Obstructive Sleep Apnea (osa) Is a Highly Prev- Alent Syndrome That Is Associated with Sub- Stantial Morbidity and Increased Mortality.1-10

OBSTRUCTIVE SLEEP APNEA (OSA) IS A HIGHLY PREVALENT SYNDROME THAT IS ASSOCIATED WITH SUBSTANTIAL MORBIDITY AND INCREASED MORTALITY.1-10 Positive airway pressure (PAP) is the most uniformly effective therapy, and to date this is the only intervention for OSA shown to have a favorable impact on both cardiovascular and neurobehavioral morbidities.1,2,6 However, approximately 25-50% of patients with OSA will either refuse the offer of PAP therapy, or will not tolerate it.11 Oral appliances and surgical procedures to improve upper airway patency are successful in certain subsets of patients, but a notable proportion of patients do not receive adequate clinical benefit from these approaches. In addition, many individuals treated with PAP therapy experience residual sleepiness, despite marked improvements in the apnea-hypopnea index.12,13 Therefore, medical therapies may be considered for the subsets of patients who will not or cannot use PAP and for patients with residual sleepiness despite alleviation of upper airway obstruction during sleep by mechanical devices such as PAP or oral appliances, or upper airway surgery. The charge given to this task force was to review literature on clinical trials regarding alternative and/or adjunctive medical therapies, such as weight reduction, pharmacotherapies (e.g., targeting the pathophysiology underlying the OSA, the sleepiness or nasal obstruction), delivery of supplemental oxygen and positional therapies. To aid in patient management, we have provided an overview of the effectiveness of various medical therapies, by describing the study designs, findings and limitations of each category of medical therapy. It is hoped that this review will provide a basis for improving the design of future studies, as we continue to search for more effective medical therapeutic options for patients with obstructive sleep apnea. Concerning terminology, although studies inconsistently defined obstructive sleep apnea-hypopnea syndrome (OSA), in the spirit of simplicity, we will only use the term OSA and report the apnea-hypopnea index (AHI) or apnea index in reviewing individual papers.