"Drug Induced" Sleep Apnea?

[SnoozyQ]

I've been further researching and experimenting with my treatment. I stopped the Ativan, started Provigil and feel considerably better.....without the CPAP.
I'm thinking about turning my pressure very low, and giving myself my own sleep study, to see if I have any events, now that I'm off of the Ativan.
I am floored to think that a year of my life was spent feeling like hell because I was trying to feel better.

I came across this article and wanted to get some feedback and food for thought.

http://www.talkaboutsleep.com/sleep-dis ... ract54.htm

Partial content but interesting:

http://www.medlink.com/medlinkcontent.asp

[SnoozyQ]

http://www.diseasesandconditions.net/sl ... rders.html

[Julie]

I haven't read any of those links (yet), but do know that while you might feel just dandy on the Provigil, it is an artificial 'high', and in no way treats your OSA. If you want to stay on the regimen, that's up to you, but don't fool yourself that you no longer have a problem.

[SnoozyQ]

The 2nd link doesn't work. If anyone wanted to read the content, here it is.

Drug-induced sleep disorders

Contributors

K K Jain MD, author. Dr. Jain is a consultant in neurology and has no relevant financial relationships to disclose.

Antonio Culebras MD, editor. Dr. Culebras of Upstate Medical University, SUNY, and the Sleep Disorders Center at Community General Hospital in Syracuse, New York, received honorariums from Boehringer Ingelheim for speaking engagements.

Publication dates

Originally released August 5, 1999; last updated July 7, 2010; expires July 7, 2013

Key points
• Several sleep disorders have been reported as secondary to adverse effects of drugs.

• Excessive daytime sleepiness and insomnia are the most common of these adverse effects but disorders of breathing and movement during sleep may also occur.

• Recognition of drug-induced sleep disorders and their distinction from primary sleep disorders and sleep disturbances that occur during the course of neurologic diseases is important for the management of patients.



Historical note and nomenclature
Sleep disorders, particularly insomnia, and the use of sleep-inducing drugs have been well known throughout medical history. Similarly, sleep disturbances induced by ill-timed use of beverages such as alcohol and coffee, as well as by the desired or undesired effects of recreational drugs, are common knowledge. In contrast to the therapy of sleep disorders, little attention was paid to the adverse effects of therapeutic drugs on sleep until the introduction of barbiturates as hypnotics. The long-term use of hypnotics as a cause of drug-induced insomnia was recognized in 1970s. Reports of sleep disturbances associated with other therapeutic drugs also started to appear in the 1970s and 1980s. Nightmares were observed with the initiation or withdrawal of tricyclic antidepressants and with the use of neuroleptic drugs (Strayhorn and Nash 1978). Although levodopa was introduced in the 1960s, reports of levodopa-induced sleep disruptions did not appear until several years later (Sharf et al 1978).

The term "rebound insomnia" is used to describe sleep disturbance characterized by an increase in wakefulness above the previous baseline level after the withdrawal of sedative-hypnotic drugs. It is not synonymous with "withdrawal insomnia," which implies drug dependence and is usually seen with long-term use of hypnotics. Other hypnotic drugs, such as chloral hydrate, can also lead to withdrawal problems. Withdrawal from sedative or hypnotic drugs is defined as a temporary increase in the severity of insomnia after stopping treatment. If insomnia is worse than it was before the treatment started, the term "recoil" or "overshoot insomnia” is used rather than "rebound insomnia.”

The term "excessive sleepiness" should be differentiated from somnolence, which literally means sleepiness, because in a medical context the term signifies abnormal drowsiness. However, the terms “sleepiness” and “drowsiness” often overlap and are used interchangeably in various reports. Falling asleep suddenly during the day ("sleep attack") has also been described as an adverse reaction to some drugs and should be differentiated from narcolepsy.

Sleep may be disturbed as a sequel of other drug-induced adverse drug reactions. For example, patients with movement disorders may have difficulty sleeping and patients on diuretics may have to get up frequently at night to urinate. This article describes sleep disorders associated with the use of therapeutic drugs. The information is based on a review of the literature and on reports of adverse reactions received by pharmaceutical manufacturers. The causal relationship is not proven by the usual scientific criteria, but the list of drugs should be considered during investigation of patients with sleep disorders. The International Classification of Sleep Disorders ICSD-2 mentions "resulting from a substance" under the following categories: insomnia, hypersomnias of central origin, circadian rhythm sleep disorders, and sleep-related movement disorders (American Academy of Sleep Medicine 2005). A practical classification of drug-induced sleep disorders, reflecting the manner in which they are reported in the literature, is shown in Table 1.



Table 1. Classification of Drug-Induced Sleep Disorders



Excessive sleepiness

• daytime sleepiness

Drug-induced insomnia

Rebound and withdrawal insomnia

Drug-induced sleep-related breathing disorders

• snoring

• sleep apnea

Drug-induced sleep-related movement disorders

• excessive movements of limbs, restless legs syndrome

• myoclonus

Drug-induced parasomnias: sleep behavioral disorders

• rapid eye movement sleep behavior disorder

• vivid dreams and nightmares

• sleepwalking

• sleep-eating

• enuresis

• bruxism




Clinical manifestations
Clinical features of sleep disorders induced by drugs are similar to those due to other causes. Temporal association with the use of drugs known to cause sleep disturbances is an important feature. Some of the clinical manifestations of various sleep disorders shown in Table 1 may be linked. For example, sleep apnea may manifest as insomnia.

Most people experience vivid dreams and nightmares at some time during their lives. These may be associated with sleep disturbances and psychiatric disorders or may be reported as isolated events. Vivid dreams are often associated with insomnia, which appears to be paradoxical. The explanation for this lies in the fact that waking appears to be necessary if the dreams are to be remembered.

[JohnBFisher]

SnoozyQ (a cute nickname, by the way), yes, medications can impact sleep. There is no doubt about that. However, stating that fact and linking it to your sleep problems is likely an intuitive leap currently without any facts.

And I would caution you about the initial link you posted. Let me take one excerpt from that link:

Lastly, turning from asthma to Parkinson's Disease, we find sleep disturbances to be one of these patients' most common complaints, present in 74-96% and considered almost as debilitating as their impaired movement. ... Where the effects on sleep of even the best-studied antiparkinson drug, levodopa, remain controversial, those of the other drugs are even more obscure, though there is suggestive evidence to exempt amantidine from the generally invidious effect of the antiparkinson drugs on sleep.

I normally offer papers via Googl'e Scholar. However, that article provides a succint summary of the issue.

There's just enough facts in there for it to seem believable. Unfortunately what the article does not note is that many neurological conditions that impact the brain and brain-stem interfere with sleep. Since our brain-stem serves as the regulatory system throughout our bodies, dysregulation is a common problem when there is damage to the brain-stem.

To quote from a Wikipedia article on the Brainstem:

Diseases of the brain stem can result to abnormalities in the function of cranial nerves which may lead to visual disturbances, pupil abnormalities, changes in sensation, muscle weakness, hearing problems, vertigo, swallowing and speech difficulty, voice change, and co-ordination problems.

My point is that the article tends to ignore the basic fact that other, significant things tend to also cause problems with sleep. So, see if it applies to you, but don't make the automatic leap that drugs definitely caused your sleep problems. Explore it as a possibility. But don't rely on the article as proof positive.

Of course, if after removing the medication you find your sleep greatly improved, you will then know it played a part in your sleep issues.

[SnoozyQ]

My point is that the article tends to ignore the basic fact that other, significant things tend to also cause problems with sleep. So, see if it applies to you, but don't make the automatic leap that drugs definitely caused your sleep problems. Explore it as a possibility. But don't rely on the article as proof positive.

Of course, if after removing the medication you find your sleep greatly improved, you will then know it played a part in your sleep issues..

Absolutely! I haven't written anything off (or on for that matter). I was exploring things outside the realm of what I've already heard. Even if meds affected my sleep less than I assume, I KNOW it was related to my daytime exhaustion. Ativan was leaving me in a sedated state! There have been days where it's been too late to take Provigil,given it's long half-life, and I still feel better than any other day in a long time.
I'm not sending the CPAP to the closet, this is just an experiment in my treatment, that I have taken the wheel of. CPAP alone hasn't been the answer thus far, so I'm still looking....everywhere!

A quote that I read elsewhere on the board really stood out to me: "If the right way doesn't work--is there a wrong way?"

[JohnBFisher]

Sounds as if you are then headed down the right path. You and you alone are most concerned with your situation. Others may want to help, but you have the highest vested interest in the outcome of different therapies.

So, exploring how medications impact you IS one of those areas of exploration. It is just one, as you note.

I had missed that quote, but certainly know the feeling. Before being titrated on ASV, I would have done just about anything for a good night of sleep. When all else fails, the crazy things start to look mighty inviting.

Hope you find the right combination to help you sleep well !!

[roster]

I'm thinking about turning my pressure very low, and giving myself my own sleep study, to see if I have any events, now that I'm off of the Ativan.

IMO, that would be the wrong way.

Assuming your breathing stats are good at your current pressure, you could take the pressure down one-half to one cm and check the results the next morning. If they are still good repeat a small lowering of the pressure the next night.

If over some days you get down to 4 cm and the stats are still good, I would run like that for a few weeks and if still good, I would ask for a home sleep study.

All of this assumes your are feeling well and do not require Provigil.

[no_more_headaches]

My wifes AHI is primarily hypopneas and her O2 levels drop.

She went to emergency a couple of times recently for Gall Bladder issues and a Broken Arm and when they put her on pain meds her O2 would drop like a rock. I could watch her just zone out in mid sentence and then her O2 would drop to the 70s.

So medications can definitely exacerbate your underlying conditions.

[Zigs]

Oh definitely - my sleep tech told me that the SSRIs (I'm on Zoloft for anxiety/depression) can delay the onset of REM...which could be why if I get REM at all, I get it toward the morning hours.

I wouldn't put it past any drug to have adverse effects more numerous to possibly name! But I also wouldn't experiment too wildly on your own - definitely seek some professional advice

[SleepingUgly]

I've been further researching and experimenting with my treatment. I stopped the Ativan, started Provigil and feel considerably better.....without the CPAP.
I'm thinking about turning my pressure very low, and giving myself my own sleep study, to see if I have any events, now that I'm off of the Ativan.
I am floored to think that a year of my life was spent feeling like hell because I was trying to feel better.

I don't know your background, so maybe you've explained this in another thread. I assume you were diagnosed with OSA by a sleep study in a lab? You were put on Ativan before or after your OSA diagnosis? I don't doubt that Ativan may make you feel tired, and there's zero doubt that Provigil will make you feel less tired, but what does that have to do with your OSA diagnosis? I don't follow why it is that you think Ativan may cause OSA.

[Laurie1041]

I've been further researching and experimenting with my treatment. I stopped the Ativan, started Provigil and feel considerably better.....without the CPAP.
I'm thinking about turning my pressure very low, and giving myself my own sleep study, to see if I have any events, now that I'm off of the Ativan.
I am floored to think that a year of my life was spent feeling like hell because I was trying to feel better.

I don't know your background, so maybe you've explained this in another thread. I assume you were diagnosed with OSA by a sleep study in a lab? You were put on Ativan before or after your OSA diagnosis? I don't doubt that Ativan may make you feel tired, and there's zero doubt that Provigil will make you feel less tired, but what does that have to do with your OSA diagnosis? I don't follow why it is that you think Ativan may cause OSA.

Any sedative/hypnotic or benzodiazepine such as Ativan (lorazepam) can cause sleep disordered breathing and/or excessive daytime sleepiness. SnoozyQ states she feels better since she stopped taking Ativan (even on days when she has not taken Provigil). A working theory could be that Ativan exacerbated (most certainly) or actually caused OSA. As an observer of the facts represented and knowledge of the action and potential of benzodiazepine use, I believe there is a causal relationship that merits a discussion with her doctor in deciding how best to determine whether or not OSA is still at issue.

[Guest]

I've been further researching and experimenting with my treatment. I stopped the Ativan, started Provigil and feel considerably better.....without the CPAP.
I'm thinking about turning my pressure very low, and giving myself my own sleep study, to see if I have any events, now that I'm off of the Ativan.
I am floored to think that a year of my life was spent feeling like hell because I was trying to feel better.

I don't know your background, so maybe you've explained this in another thread. I assume you were diagnosed with OSA by a sleep study in a lab? You were put on Ativan before or after your OSA diagnosis? I don't doubt that Ativan may make you feel tired, and there's zero doubt that Provigil will make you feel less tired, but what does that have to do with your OSA diagnosis? I don't follow why it is that you think Ativan may cause OSA.

Yes, I did have my OSA diagnosed after a study in August. I was taking Ativan for a year prior to that study (and up until a couple of weeks ago), originally for anxiety then for insomnia. After Neuro casually asked me when I started the med., I realized that was when my symptoms became worse and more obvious.

Laurie1041 hit the nail on the head. I think there's a correlation between the two. What that means for me has yet to be fully determined but I find the topic interesting. I've been reading and searching alot and have learned things that make the lightbulb go off, as far as my symptoms and reactions to treatment.

In no way am I declaring I'm OSA free and it was all Ativan's fault. I'm merely exploring.

[RDawkinsPhDMPH]

The benzodiazepines (ativan, librium, klonopin, xanax, valium, etc.) were discovered in 1957 (I think) and they quickly took over the market for sedative/hypnotics from barbiturates because they have very little respiratory depressant effect. Many people died from accidental overdose of barbiturates but with benzodiazepines (and with the later derivatives ambien, lunesta, sonata, etc.) an accidental overdose may make your stuporous but will probably not result in your death unless you also took a barbiturate or alcohol. Please don't try to test this!

Therefore, normal doses of benzodiazepines are unlikely to result in a diagnosis of OSAS in someone who doesn't have it otherwise.

However, since the benzodiazepines (and the later drugs) will reduce your arousability, and the arousals are usually the terminating factor for the respiratory events, these drugs will probably result in longer apneas & hypopneas and, therefore, possibly lower desats.

So if you were diagnosed in a sleep lab, do not stop your CPAP without further testing.

And yes, you probably didn't feel particularly well after taking ativan at night. Studies have shown that for many people, they do not feel or perform better after a night on benzodiazepines than after a night of insomnia. A significant part of our business is getting people off these meds.

[secret agent girl]

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