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The treatment of Narcolepsy including Sodium Oxybate (Xyrem) and Modafinil

Narcolepsy is one of the most complex of non-respiratory Sleep Disorders, consisting of a tetrad was Excessive Daytime Sleepiness, Cataplexy, Sleep Paralysis and Hypnagogic Hallucinations. Once we’ve diagnosed Narcolepsy, treatment for your Narcolepsy comes in many forms including :

Behavioral Therapy

Good sleep hygiene is crucial in managing Narcolepsy symptoms in the long term. Adequate sleep at night is important, daytime timed-naps can be useful.

Medications

Many medications can be used to treat Narcolepsy, each with their own pros and cons.

CNS stimulants such as Methylphenidate (Ritalin, Concerta) and dextroamphetamine (dexamphetamine, dexamfetamine) work well but have long term complications. Pemoline is less commonly used due to the potential side effects.

Modafinil and Armodafinil (Modavigil, Nuvigil) are generally better-tolerated than amphetamine-based medications, and with less side effects. These still however require longterm vigilance.

Sodium oxybate (Xyrem, metabolite of gamma-aminobutyric acid) has been used in the USA since 2002, and has been used by our clinic since it’s Australian approval in late 2014. We have the largest known group of patients in South Australia on treatment, with impressive symptomatic results. We provide continuous regular clinical monitoring in conjunction with patients’ General Practitioners, to ensure optimal titration of treatment modalities based on the patient’s current clinical status.

At Adelaide Sleep, we routinely counsel, diagnose, and treat all aspects of Narcolepsy and Idiopathic Hypersomnia. We have experience in all medications used for Narcolepsy and Narcolepsy-like conditions. If you’d like to know more, contact us now.

© APSS 2018

Showcasing the Burnside Sleep Centre

Your sleep study produces over 1,000 pages of data – and that’s why we prefer a local Adelaide centre with staff who are well trained with higher degrees. We prefer not to rely on computer-automation, someone who won’t outsource your important medical data to interstate- or overseas-groups.

That’s why our Sleep Studies are performed at the Burnside War Memorial Hospital.

Burnside Sleep Centre (BSC) is an independent purpose-built six-bed facility within Burnside Hospital, catering to the sleep needs of our community. It’s location is perfect for sleep studies : free parking overnight surrounding the hospital, in a quiet inner-city suburb.

Designed with the comforts of home in mind, each private sleep study room comes with Wifi, a king-single bed, sound proofing, its own ensuite and TV.

BSC staff continue to participate in regular National Quality Control programs (both in-house, and national Q-Sleep), and hold regular meetings with their medical Sleep Committee.

BSC is also one of the very few Sleep Laboratories to offer the full range of Sleep Tests, including :

•  Diagnostic sleep studies
•  CPAP titration studies
•  BiLevel PAP studies
•  Adaptive- or Auto- Servo Ventilation (ASV) titration studies
•  Supplementary Oxygen titration, Carbon Dioxide (TcCO2) monitoring
•  Multiple Sleep Latency Testing (MSLT)
•  Maintenance of Wakefulness Testing (MWT).
•  Specialising in sleep studies for adolescents, adults, and the elderly.

At Adelaide Sleep, in conjunction with BSC, the doctor who sees you is also the doctor who analyses and interprets your complex sleep study. Both Adelaide Sleep doctors and BSC do not have any affiliation with CPAP outlets, CPAP sales, or vested interest in particular treatments.

This is why we believe the Burnside Sleep Centre is the premiere Sleep Centre for diagnostic testing, and we’re excited to refer our sleep studies to Burnside Hospital.

Contact us now for an appointment.

© APSS 2017

CPAP for OSA can lower the risk of Car Accidents

There is a wealth of data that acknowledges poor sleep (namely poor sleep due to Obstructive Sleep Apnoea (OSA)) being associated with Motor Vehicle Accidents, and now there is evidence that fixing OSA with CPAP will lessen your risk of car accidents.

In a Swedish Study performed by Karimi et al (1), MVA rates were monitored in the those with OSA, and then those with OSA on CPAP. This was compared to the risk of MVAs from the general population as provided y the Swedish Traffic Accident Registry.

They came to some predictable (and not so predictable) conclusions :

•  Untreated OSA increases your risk of car accidents
•  Using CPAP for OSA reduces that risk considerably

Surprisingly, the ‘severity’ of OSA did not entirely correlate with MVA risk… Suggesting it’s more than just about how Severe someone’s OSA is.

Treating OSA won’t make you a formula-One driver, but will at least lower your risk of a Car Accident in everyday driving. If you’d like to see one of our Medical Sleep Specialists, contact us for an appointment.

1. Karimi et al. Sleep. 2015.

© APSS 2016

Cancer and OSA – an unlikely link?

Does having Severe OSA increase your risk of Cancer? Looking back on the years of Obstructive Sleep Apnoea (OSA) research, we’ve been eagerly watching this unexpected link.

This association has not been studied widely. We’ve known for a long time that repeated intermittent hypoxaemia (low blood oxygen levels) can result in demonstrable problems to the human body – increasing your heart attack risk, stroke risk, Atrial Fibrillation risk, and even cognitive decline.

Martinez-Garcia et al has published both in the Am J Respir Crit Care Med (2013) and Sleep med (2014) with data suggesting those with OSA have an unusually high link to Cancer.

They found that Severe OSA measured by a drop in Oxygen Saturations below 90% (TSat90) and now the Apnoea Hypopnoea Index (AHI) is independently associated with increased cancer mortality. This was even after correcting for confounding variables, particularly true in those below the age of 65, and men.

This is however not a firm causal-link… but not beyond the realm of possibility. More research needs to be done in this field, and we’ll be watching that space closely. Drop us a line and we’ll be able to discuss your sleep in more detail.

Campos-Rodriguez, Martinez-Garcia et al. Am J Respir Crit Care Med. 2013.
Martinez-Garcia et al. Sleep Med. 2014.

© APSS 2016

45% of those with heart disease have OSA

OSA has long been known to increase your Cardiovascular (heart attack) and Cerebrovascular (stroke) risk. The constant drops in your oxygen levels known as desaturations, cortical arousals, and cardiovascular responses can have significant detrimental effects on your cardiac state, and predispose to heart disease.

We’ve known about this link for a long time, and we’ve advocated screening for OSA in all people with heart disease.

A recent multicentre observational study by Furlan et al (1) has confirmed the extremely high prevalence of OSA in those with known Coronary Artery Disease.

The study looked at over 1300 adults over the age of 18 from another multicentre study (Sleep and Stent Study), across multiple countries. These adults underwent percutaneous coronary intervention (PCI) for known coronary artery disease – ie. atherosclerosis, blockages inside their coronary arteries, angina, and heart attacks.

OSA was found in 45% of individuals with Coronary Artery Disease!

Given this extremely high prevalance of OSA, we highly recommend you have an in-hospital Sleep Study if you have Coronary Artery Disease, including:

•  Atherosclerosis
•  A history of angina or heart attacks
•  Coronary blockages needing ballon / stent insertion
•  Coronary bypass surgery

 Your heart health is important to us. Contact us now for an appointment.

 

1. Furlan et al. Am J Respir Crit Care Med. 2015.

© APSS 2015

Urgent recall : Resmed ASV machines could increase mortality risk in heart failure

Central Sleep Apnoea (CSA) in the setting of Heart Failure usually presents as Cheyne Stokes Respiration (CSR) on a sleep study. One of the ways to attempt to correct CSR is with a particular kind of PAP machine called “ASV”… Auto Servo Ventilation.

ASV machines map your breathing, and apply particular pressures on a breath-to-breath basis.

Today, Resmed released an Urgent Recall of their ASV machines because of an apparent safety concern.

Preliminary analysis of their data suggests an exceedingly high risk of cardiovascular death (33.5% higher) in those with Heart Failure using ASV, compared to those not on ASV.

At Adelaide Sleep, we keep abreast of all new Sleep Developments. All of our patients are consulted before and after their sleep studies, and before and after their treatment commencement, as per the current recommendations by the Australasian Sleep Association (ASA). We do not believe in direct-CPAP-outlet sales, nor do we believe in direct-to-consumer-sleep-study services. By seeing a Medical Specialist, you would’ve had a face-to-face medical consultation regarding your ASV machine.

If you believe that you are on an ASV machine, and would like to speak to a Medical Specialist regarding this, contact us now.

Addit : Philips Respironics have also released a statement echoing that of Resmed – caution in prescribing and using their BiPAP autoSV / BiPAP autoSV Advanced therapy machines and algorithm, in the at-risk group.

© APSS 2015

RLS Treatment associated with gambling, Impulse Control Disorders

One of the most common sleep disorders is The Restless legs Syndrome (RLS), and one of the common treatments is associated with Gambling and Impulse Control Disorders (ICDs).

RLS is a common sensorimotor disorder, typically amenable to treatment with dopamine agonist therapy. Dopamine agonists are mainly used for Parkinson Disease, but they have an important role in treating RLS.

These medications include pramipexole (Sifrol), ropinirole (Repreve), cabergoline (Cabaser, Bergoline), pergolide (Permax), and levodopa (Kinson, Madopar).

One of the unfortunate unpredictable side effects is that of Impulse Control Disorders (ICDs). These include :

•  Compulsive gambling (casino, pokies, tele-lotteries)
•  Compulsive shopping
•  Hypersexuality
•  Intermittent Explosive Disorder
•  Punding
•  Kleptomania (stealing)

More recently, there have been legal proceedings regarding some medications and ICDs.

We’ve known about this for some time, and we published the first Australian cohort of RLS patients with ICDs. We’ve looked after one of the largest groups of RLS patients in Australia, we routinely manage these problems effectively, and can adjust medications / medication-types as required.

RLS is easy to treat, and also easy to monitor even in the setting of potential side effects. And if Dopaminergic agents are not suitable, we have many more alternative medications at hand.

Call us now if you’d like to discuss this further.

© APSS 2015

Untreated OSA : Costing Australians health, time, and lost productivity

Untreated OSA is associated with a higher risk of heart attacks, strokes, worsening diabetes, and car accidents. Did you know that it could be costing you a lot more than you think? Consider the sick days, lost productivity, and higher long-term health costs.

In a recent economic review by Tarasiuka et al (Curr Opin Pulm Med. 2013), leaving OSA untreated doubled your overall medical expenses – mainly because of heart disease.

Hillman et al (Sleep 2006) similarly found disturbing costs associated with Sleep Disorders in Australia, costs that are unseen and affect every citizen. These included costs from work-related accidents, car accidents, reduced productivity, and lost work days. Hillman estimated a loss of $7,494,000,000 USD (yes, that many zeros!) to the Australian economy in 2004 as a result of Sleep Disorders.

How are you performing?

•  Lost productivity from poor memory?
•  Walking in a fog?
•  Waking up unrefreshed?
•  Sleeping away your days?
•  Finding it difficult to stay awake, even when off-work?

 

Don’t lose any more productivity.

Enjoy your time at home more. Make each day count. Come see one of our Adelaide Sleep Specialists now.

© APSS 2014

Atrial Fibrillation (AF) and OSA

Obstructive Sleep Apnoea is associated with diabetes, hypertension, erectile dysfunction, glaucoma, and of course heart disease. One of the more exciting and new links is between Atrial Fibrillation (AF) and OSA.

Both conditions are very common. AF is the most common cardiac arrhythmia in Australia, and OSA affects upto 24% of men and 9% of women. OSA combined with sleepiness (OSA Syndrome) occurs in 4% of men and 2% of women (1).

Patients with AF and those with OSA share similar demographic features – they are more likely to be male, hypertensive, of an older age, and have a higher body mass index. However, this link is much more than statistical chance.

Many studies have established that patients with severe OSA are significantly more likely to develop AF, increasing their risk by four times (2).

OSA decreases the likelihood of successful cardioversion (from medications or electrically) and increases the risk of AF returning. The recurrence rate of AF after cardioversion can be as high as 82% (3).

AF also recurs more often in those with OSA after radiofrequency catheter ablation (4).

According to Sleep Disorders Physician Dr Dien Dang, this is unsurprising considering the severe degree of haemodynamic compromise that occurs with OSA.

“OSA causes severe desaturations, cyclical hypoxaemia, and can structurally change your heart over time,” said Dr Dang, “Everyone who has ever had AF should consider a Sleep Study at Burnside Hospital.”

•  The OSA and AF population overlap considerably.
•  OSA can affect AF profoundly
•  Untreated OSA increases AF risk by 4x
•  Untreated OSA increases cardioversion failure by 4x

 

If you have Atrial Fibrillation, call us now for an in-Hospital Sleep Study.

1.  Young et al. NEJM 1993
2.  The Sleep Heart Health Study. AJRCCM 2006
3.  Kanagala et al. Circulation 2003
4.  Naruse Y et al. Heart Rhythm. 2012

© APSS 2014