Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions

1st line – continuous positive airway pressure (CPAP)

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
1st line – 

continuous positive airway pressure (CPAP)

CPAP is recommended as first-line therapy for the treatment of OSA, and is the treatment of choice for severe OSA (AHI ≥30 episodes/hour).[70]

CPAP improves survival and sleepiness, and may possibly improve mood and cognitive function.[24][63]​​​​​​[104][105][106][107][108][109][110]​ CPAP therapy appears to reduce motor vehicle accident risk.[26][111]​​

CPAP therapy may also modestly reduce blood pressure (approximately 2-4 mmHg SBP), and reduce incidence and risk of recurrence of atrial fibrillation, particularly in younger patients.[112][113][114][115][116][117][118][119]​​

Cardiovascular disease may not be reduced with CPAP use in nonsleepy patients.[120][121][122] CPAP use does not appear to result in weight loss or improved glycemic control.[123][124][125]

Complications of CPAP therapy include sleep disturbance, rhinitis, dermatitis, conjunctivitis, aerophagia, dyspnea, and dentofacial changes.[70][147] Skin reactions and mask discomfort, in addition to the symptoms described, may lead to noncomplicance.[148]

Consider – measures to improve CPAP adherence

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
Consider – 

measures to improve CPAP adherence

Treatment recommended for SOME patients in selected patient group

Patient preparation, education, comfort, and fit of the interface may affect adherence and acceptance of CPAP. Therefore, proper fit of the interface is critical. Interface selection should be guided by patient preference. Nasal interfaces are preferable to oronasal interfaces as they are more comfortable and result in lower effective pressures. Oronasal interfaces may be used in patients with persistent mouth opening in sleep.[130] A chin strap may also be considered to reduce oral air leak.[131] Interface desensitization and trial of various interfaces based on patient preference may be used for claustrophobic patients.

Patient support, education, and behavioral interventions, such as cognitive behavioral therapy, can improve adherence.[132] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] Telemedicine-based intervention appears to be effective.[133]

Nasal resistance is associated with CPAP nonacceptance, and nasal surgery may be used to lower nasal resistance and possibly promote improved CPAP adherence.[134][135][136][137][138]​ Intranasal corticosteroid application may improve adherence in patients with rhinitis or turbinate hypertrophy.[139]

Nonbenzodiazepine soporifics, such as eszopiclone, have been used to improve CPAP titration and may potentially improve adherence in selected patients.[140]

Review of data obtainable from current CPAP devices may be used to troubleshoot patterns of use and assess for excessive system air leak rates and persistent obstructions. This, in turn, may lead to intervention for improved usage.

Patients prefer autoadjusting and bilevel PAP to CPAP, but evidence for improved outcome is lacking or not clinically significant.[141][142] [ Cochrane Clinical Answers logo ] Heated humidified air may be considered, but data regarding CPAP adherence in adults are not compelling.[143][144] Expiratory pressure relief (e.g., C-flex) use does not seem to increase adherence time.[145] ​Currently, there is no robust evidence from systematic reviews and meta-analyses to indicate that modifications to CPAP have a clinically significant impact upon patient adherence.[146]

If regular CPAP use is not accomplished or symptoms do not sufficiently improve, then oral appliances, surgery, or hypoglossal neurostimulation should be considered.

2nd line – oral appliance therapy

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
2nd line – 

oral appliance therapy

Titratable (adjustable) oral appliances are preferred. Oral appliance therapy may be used as second-line therapy for patients with severe OSA who are CPAP-intolerant. Oral appliance effectiveness should be assessed using a sleep test when the AHI is >15.

In patients with severe OSA, successful AHI reduction is usually better with CPAP.[149][150][151][152]​ Symptoms and quality-of-life outcomes are similar for CPAP and oral appliances.​[150][151][153]

Absence of trismus, presence of sufficient stable dentition or implants for appliance retention, and presence of manual dexterity are prerequisites for oral appliance use.

Mandibular repositioning appliances (MRAs) are less effective than CPAP at lowering the AHI but may be better tolerated.[149][154] Favorable patient characteristics for successful treatment using MRAs are younger age, lower body mass index, higher degree of mandibular protrusion (75%), smaller neck, mildly elevated AHI, and positionally dependent AHI.[150]

Tongue-retaining devices are second-line appliance therapy in patients in whom MRAs cannot be used, such as patients with macroglossia or who are edentulous.[150] Their effectiveness and tolerance is lower than for MRAs.[157][158]

Complications of oral appliance therapy include oral dryness, tooth discomfort, hypersalivation, occlusal changes, tooth movement, jaw pain, and treatment failure.

Consider – measures to improve oral appliance therapy adherence

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
Consider – 

measures to improve oral appliance therapy adherence

Treatment recommended for SOME patients in selected patient group

If adherence to an oral appliance treatment regimen is low, consider reducing jaw protrusion for discomfort problems; troubleshooting appliance fit, ensuring symmetry (even intercuspation [proper fitting cusp-fossa of opposing teeth]), addressing temporomandibular joint problems, and/or applying posterior stops; using or reattempting CPAP treatment (CPAP is more effective for AHI reduction, and reuse for those with moderate to severe condition is recommended); using a different type of appliance (decision made based on dental anchoring mechanism/location and discomfort); treating nasal obstruction; undergoing upper airway surgery (for patients who cannot tolerate oral appliances or CPAP).

2nd line – implantable hypoglossal neurostimulation

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
2nd line – 

implantable hypoglossal neurostimulation

Indicated for CPAP intolerance or nonacceptance in patients with an AHI ≥15, BMI <32, and who do not have complete concentric upper airway collapse during drug-induced sleep endoscopy (DISE).

An implantable hypoglossal neurostimulation system (Inspire) improved objective and subjective measurements of OSA severity in an uncontrolled cohort study.[184]

The system consists of an implantable pulse generator that stimulates the medial branch of the hypoglossal nerve via an electrode cuff, implanted unilaterally. Stimulation is phasic and is timed based on respiratory signals obtained from a sensor implanted on the chest wall. The therapy thus does not require the patient to wear any device on the face or intraorally, and is activated using a remote control.

2nd line – upper airway surgery

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
2nd line – 

upper airway surgery

Upper airway surgery is indicated in adults when CPAP or oral appliances are not accepted, have failed, or have not been tolerated.

Oropharyngeal procedures include uvulopalatopharyngoplasty, tonsillectomy, lateral pharyngoplasty, transpalatal advancement pharyngoplasty, expansion sphincter pharyngoplasty, barbed reposition pharyngoplasty, and maxillomandibular advancement (MMA).[160][161][162][163]​​

Hypopharyngeal approaches include genioglossus advancement, hyoid suspension, midline glossectomy, tongue suture suspension, epiglottoplasty, and MMA.

Multiple procedures may be performed simultaneously or in a staged fashion.[164]

The selection of particular procedures for a patient is directed by the apparent sites and structures mediating obstruction, and by patient preference. Usually the AHI severity does not determine the method used.[181][182][183] Alternatively, the upper airway obstruction may be bypassed by performing a tracheotomy.

Complications of OSA surgery include airway obstruction, bleeding, hematoma, infection, pain, dysphagia, velopharyngeal insufficiency, dysarthria, throat dryness, pharyngeal stenosis, worsening of AHI, death (very rarely), and, in the case of skeletal surgery, may also include loss of dentition, fracture, paresthesias, malocclusion, and fistula.

Plus – weight loss ± bariatric surgery

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
|
with concurrent obesity
Plus – 

weight loss ± bariatric surgery

Treatment recommended for ALL patients in selected patient group

Weight loss is recommended for overweight or obese patients with OSA.[12][139]​ Systematic reviews and meta-analyses conclude that intensive lifestyle interventions that lead to weight loss are effective in the treatment of OSA, and improve daytime sleepiness.[199][200][201] Improvement in AHI may be lost with subsequent weight gain, and it is recommended that the importance of maintaining lower weight is emphasized to patients.[12][202][203]

Bariatric surgery is considered for patients with a BMI of >40 kg/m², or for patients with lower BMI with comorbidities, as it may lower the AHI and reduce cardiopulmonary disease severity.[139][204] Bariatric surgery may offer markedly greater improvement in BMI and AHI than nonsurgical alternatives.[205]​ It should be noted that, despite considerable weight loss, OSA may not be eliminated, or may recur (without weight gain).[206] Therefore, all obese patients should be monitored for signs and symptoms of OSA, and polysomnography performed if OSA is suspected.​

Plus – pharmacotherapy

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
|
with persistent hypersomnolence
Plus – 

pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Armodafinil is partially effective at treating residual sleepiness in patients treated for OSA, as is modafinil.[139][190]

Treatment complications include headaches, insomnia, nervousness, and rhinitis. Armodafinil or modafinil may be added to CPAP to reduce somnolence.

Pitolisant, a selective histamine H3-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) to improve wakefulness and reduce excessive daytime sleepiness in adults with OSA. In the US, it is currently approved by the Food and Drug Administration (FDA) only for excessive daytime sleepiness or cataplexy in patients with narcolepsy. Pitolisant is used when other treatments, such as CPAP, have not satisfactorily improved excessive daytime sleepiness or cannot be tolerated by the patient.[191][192][193]​ One meta-analysis of individual patient data concluded that pitolisant significantly improved excessive daytime sleepiness and fatigue compared with placebo.[191]

Solriamfetol, a dopamine-norepinephrine reuptake inhibitor approved for the treatment of OSA by the FDA and EMA, reduces excess sleepiness in patients with OSA and narcolepsy.[194][195] Longer-term solriamfetol efficacy (up to 50 weeks) has been demonstrated.[196]

The UK National Institute for Health and Care Excellence (an independent public body that provides national guidance and advice to improve health) does not recommend pitolisant or solriamfetol for adults with obstructive sleep apnea because of uncertainty of evidence relating to the former, and lack of evidence of improved patient quality of life with solriamfetol use.[197][198] 

Primary options

modafinil: 200 mg orally once daily in the morning, maximum 400 mg/day

OR

armodafinil: 150-250 mg orally once daily in the morning

OR

solriamfetol: 37.5 mg orally once daily in the morning initially, increase gradually according to response, maximum 150 mg/day

OR

pitolisant: consult specialist for guidance on dose

Plus – positional therapy

Back
ACUTE
|
Apnea-Hypopnea Index (AHI) or Respiratory Event Index (REI) of ≥30 episodes/hour: no discrete anatomic lesions
|
with positional component
Plus – 

positional therapy

Treatment recommended for ALL patients in selected patient group

Positional therapy is used to maintain a nonsupine sleep position in individuals in whom AHI is low in a nonsupine position; polysomnographic documentation of effectiveness is advised. Positional therapy is more effective in young patients and those with a low BMI.

It is a heterogeneous treatment method that includes lateral or upright sleep and the use of special pillows, shirts, electronic vibrational devices, or other means to prevent sleep in the supine position. Evidence for positional therapy is promising; however, reliable long-term data is lacking.​​[207]

AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions

1st line – oral appliance therapy

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
1st line – 

oral appliance therapy

Titratable (adjustable) oral appliances are preferred. Oral appliances are recommended for the treatment of mild to moderate OSA in patients who prefer them to CPAP therapy, or who do not tolerate CPAP therapy.[149][Evidence B] Oral appliance effectiveness should be assessed using a sleep test when the AHI is >15.

Symptoms and quality-of-life outcomes are similar for CPAP and oral appliances.​[150][151][153]

Absence of trismus, presence of sufficient stable dentition or implants for appliance retention, and presence of manual dexterity are prerequisites for oral appliance use.

Mandibular repositioning appliances (MRAs) are less effective than CPAP at lowering the AHI but may be better tolerated.[149][154] Favorable patient characteristics for successful treatment using MRAs are younger age, lower body mass index, higher degree of mandibular protrusion (75%), smaller neck, mildly elevated AHI, and positionally dependent AHI.[150]

Tongue-retaining devices are second-line appliance therapy in patients in whom MRAs cannot be used, such as patients with macroglossia or who are edentulous.[150] Their effectiveness and tolerance is lower than for MRAs.[157][158]

Complications of oral appliance therapy include oral dryness, tooth discomfort, hypersalivation, occlusal changes, tooth movement, jaw pain, and treatment failure.

Consider – measures to improve oral appliance therapy adherence

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
Consider – 

measures to improve oral appliance therapy adherence

Treatment recommended for SOME patients in selected patient group

If adherence to an oral appliance treatment regimen is low, consider: reducing jaw protrusion for discomfort problems; troubleshooting appliance fit, ensuring symmetry (even intercuspation [proper fitting cusp-fossa of opposing teeth]), addressing temporomandibular joint problems, and/or applying posterior stops; using or reattempting CPAP treatment (CPAP is more effective for AHI reduction, and reuse for those with moderate to severe condition is recommended); using a different type of appliance (decision made based on dental anchoring mechanism/location and discomfort); treating nasal obstruction; undergoing upper airway surgery (for patients who cannot tolerate oral appliances or CPAP).

1st line – CPAP

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
1st line – 

CPAP

For patients with mild (AHI of 5-15 episodes/hour) to moderate OSA (AHI 15-30 episodes/hour), evidence for beneficial outcome is inconsistent.[70][126] CPAP is, however, recommended as a first-line therapy (along with oral appliances) for symptomatic patients.

Complications of CPAP therapy Include sleep disturbance, rhinitis, dermatitis, conjunctivitis, aerophagia, dyspnea, and dentofacial changes.[70][147] Skin reactions and mask discomfort, in addition to the symptoms described, may lead to noncomplicance.[148]

Consider – measures to improve CPAP adherence

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
Consider – 

measures to improve CPAP adherence

Treatment recommended for SOME patients in selected patient group

Patient preparation, education, comfort, and fit of the interface may affect adherence and acceptance of CPAP. Therefore, proper fit of the interface is critical. Interface selection should be guided by patient preference. Nasal interfaces are preferable to oronasal interfaces as they are more comfortable and result in lower effective pressures. Oronasal interfaces may be used in patients with persistent mouth opening in sleep.[130] A chin strap may also be considered to reduce oral air leak.[131] Interface desensitization and trial of various interfaces based on patient preference may be used for claustrophobic patients.

Patient support, education, and behavioral interventions, such as cognitive behavioral therapy, can improve adherence.[132] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] [ Cochrane Clinical Answers logo ] ​ Telemedicine-based intervention appears to be effective.[133]

Nasal resistance is associated with CPAP nonacceptance, and nasal surgery may be used to lower nasal resistance and possibly promote improved CPAP adherence.[134][135][136][137][138]​​ Intranasal corticosteroid application may improve adherence in patients with rhinitis or turbinate hypertrophy.[139]

Nonbenzodiazepine soporifics, such as eszopiclone, have been used to improve CPAP titration and may potentially improve adherence in selected patients.[140]

Review of data obtainable from current CPAP devices may be used to troubleshoot patterns of use and assess for excessive system air leak rates and persistent obstructions. This, in turn, may lead to intervention for improved usage.

Patients prefer autoadjusting and bilevel PAP to CPAP, but evidence for improved outcome is lacking or not clinically significant.[141][142] [ Cochrane Clinical Answers logo ] ​ Heated humidified air may be considered, but data regarding CPAP adherence in adults are not compelling.[143][144]​ Expiratory pressure relief (e.g., C-flex) use does not seem to increase adherence time.[145] ​Currently, there is no robust evidence from systematic reviews and meta-analyses to indicate that modifications to CPAP have a clinically significant impact upon patient adherence.[146]

If regular CPAP use is not accomplished or symptoms do not sufficiently improve, then oral appliances, surgery, or hypoglossal neurostimulation should be considered.

2nd line – implantable hypoglossal neurostimulation

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
2nd line – 

implantable hypoglossal neurostimulation

Indicated for CPAP intolerance or nonacceptance in patients with an AHI ≥15, BMI <32, and who do not have complete concentric upper airway collapse during drug-induced sleep endoscopy (DISE).

An implantable hypoglossal neurostimulation system (Inspire) improved objective and subjective measurements of OSA severity in an uncontrolled cohort study.[184]

The system consists of an implantable pulse generator that stimulates the medial branch of the hypoglossal nerve via an electrode cuff, implanted unilaterally. Stimulation is phasic and is timed based on respiratory signals obtained from a sensor implanted on the chest wall.

The therapy thus does not require the patient to wear any device on the face or intraorally, and is activated using a remote control.

2nd line – upper airway surgery

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
2nd line – 

upper airway surgery

Upper airway surgery is indicated in adults when CPAP or oral appliances are not accepted, have failed, or have not been tolerated.

Oropharyngeal procedures include uvulopalatopharyngoplasty, tonsillectomy, lateral pharyngoplasty, transpalatal advancement pharyngoplasty, expansion sphincter pharyngoplasty, barbed reposition pharyngoplasty, and maxillomandibular advancement (MMA).[160][161][162][163]​​

Hypopharyngeal approaches include genioglossus advancement, hyoid suspension, midline glossectomy, tongue suture suspension, epiglottoplasty, and MMA.

Multiple procedures may be performed simultaneously or in a staged fashion.[164]

The selection of particular procedures for a patient is directed by the apparent sites and structures mediating obstruction, and by patient preference. Usually the AHI severity does not determine the method used.[181][182][183] Alternatively, the upper airway obstruction may be bypassed by performing a tracheotomy.

Complications of OSA surgery include airway obstruction, bleeding, hematoma, infection, pain, dysphagia, velopharyngeal insufficiency, dysarthria, throat dryness, pharyngeal stenosis, worsening of AHI, death (very rarely), and, in the case of skeletal surgery, may also include loss of dentition, fracture, paresthesias, malocclusion, and fistula.

Plus – weight loss ± bariatric surgery

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
|
with concurrent obesity
Plus – 

weight loss ± bariatric surgery

Treatment recommended for ALL patients in selected patient group

Weight loss is recommended for overweight or obese patients with OSA.​[12][139]​ Systematic reviews and meta-analyses conclude that intensive lifestyle interventions that lead to weight loss are effective in the treatment of OSA, and improve daytime sleepiness.[199][200][201]​​ Improvement in AHI may be lost with subsequent weight gain, and it is recommended that the importance of maintaining lower weight is emphasized to patients.[12][202][203]

Bariatric surgery is considered for patients with a BMI of >40 kg/m², or for patients with lower BMI with comorbidities, as it may lower the AHI and reduce cardiopulmonary disease severity.[139][204] Bariatric surgery may offer markedly greater improvement in BMI and AHI than nonsurgical alternatives.[205]​ It should be noted that, despite considerable weight loss, OSA may not be eliminated, or may recur (without weight gain).[206] Therefore, all obese patients should be monitored for signs and symptoms of OSA, and polysomnography performed if OSA is suspected.

Plus – pharmacotherapy

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
|
with persistent hypersomnolence
Plus – 

pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Armodafinil is partially effective at treating residual sleepiness in patients treated for OSA, as is modafinil.[139][190] Treatment complications include headaches, insomnia, nervousness, and rhinitis. Armodafinil or modafinil may be added to CPAP to reduce somnolence.

Pitolisant, a selective histamine H3-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) to improve wakefulness and reduce excessive daytime sleepiness in adults with OSA. In the US, it is currently approved by the Food and Drug Administration (FDA) only for excessive daytime sleepiness or cataplexy in patients with narcolepsy. Pitolisant is used when other treatments, such as CPAP, have not satisfactorily improved excessive daytime sleepiness or cannot be tolerated by the patient.[191][192][193]​​ One meta-analysis of individual patient data concluded that pitolisant significantly improved excessive daytime sleepiness and fatigue compared with placebo.[191]

Solriamfetol, a dopamine-norepinephrine reuptake inhibitor approved for the treatment of OSA by the FDA and EMA, reduces excess sleepiness in patients with OSA and narcolepsy.[194][195] Longer-term solriamfetol efficacy (up to 50 weeks) has been demonstrated.[196]

The UK National Institute for Health and Care Excellence (an independent public body that provides national guidance and advice to improve health) does not recommend pitolisant or solriamfetol for adults with obstructive sleep apnoea because of uncertainty of evidence relating to the former, and lack of evidence of improved patient quality of life with solriamfetol use.[197][198]

Primary options

modafinil: 200 mg orally once daily in the morning, maximum 400 mg/day

OR

armodafinil: 150-250 mg orally once daily in the morning

OR

solriamfetol: 37.5 mg orally once daily in the morning initially, increase gradually according to response, maximum 150 mg/day

OR

pitolisant: consult specialist for guidance on dose

Plus – positional therapy

Back
ACUTE
|
AHI or REI of ≥5 but <30 episodes/hour: no discrete anatomic lesions
|
with positional component
Plus – 

positional therapy

Treatment recommended for ALL patients in selected patient group

Positional therapy is used to maintain a nonsupine sleep position in individuals in whom AHI is low in a nonsupine position; polysomnographic documentation of effectiveness is advised. Positional therapy is more effective in young patients and those with a low BMI.

It is a heterogeneous treatment method that includes lateral or upright sleep and the use of special pillows, shirts, electronic vibrational devices, or other means to prevent sleep in the supine position. Evidence for positional therapy is promising; however, reliable long-term data is lacking.​​[207]

AHI or REI of ≥5 episodes/hour with discrete anatomic lesions

1st line – upper airway surgery

Back
ACUTE
|
AHI or REI of ≥5 episodes/hour with discrete anatomic lesions
1st line – 

upper airway surgery

Primary treatment for patients with discrete anatomic lesions, such as palatine or lingual tonsils, whose treatment is straightforward and is likely to effectively treat the OSA.

Complications of OSA surgery include airway obstruction, bleeding, hematoma, infection, pain, dysphagia, velopharyngeal insufficiency, dysarthria, throat dryness, pharyngeal stenosis, worsening of AHI, and death (very rarely).

Plus – weight loss ± bariatric surgery

Back
ACUTE
|
AHI or REI of ≥5 episodes/hour with discrete anatomic lesions
|
with concurrent obesity
Plus – 

weight loss ± bariatric surgery

Treatment recommended for ALL patients in selected patient group

Weight loss is recommended for overweight or obese patients with OSA.​[12][139]​ Systematic reviews and meta-analyses conclude that intensive lifestyle interventions that lead to weight loss are effective in the treatment of OSA, and improve daytime sleepiness.[199][200][201]​ Improvement in AHI may be lost with subsequent weight gain, and it is recommended that the importance of maintaining lower weight is emphasized to patients.[12][202][203]​​

Bariatric surgery is considered for patients with a BMI of >40 kg/m², or for patients with lower BMI with comorbidities, as it may lower the AHI and reduce cardiopulmonary disease severity.[139][204] Bariatric surgery may offer markedly greater improvement in BMI and AHI than nonsurgical alternatives.[205] It should be noted that, despite considerable weight loss, OSA may not be eliminated, or may recur (without weight gain).[206] Therefore, all obese patients should be monitored for signs and symptoms of OSA, and polysomnography performed if OSA is suspected.

Plus – pharmacotherapy

Back
ACUTE
|
AHI or REI of ≥5 episodes/hour with discrete anatomic lesions
|
with persistent hypersomnolence
Plus – 

pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Armodafinil is partially effective at treating residual sleepiness in patients treated for OSA, as is modafinil.[139][190] Treatment complications include headaches, insomnia, nervousness, and rhinitis. Armodafinil or modafinil may be added to CPAP to reduce somnolence.

Pitolisant, a selective histamine H3-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) to improve wakefulness and reduce excessive daytime sleepiness in adults with OSA. In the US, it is currently approved by the Food and Drug Administration (FDA) only for excessive daytime sleepiness or cataplexy in patients with narcolepsy. Pitolisant is used when other treatments, such as CPAP, have not satisfactorily improved excessive daytime sleepiness or cannot be tolerated by the patient.[191][192][193] One meta-analysis of individual patient data concluded that pitolisant significantly improved excessive daytime sleepiness and fatigue compared with placebo.[191]

Solriamfetol, a dopamine-norepinephrine reuptake inhibitor approved for the treatment of OSA by the FDA and EMA, reduces excess sleepiness in patients with OSA and narcolepsy.[194][195] Longer-term solriamfetol efficacy (up to 50 weeks) has been demonstrated.[196]

The UK National Institute for Health and Care Excellence (an independent public body that provides national guidance and advice to improve health) does not recommend pitolisant or solriamfetol for adults with obstructive sleep apnea because of uncertainty of evidence relating to the former, and lack of evidence of improved patient quality of life with solriamfetol use.[197][198]​ 

Primary options

modafinil: 200 mg orally once daily in the morning, maximum 400 mg/day

OR

armodafinil: 150-250 mg orally once daily in the morning

OR

solriamfetol: 37.5 mg orally once daily in the morning initially, increase gradually according to response, maximum 150 mg/day

OR

pitolisant: consult specialist for guidance on dose

Plus – positional therapy

Back
ACUTE
|
AHI or REI of ≥5 episodes/hour with discrete anatomic lesions
|
with positional component
Plus – 

positional therapy

Treatment recommended for ALL patients in selected patient group

Positional therapy is used to maintain a nonsupine sleep position in individuals in whom AHI is low in a nonsupine position; polysomnographic documentation of effectiveness is advised. Positional therapy is more effective in young patients and those with a low BMI.

It is a heterogeneous treatment method that includes lateral or upright sleep and the use of special pillows, shirts, electronic vibrational devices, or other means to prevent sleep in the supine position. Evidence for positional therapy is promising; however, reliable long-term data is lacking.​​[207]

ONGOING

persistent postoperative OSA

1st line – retrial of non- or minimally invasive therapies

Back
ONGOING
|
persistent postoperative OSA
1st line – 

retrial of non- or minimally invasive therapies

Retrying CPAP or oral appliances is a first-line treatment for residual OSA, if accepted by the patient.

Implantable hypoglossal neurostimulation may be appropriate in selected patients.

2nd line – additional upper airway surgery

Back
ONGOING
|
persistent postoperative OSA
2nd line – 

additional upper airway surgery

Consult with the patient if CPAP or oral appliances are not accepted or tolerated.

Additional surgical treatment to address residual sites or structures mediating anatomic obstruction may be an option.

In cases of severe OSA, in addition to pharyngeal procedures, surgical options include more aggressive procedures such as tracheotomy or MMA, which are very effective at normalizing the AHI but are less often accepted by patients.

Plus – weight loss ± bariatric surgery

Back
ONGOING
|
persistent postoperative OSA
|
with concurrent obesity
Plus – 

weight loss ± bariatric surgery

Treatment recommended for ALL patients in selected patient group

Weight loss is recommended for overweight or obese patients with OSA.[12][139] Systematic reviews and meta-analyses conclude that intensive lifestyle interventions that lead to weight loss are effective in the treatment of OSA, and improve daytime sleepiness.[199][200][201] Improvement in AHI may be lost with subsequent weight gain, and it is recommended that the importance of maintaining lower weight is emphasized to patients.[12][202][203]

Bariatric surgery is considered for patients with a BMI of >40 kg/m², or for patients with lower BMI with comorbidities, as it may lower the AHI and reduce cardiopulmonary disease severity.[139][204]​ Bariatric surgery may offer markedly greater improvement in BMI and AHI than nonsurgical alternatives.[205] It should be noted that, despite considerable weight loss, OSA may not be eliminated, or may recur (without weight gain).[206] Therefore, all obese patients should be monitored for signs and symptoms of OSA, and polysomnography performed if OSA is suspected.

Plus – pharmacotherapy

Back
ONGOING
|
persistent postoperative OSA
|
with persistent hypersomnolence
Plus – 

pharmacotherapy

Treatment recommended for ALL patients in selected patient group

Armodafinil is partially effective at treating residual sleepiness in patients treated for OSA, as is modafinil.[139][190] Treatment complications include headaches, insomnia, nervousness, and rhinitis. Armodafinil or modafinil may be added to CPAP to reduce somnolence.

Pitolisant, a selective histamine H3-receptor antagonist/inverse agonist, is approved by the European Medicines Agency (EMA) to improve wakefulness and reduce excessive daytime sleepiness in adults with OSA. In the US, it is currently approved by the Food and Drug Administration (FDA) only for excessive daytime sleepiness or cataplexy in patients with narcolepsy. Pitolisant is used when other treatments, such as CPAP, have not satisfactorily improved excessive daytime sleepiness or cannot be tolerated by the patient.[191][192][193] One meta-analysis of individual patient data concluded that pitolisant significantly improved excessive daytime sleepiness and fatigue compared with placebo.[191]

Solriamfetol, a dopamine-norepinephrine reuptake inhibitor approved for the treatment of OSA by the FDA and EMA, reduces excess sleepiness in patients with OSA and narcolepsy.[194][195] Longer-term solriamfetol efficacy (up to 50 weeks) has been demonstrated.[196] 

The UK National Institute for Health and Care Excellence (an independent public body that provides national guidance and advice to improve health) does not recommend pitolisant or solriamfetol for adults with obstructive sleep apnea because of uncertainty of evidence relating to the former, and lack of evidence of improved patient quality of life with solriamfetol use.[197][198] 

Primary options

modafinil: 200 mg orally once daily in the morning, maximum 400 mg/day

OR

armodafinil: 150-250 mg orally once daily in the morning

OR

solriamfetol: 37.5 mg orally once daily in the morning initially, increase gradually according to response, maximum 150 mg/day

OR

pitolisant: consult specialist for guidance on dose

Plus – positional therapy

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ONGOING
|
persistent postoperative OSA
|
with positional component
Plus – 

positional therapy

Treatment recommended for ALL patients in selected patient group

Positional therapy is used to maintain a nonsupine sleep position in individuals in whom AHI is low in a nonsupine position; polysomnographic documentation of effectiveness is advised. Positional therapy is more effective in young patients and those with a low BMI.

It is a heterogeneous treatment method that includes lateral or upright sleep and the use of special pillows, shirts, electronic vibrational devices, or other means to prevent sleep in the supine position. Evidence for positional therapy is promising; however, reliable long-term data is lacking.​​[207]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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