What are the precautions for using Lexapro (escitalopram) and Lunesta (eszopiclone) in patients with sleep apnea?

Use of Lexapro and Lunesta in Patients with Sleep Apnea

Lexapro (Escitalopram) in Sleep Apnea

Lexapro can be used cautiously in patients with sleep apnea, but requires careful monitoring for respiratory compromise. The American Academy of Sleep Medicine guidelines specifically state that caution is advised when prescribing sedatives/hypnotics if signs or symptoms of compromised respiratory function (including sleep apnea) are present 1. While escitalopram is not specifically mentioned in sleep apnea guidelines, it belongs to the SSRI class which has a more favorable profile than sedating antidepressants in terms of respiratory effects 1.

Key Considerations for Lexapro:

• SSRIs like escitalopram are generally safer than sedating antidepressants (such as trazodone, mirtazapine, or tricyclics) in patients with respiratory compromise 1.
• Weight gain monitoring is essential, as some antidepressants can induce weight gain that may exacerbate sleep apnea 1. Notably, fluoxetine and sertraline are associated with less weight gain than paroxetine 1.
• If insomnia is comorbid with depression, low-dose sedating antidepressants do not constitute adequate treatment of major depression and full-dose antidepressant therapy is required 1.

Lunesta (Eszopiclone) in Sleep Apnea

Lunesta can be used selectively in sleep apnea patients who do not have severe hypoxemia (nadir oxygen saturation >70%), particularly those with a low arousal threshold, but is contraindicated in patients with severe OSA or significant nocturnal desaturation.

Evidence-Based Guidance:

The most recent high-quality evidence demonstrates that eszopiclone may actually benefit a specific subgroup of OSA patients 2. A 2011 physiological study found that eszopiclone 3 mg increased the respiratory arousal threshold and significantly lowered the apnea-hypopnea index (AHI) from 25±6 to 14±4 events/hour in patients with a low arousal threshold and without marked hypoxemia 2.

Critical Safety Parameters:

• Absolute requirement: Nadir oxygen saturation must be >70% during baseline sleep studies before considering eszopiclone 2.
• Best candidates: Patients with low arousal threshold (awakening at 0 to -15 cm H₂O epiglottic pressure) show the most pronounced AHI reductions 2.
• Contraindicated in severe OSA with significant hypoxemia, as the American Academy of Sleep Medicine guidelines emphasize caution with compromised respiratory function 1.

Cochrane Review Findings:

A systematic review found no significant worsening of OSA (no significant increase in AHI) with eszopiclone compared to placebo 1. This contrasts with some benzodiazepines like flurazepam and triazolam, which significantly lowered nighttime oxygen saturation 1.

Clinical Application Algorithm:

1. Assess OSA severity and overnight oximetry:

   • If nadir SaO₂ <70%: Do not prescribe eszopiclone 2
   • If severe OSA (AHI >30) with significant desaturation: Avoid eszopiclone 1

2. For mild-moderate OSA with adequate oxygenation:

   • Consider eszopiclone 2-3 mg at bedtime for sleep-onset and maintenance insomnia 1
   • Use lowest effective dose 1
   • Monitor for next-morning impairment (FDA requires lower dosing awareness) 1

3. Special populations:

   • Elderly or debilitated: Start with 1 mg, maximum 2 mg 1
   • Severe hepatic impairment: 1 mg maximum 2 mg 1

Important Caveats:

• Eszopiclone may improve CPAP adherence when used during the first 14 nights of therapy, increasing CPAP use by 20.8% more nights and 1.3 more hours per night 3.
• Combination therapy with oxygen and eszopiclone markedly improved OSA in patients with mild-moderate upper airway collapsibility, reducing AHI from 51.9 to 29.5 events/hour 4.
• FDA warning: All benzodiazepine receptor agonists carry risk of sleep-related behaviors (sleepwalking, sleep driving) 1. Counsel patients about allowing appropriate sleep time, using only prescribed doses, and avoiding combination with alcohol or other sedatives 1.
• Avoid in elderly with cognitive impairment due to decreased cognitive performance risk 1.

Monitoring Requirements:

• Repeat polysomnography may be warranted after initiating eszopiclone to confirm no worsening of respiratory events 1.
• Assess for residual daytime sedation and adjust dosing accordingly 1.
• Monitor for tolerance and withdrawal with chronic use, though eszopiclone shows no evidence of tolerance during 12 months of treatment 5.