From the Guidelines
Benzodiazepines are generally avoided in patients with obstructive sleep apnea (OSA) due to their respiratory depressant effects which can worsen sleep-disordered breathing. If a benzodiazepine must be used in a patient with OSA, lorazepam (Ativan) is often considered the preferred option due to its shorter half-life (10-20 hours) and lack of active metabolites, which may reduce the risk of prolonged respiratory depression, as noted in various studies 1. When absolutely necessary, lorazepam should be used at the lowest effective dose (typically starting at 0.5mg) for the shortest duration possible, preferably under close monitoring. Patients should be warned about potential worsening of their OSA symptoms, including increased apneic episodes and daytime sleepiness. Alternative non-benzodiazepine options for anxiety or insomnia in OSA patients include cognitive behavioral therapy, certain antidepressants like trazodone, or in some cases, non-benzodiazepine hypnotics (though these also carry risks), as discussed in the context of managing OSA 1. The safest approach remains optimizing OSA treatment with continuous positive airway pressure (CPAP) therapy and avoiding sedative medications whenever possible. Key considerations in managing OSA include the potential impact of concomitant medications on the condition, with some medications exacerbating OSA and others having a possible positive effect 1. Ultimately, the goal is to minimize morbidity, mortality, and improve quality of life for patients with OSA, and the use of benzodiazepines should be carefully weighed against these outcomes.
From the Research
Benzodiazepines for Obstructive Sleep Apnea (OSA)
There is no evidence to suggest a specific benzodiazepine as the drug of choice for Obstructive Sleep Apnea (OSA) 2, 3, 4, 5, 6.
Risks Associated with Benzodiazepines
- Benzodiazepine use may increase the risk of acute respiratory failure in OSA patients 5.
- Recent and long-term benzodiazepine use has been linked to an increased risk of acute respiratory failure compared to never using benzodiazepines 5.
Alternative Treatments for OSA
- Continuous positive airway pressure (CPAP) is the first choice of treatment for patients with moderate or severe OSA 2, 3, 4.
- Other treatments may include positional therapy, weight loss, or oral appliances 4.
- Pharmacotherapy has not been shown to be significantly effective in the treatment of OSA and should be considered as an adjunctive treatment class 4, 6.
Drug Therapy for OSA
- A systematic review of randomized controlled trials found that drugs had several different proposed modes of action, but the results were limited by small study sizes and methodological limitations 6.
- Certain agents, such as fluticasone, donepezil, and paroxetine, have been shown to reduce the apnoea hypopnoea index (AHI) in some studies, but the evidence is insufficient to recommend their use in the treatment of OSA 6.