ratio = 1.90) as patients using eszopiclone. Results were unrelated to apnea severity, age, or baseline sleepiness scores.

Conclusion: The authors conclude that an initial two-week course of eszopiclone in patients with OSA increases their CPAP adherence, and significantly decreases discontinuation rates within the first six months of use.

editor's note: Although nonbenzodiazepine agents can be used in patients with OSA, the findings in this study with eszopiclone may not be generalizable to similar agents. A randomized trial using zolpidem (Ambien) under similar circumstances did not improve CPAP adherence.1 No studies examining initial therapy with zaleplon (Sonata) or ramelteon (Rozerem) and its effect on CPAP adherence were identified.—k.t.m.

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