"Drug Induced" Sleep Apnea?

[SleepingUgly]

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.

That is what I was asking: Were you on Ativan the night of your sleep study in which you were diagnosed with OSA? Sounds like you were.

After Neuro casually asked me when I started the med., I realized that was when my symptoms became worse and more obvious.

What symptoms are those? If you're talking about EDS, then Ativan can cause that directly via next day sedation, which according to what RD noted, is more likely than that it caused EDS indirectly via OSA. Also, benzodiazepines can disrupt sleep architecture.

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.

[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.

Hi SnoozyQ,

I have a few questions - please feel free to answer only those questions you feel comfortable with. My first question is how much Ativan (mg.) were you taking daily and please remind me how long you were taking Ativan? My second question is how you managed to discontinue Ativan? In other words, did your doctor give you recommendations as to how to taper off of the Ativan?

I ask these questions because your post planted a seed that led me to start thinking about my own long term use of benzos and the fact that my abnormal snoring, initial OSA diagnosis, and excessive daytime sleepiness all began after I started on clonazepam for panic disorder. As a matter of fact, I just put 2 and 2 together and have made the correlation that my hypersommnia and difficulty getting out of bed in the morning is most likely due to an increase in my dose of clonazepam from 1 mg. to 2 mg. (increased after 10 years per doctor's orders).

My first study in 2002 revealed mild OSA, 2 subsequent studies in 2004 and 2005 revealed moderate OSA and my last study in October 2010 revealed severe OSA. I started on APAP on October 27, 2010 and am 100% compliant but still cannot get out of bed without a struggle. I have the strongest conviction that my meds are the root cause of my EDS. I should be feeling better on APAP - NOT the same!

I am likewise untangling the threads in the hopes that I can get to the core issues and have a better quality of life. I have made peace with my APAP, but certainly want to address getting off medications that are most certainly causing havoc with sleep architecture and resulting in my EDS.

Because you are off Ativan, I believe you may benefit from a repeat PSG. I have pasted a paragraph from a journal article concerning sleep apnea accessed from Medscape concerning when patients should be reassessed.

Thank you for bringing these issues to light. I feel a renewed sense of hope. Hugs, Laurie

Repeat PSG

Repeat PSG if symptoms persist despite adequate adherence with prescribed CPAP treatment. PSG can be used to assess response to UA surgical procedures and to assess response to oral appliance (OA) therapy. If sustained weight change of greater than 15% occurs, PSG should be repeated. If results of the first PSG are of poor quality, a repeat study is indicated. Patients who stop REM sleep–suppressant medications should be restudied, if symptomatic on treatment, because obstructive sleep apnea is most prevalent in REM sleep the obstructive sleep apnea that occurs during REM sleep should be examined whenever possible to avoid undertreatment of the obstructive sleep apnea or a false-negative diagnosis on a diagnostic study.
Retrieved December 9, 2010http://emedicine.medscape.com/article/295807-diagnosis

[davecpap]

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'm wondering if the 20mg of Celexa I'm on is causing this. Could delayed REM make you tired the next day? It would seem millions of folks on SSRIs would be affected and this would be bigger news. What I can't figure out if how long I'd have to be off it to determine if the celexa is causing me to be tired.... like if I stopped for a couple days could I solve this mystery.

I definitely dream, and I definitely experienced REM rebound when I started CPAP... if I don't sleep well for a night or two, the following week I've got dream overload.

[SleepingUgly]

I don't know about delayed REM, but it's reasonably well known that antidepressants generally suppress REM.

[davecpap]

I don't know about delayed REM, but it's reasonably well known that antidepressants generally suppress REM.

Don't you need REM? I asked this of my sleep doctor, he said the goal of treating sleep apnea was NOT to increase the amount of REM (didn't follow-up with what the goal is then..)

I thought part of the reason sleep apnea made you tired was the fragmented sleep structure that kept you from deep sleep like REM. So... wouldn't sleep apnea keeping you from REM and SSRIs suppressing REM both make you exhausted?

My sleep doc (pulmonologist) is always like, go ask a psychiatrist. Psychiatrist said go ask a sleep specialist.

[JohnBFisher]

davecpap, yes, we do need REM sleep. Though some antidepressants suppress REM sleep they do not eliminate it. Instead they tend to decrease it.

There are some case histories of people who loose the ability to go into REM sleep. Unfortunately for them, that is generally seen as a fatal problem.

I know before my OSA diagnosis, I was so sleep deprived (not getting enough dreams) that I would dream just when I would blink. Talk about confusing. So, yes. Not only is REM sleep normal, but for some reason it is vital that we get enough. Though antidepressants decrease the amount, it does not eliminate REM sleep.

Essentially, anything that interferes with the normal progression of sleep will cause us to feel tired and out of sorts. Periodic Limb Movements, Obstructive Sleep Apneas, Central Sleep Apneas, loud snoring (even if no apneas occur). If it causes sleep fragmentation we will tend to not awaken feeling refreshed.

Hope that helps.

[davecpap]

Though some antidepressants suppress REM sleep they do not eliminate it. Instead they tend to decrease it.

So then do people on antidepressants need to sleep more so that they get a sufficient amount of REM sleep? Thats the crux of what I'm trying to figure out, and doctors haven't been able to answer. I went to a couple psychiatrists and they're of the opinion that it helps sleep, not hurts it, but I think thats a rather simplistic view.

Bottom line: are the antidepressants helping or hurting me Being tired is a major source of my anxiety/depression, on days I have energy I feel great both mentally and physically. It would be a shame if the SSRIs i'm taking for anxiety about fatigue are in turn causing fatigue and making a big feedback loop.

[fuzzy96]

Bottom line: are the antidepressants helping or hurting me Being tired is a major source of my anxiety/depression, on days I have energy I feel great both mentally and physically. It would be a shame if the SSRIs i'm taking for anxiety about fatigue are in turn causing fatigue and making a big feedback loop.

shhhhhh!!!!! don't say out loud what the pharmacuticals don't whant people to know. talk about job(sales)security!! though we don't know this for sure, it is a question that needs real answers.
think about the old addage---"we are what we eat"
it takes years and years for science to catch up with the "minor" side effects of foos and drugs. msg was a miracle addative to help preserve food. now the list of ailments associated with it's use continues to grow.

it will be interesting to see in 20 years what has been learned about osa and it's causes.(not to mention everything else we think we know now)

[hannahF]

I know the goal is to get people off antianxiety and antidpressants. And many people can do that and be successful with other coping mechanisms and a strong support system.

I have tried several times to wean myself of these medications - which cause weight gain, drowsiness, and memory loss.

I my case, had to accept the fact that I need my celexa and attivan probably for life, as I just cannot function without them - else I spiral into that black hole and cannot drag myself out. The impact of anxiety and depression is worse than the drug side- effects for me.

talk to your prescribing doc for the antidepressants and antianxiety meds , with alot of help and support, you may be able to succesfully cope and wean yourself off. However, please dont get discouraged if you find you cannot. I know lorazepam is especially not intended for long term use, but I follow up with my doc on a very regular basis and decided the benefit outweighed the risk. My sleep doc is also aware I am on these meds.

Also dont stop taking these meds suddenly - its better to slowly ease out of them.

[SleepingUgly]

I don't know the answers to some of these questions, and I've wondered this myself. When I found out I had largely REM-dependent OSA, I looked online to see if any research indicated that REM-suppressing agents have a role in treating REM-dependent OSA. It looks like others have proposed it, but found, interestingly enough, that antidepressants increased airway patency in NON-REM. I do not know enough about antidepressants' effects on sleep (sleep techs & MDs, weigh in here), but certain antidepressants may wreak more havoc on sleep than others. For example, SSRIs can cause PLMS, but Wellbutrin has less of an impact. I can't give a blanket endorsement to Wellbutrin, but if I had anxiety and depression, I would ask about that one and try to steer clear of some of the others, if I could. But DEPRESSION has negative impacts on sleep, so if someone has depression, it needs to be treated, and sometimes medication is necessary.

Recently a doctor prescribed Klonopin for sleep for me because of some chronic pain I'm having lately. I was reluctant to take it because my biggest problem is EDS, and I don't want to take anything that might make that worse. In addition, I read that it reduces SWS and has other effects of sleep architecture that didn't sound advantageous to me. On the other hand, after some recent nights, I wonder if I'm shooting myself in the foot by not taking it...

[Laurie1041]

Recently a doctor prescribed Klonopin for sleep for me because of some chronic pain I'm having lately. I was reluctant to take it because my biggest problem is EDS, and I don't want to take anything that might make that worse. In addition, I read that it reduces SWS and has other effects of sleep architecture that didn't sound advantageous to me. On the other hand, after some recent nights, I wonder if I'm shooting myself in the foot by not taking it...

I started out taking clonazepam for sleep and yes it worked well and here I am almost 11 years later still on it. I cannot stop taking it without a very slow (6 months or longer) taper or else the withdrawal symptoms will be excruciating. Any benzo taken for more than 3 weeks continuously has a great risk of causing dependency. A benzo is not a recommended first line sleep medication unless anxiety is an underlying issue. It's a pretty complicated issue when dealing with chronic pain - pain, insomnia, some form of pain medication, EDS. If your biggest problem is EDS, I can tell you that my days are living hell since I started on clonazepam. Clonazepam has a super big half-life. I hope you find some form of pain relief and soon! Laurie

[jonquiljo]

Recently a doctor prescribed Klonopin for sleep for me because of some chronic pain I'm having lately.

Lots of Dr's prescribe Klonopin for sleep - mainly because they are poorly informed. Klonopin is a long-acting benzodiazepine. This means it has a long half-life in the body and will build up to a certain extent. So taking it at night - it will be with you all the next day and then some. Short acting benzodiazepines are better as they don't do this (Ativan, Xanax, etc.) but they have other issues and Dr's are prjudiced about addiction. But you are esentially addicted no matter what benzodiazepine you use. I find Valium works best - it is somwewhere in between and does not allow morning anxiety rebound. But I have been taking these drugs on and off over 40 years - most Dr's have never taken them and go by their anecdotal reputation.

The biggest problem I have experienced with Klonopin (as well as other people who I know) has been people are tired ALL the time. Klonopin is a lousy sleep drug - period.

[SnoozyQ]

Laurie1041,

I was taking 1 mg of Ativan per night. I also take 40 mg of Celexa in the morning. As far as discontinuing the Ativan, no, he did not suggest a tapering pattern. Which I'm fine with--I'm the type of person that would rather feel the "withdrawal" for a few days than continue with the side effects for weeks, then wait for the final exit from my body. I'm impatient that way.
I was taking the Ativan for over a year when I stopped a few weeks ago. I was prescribed the medication for anxiety, but found that it worked well for my insomnia (that melatonin was no longer taking care of). My PCP was fine with me using it in this manner and as needed.

I find all of this very interesting, thanks for the discussion

[Laurie1041]

Laurie1041,

I was taking 1 mg of Ativan per night. I also take 40 mg of Celexa in the morning. As far as discontinuing the Ativan, no, he did not suggest a tapering pattern. Which I'm fine with--I'm the type of person that would rather feel the "withdrawal" for a few days than continue with the side effects for weeks, then wait for the final exit from my body. I'm impatient that way.
I was taking the Ativan for over a year when I stopped a few weeks ago. I was prescribed the medication for anxiety, but found that it worked well for my insomnia (that melatonin was no longer taking care of). My PCP was fine with me using it in this manner and as needed.

I find all of this very interesting, thanks for the discussion

I am very surprised that your doctor did not recommend a taper schedule of any duration because of the risks of severe withdrawal symptoms which can not only be extremely unpleasant but can cause seizures particularly in those with an underlying seizure disorder or those with a history of substance abuse.

Without my doctor's recommendations, I have tried in the past to abruptly discontinue clonazepam and my withdrawal symptoms were so intense that I ended up in the ER with a racing heart, sensations of "bugs" crawling over my skin, and extreme panic and anxiety. I was given a "stat" dose of a fast-acting benzo and a stern admonishment to never stop taking clonazepam without first consulting my doctor for an appropriate "taper schedule". I talked to my doctor about my little experiment and he indicated that long term benzo use required careful tapering in most patients.

My tapering schedule will begin after I see my doctor the first week of January and will consist of reducing my dose by 10% each week. If I have any trouble with each weekly dose reduction, I am to stay at the same dose until the next week and then reduce my dose by another 10% and so on until I have successfully discontinued the clonazepam. I am a very impatient person as well, but realize that if I try to hurry things up, I will end up having to start all over again. I have to remember that I have been on clonazepam for 11 years and keep my eye on my goal - complete and successful discontinuation.

I feel very happy that you have gotten off of Ativan successfully and I wish you continued health and well-being. Hugs, Laurie

[Zigs]

I would be very careful, as SnoozyQ said, with benzodiazapines...a lot of docs hand 'em out like candy and do not tell you that within just a few weeks, they can cause serious dependency and severe withdrawal symptoms (like Snoozy said, seizures, etc.)