What are the next steps for a patient with sleep apnea and insomnia who has not improved with 1mg of Lunesta (eszopiclone)?

Management of Sleep Apnea with Insomnia Not Responding to Eszopiclone 1mg

For a patient with sleep apnea and insomnia who has not improved with 1mg of Lunesta (eszopiclone), the next step should be optimizing PAP therapy as the primary treatment while considering an increase in eszopiclone dosage to 2-3mg if necessary.

Primary Management: Optimize PAP Therapy

• PAP therapy is the first-line treatment for obstructive sleep apnea (OSA) and should be used for the entirety of the patient's sleep period 1
• Even if the patient is using PAP for less than 4 hours per night (below Medicare standard), therapy should be continued as benefits for health-related quality of life have been documented with less than 4 hours of use 1
• Supportive, educational, and behavioral interventions should be provided to improve adherence early in treatment 1
• Alcohol and sedative hypnotics (including eszopiclone) can worsen OSA in some patients and should be used with caution 1

Medication Management Options

Eszopiclone Dosage Adjustment

• The recommended starting dosage for non-elderly patients is 2mg immediately before bedtime, with adjustment to 3mg if clinically indicated 2
• The current 1mg dose is below the standard effective dose range for adults with insomnia 1
• Eszopiclone has demonstrated efficacy for both sleep onset and sleep maintenance insomnia at 2-3mg doses 1, 3

Alternative Pharmacologic Options

If increasing eszopiclone dose is ineffective:

• Consider low-dose doxepin (3-6mg) which has shown efficacy for sleep maintenance insomnia with minimal side effects 1
• Avoid benzodiazepines as their risks (dependency, falls, cognitive impairment, respiratory depression) outweigh benefits, especially in patients with OSA 1
• Avoid trazodone as evidence does not support its use for insomnia 1

Behavioral Interventions

• Cognitive behavioral therapy for insomnia (CBT-I) is more effective than pharmacotherapy for chronic insomnia and should be strongly considered 1
• CBT-I components include sleep restriction therapy, stimulus control, relaxation therapy, and sleep hygiene education 1
• Brief behavioral therapy for insomnia (BBT-I) focusing on behavioral components only is an alternative when full CBT-I is not available 1

Monitoring and Follow-up

• Monitor PAP therapy adherence and efficacy 1
• Assess for potential reoccurrence of OSA symptoms throughout follow-up 4
• Evaluate for adverse effects of eszopiclone including unpleasant taste, headache, and dry mouth 2
• Watch for rare but serious adverse effects such as sleep-related behaviors (sleepwalking, sleep driving) 1

Special Considerations

• A short course of eszopiclone (3mg for 14 nights) has been shown to improve long-term CPAP adherence compared to placebo, suggesting potential benefit of appropriate dosing in this specific population 5
• Some research suggests eszopiclone may increase the respiratory arousal threshold and potentially lower the apnea/hypopnea index in certain OSA patients without marked overnight hypoxemia 6
• In patients with uncertain diagnosis of OSA or for whom treatment proves challenging, consultation with a sleep specialist is recommended 1

Cautions

• Sedative hypnotics should be administered at the lowest effective dose and for the shortest possible duration 1
• All patients offered these agents should be counseled on potential risks 1
• The FDA has issued warnings about serious injuries caused by sleep behaviors associated with non-benzodiazepine hypnotics 1