Can Buspar (buspirone) help treat high loop gain low arousal threshold obstructive sleep apnea (OSA)?

Buspirone is Not Recommended for High Loop Gain Low Arousal Threshold OSA

Buspirone is not recommended for the treatment of high loop gain low arousal threshold obstructive sleep apnea (OSA) as there is insufficient evidence to support its efficacy. 1, 2

First-Line Treatment Options for OSA

CPAP Therapy

• Continuous positive airway pressure (CPAP) remains the gold standard first-line treatment for OSA with strong recommendation and moderate-quality evidence 3
• CPAP has been shown to effectively improve Epworth Sleepiness Scale (ESS) scores, reduce Apnea-Hypopnea Index (AHI), lower arousal index scores, and increase oxygen saturation 3
• Greater AHI and ESS scores are generally associated with better adherence to CPAP therapy 3

Alternative Treatments for CPAP-Intolerant Patients

Mandibular Advancement Devices (MADs)

• MADs are recommended as an alternative therapy for patients who are intolerant of CPAP or prefer an alternate therapy (weak recommendation, low-quality evidence) 3
• Custom, titratable MADs provide moderate improvement in quality of life outcomes and are not inferior to CPAP in reducing subjective daytime sleepiness 3
• MADs are most appropriate for patients with mild to moderate OSA with AHI scores between 18 and 40 events per hour 3
• MADs should be provided with oversight from qualified dentists to monitor for dental-related side effects 3

Pharmacologic Therapy for OSA

Current Evidence on Medications

• Pharmacologic therapy is not currently supported by evidence and should not be prescribed for OSA treatment 3
• A Cochrane review specifically evaluated buspirone among other drugs and found no beneficial effects for OSA 1
• An updated Cochrane review concluded there is insufficient evidence to recommend the use of drug therapy in the treatment of OSA 2
• Multiple pharmacologic agents have been evaluated (including buspirone, mirtazapine, protriptyline, etc.) with insufficient evidence to support their use 3

Specific Considerations for High Loop Gain Low Arousal Threshold OSA

• For patients with specific OSA phenotypes such as high loop gain and low arousal threshold, targeted therapies are being investigated but remain experimental 4
• Recent research has focused on combined noradrenergic and antimuscarinic agents with modest effects, but these are not specifically addressing buspirone for high loop gain low arousal threshold OSA 5

Other Alternative Treatments

Hypoglossal Nerve Stimulation (HNS)

• HNS is not recommended as first-line treatment but may be considered as a salvage treatment in patients with symptomatic OSA who cannot be treated with CPAP or MAD (conditional recommendation, very low quality of evidence) 3
• HNS should be limited to patients with AHI <50 events/hour and BMI <32 kg/m² 3

Positional Therapy

• Positional therapy can yield moderate reductions in AHI in younger patients with low AHI and less obesity, but is clearly inferior to CPAP 3
• Long-term compliance with positional therapy is poor 3

Treatment Algorithm for OSA with High Loop Gain Low Arousal Threshold

1. First-line treatment: CPAP therapy 3
2. If CPAP intolerance or patient preference:
   • Custom, titratable mandibular advancement device 3
3. If both CPAP and MAD fail:
   • Consider hypoglossal nerve stimulation if patient meets criteria (AHI <50, BMI <32) 3
   • Consider positional therapy if predominantly positional OSA 3
4. Avoid pharmacologic therapy including buspirone due to lack of evidence for efficacy 1, 2

Common Pitfalls and Caveats

• Do not rely on pharmacologic agents like buspirone as primary treatment for OSA as they have shown no significant benefit 1, 2
• Do not neglect the importance of weight loss in obese patients with OSA, as it may reduce symptoms and provide additional health benefits 3
• Ensure proper follow-up for patients using MADs to monitor for dental-related side effects 3
• Be aware that surgical treatments are associated with risks and serious adverse effects and should not be used as initial treatment 3