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Topiramate for Obstructive Sleep Apnea and Snoring

To the Editor: Characterized by a symptom profile that includes snoring, excessive daytime somnolence, and reports of respiratory arrests during sleep, obstructive sleep apnea affects approximately 2% of the 30- to 60-year-old male population (1). It is believed that between 7 and 18 million North Americans could be afflicted with the disease. The most studied forms of treatment include surgery on the upper airway, intraoral-mandibular advancement devices, and long-term treatment with nasal continuous-positive-airway pressure (2). These treatments are cumbersome and expensive. Several pharmacologic treatments have been proposed, but we know of no widely used drug of reference.

Topiramate is a broad-spectrum antiepileptic and neurotherapeutic agent that may be used in treating several neurologic, psychiatric, and metabolic conditions, such as migraine and other forms of headache, bipolar disorder, eating disorders, and obesity. Topiramate has shown side effects, such as somnolence, cognitive impairment, and paresthesias. This report concerns a patient who suffered from bipolar disorder and obstructive sleep apnea who was successfully treated with the addition of topiramate to his previous medication regimen.

Mr. A was a 50-year-old married engineer who had been in treatment for bipolar disorder for several years. His initial treatment was with 450 mg b.i.d. of controlled-release lithium carbonate, 75 mg/day of venlafaxine, 30 mg/day of mirtazapine, and 1 mg/day of clonazepam. He had remained on this same regimen until the present. As a result of complaints of snoring and breathing arrests, polysomnography was performed. It indicated obstructive sleep apnea of degree III, severe snoring, and a marked reduction in REM and slow-wave sleep. (Operational definitions for scoring of obstructive sleep apnea were suggested by an American Academy of Sleep Medicine task force [3]. Data to justify a severity index based on event frequency were derived from the Wisconsin Sleep Cohort.) The use of a continuous-positive-airway-pressure device was recommended, but Mr. A refused it because of financial concerns.

He began treatment with topiramate, 25 mg/day; the dose was progressively increased to 100 mg/day. My sole recommendation was the use of this medication. A remarkable reduction in snoring was reported soon thereafter; there remained only slight dorsal-decubitus snoring. A follow-up polysomnography, allowed by Mr. A’s health insurance, showed obstructive sleep apnea of degree I, moderate snoring, periodic-movement syndrome of the legs, and fragmented sleep. There was a drastic decrease (approximately 70%) in his episodes of apnea, falling from 20.0/hour to 6.6/hour. There were no changes in body weight.

In view of its excellent tolerability, which leads to high compliance, and its excellent clinical results, topiramate should be seen as a promising pharmacological option for the treatment of obstructive sleep apnea and snoring. More in-depth, controlled studies with a larger number of patients are warranted.

References

1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S: The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 1993; 328:1230-1235[Abstract/Free Full Text]
2. Reimão R, Joo SH: [Obstructive sleep apnea: diagnostic and therapeutic choice.] Diagnostico & Tratamento 1997; 2:35-37 (Portuguese)
3. Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research: the report of an American Academy of Sleep Medicine task force. Sleep 1999; 22:667-689[Medline]

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