Richard Bogan on Excessive Daytime Sleepiness

October 23, 2018

The Associate Clinical Professor at the University of South Carolina School of Medicine and Chief Medical Officer at SleepMed emphasized that clinicians need to recognize the impact of sleepiness in terms of quality of life.

Richard Bogan, MD

Jazz Pharmaceuticals recently announced findings from a survey of more than 300 patients living with sleep apnea and their partners. The survey inquired about key topics connected to patient experiences with sleep apnea which can cause significant problems and affect quality of life.

To provide additional insight into the survey, among other topics associated with excessive daytime sleepiness related to sleep apnea, NeurologyLive spoke with Richard Bogan, MD, Associate Clinical Professor at the University of South Carolina School of Medicine, and Chief Medical Officer at SleepMed in Columbia, S.C. in an exclusive interview.

As clinicians treat the potential morbidity and mortality of any disorder, particularly excessive daytime sleepiness, it’s important to recognize that these individuals are symptomatic and the impact this has on the quality of life. Bogan emphasized that it’s important for clinicians not only to make sure patients are adherent to their CPAP but also are addressing these functional impairments.

NeurologyLive: What are the key results from the survey?

Richard Bogan, MD: The survey was sponsored by JAZZ and what they did was they queried patients with obstructive sleep apnea with no other sleep disorder but who did have sleepiness based on the Epworth Sleepiness Score—the Epworth Sleepiness Score is patient reported outcome measure of sleepiness. The patients also talked to their partners and I think the outcome of the measure was that many of these patients, really 2/3 of the patients in general with sleep apnea, 22 million people have excessive sleepiness associated with sleep apnea and of this group, what the survey shows is that the sleepiness has a marked effect because it’s obviously chronic fatigue, but this in turn impacts their daily life in terms of work and personal life with their family, and social interactions with others, it has a huge impact.

Can you discuss the current therapeutic landscape of excessive daytime sleepiness?

RB: We approach our patients from 2 perspectives. One is, and this is what many physicians get caught up in, we treat the potential morbidity and mortality. This is a clinically relevant disorder that’s associated morbidity and mortality, cardiovascular and CNS and we want to reduce morbidity and mortality and treat the patients. CPAP is the most common treatment and while there are other treatment options, many of the patients still have daytime excessive daytime sleepiness, so it’s important for us as clinicians to recognize this excessive daytime sleepiness and its impact on quality of life.

As you know sleepiness can cause many different types of symptoms in patients, so they don’t always recognize they have sleepiness and we actually saw this in the survey that many of the patients said ‘I have sleep apnea and I’m supposed to be tired and I’m supposed to be sleepy,’ but they didn’t really realize that there are other potential treatment options because they translated their sleepiness into other symptoms, I’m tired, I can’t think, I can’t remember, I have problems with focus and concentration, or I’m moody or irritable, and these symptoms then related to the individual in terms of a significant impact on work performance based on the survey. The survey results are really telling in terms of sleepiness while driving, falling asleep at work, or other significant impacts like relationships with a spouse.

Are there any therapies in the pipeline for excessive daytime sleepiness that excite you?

RB: As a clinician who treats patients who are exceptionally sleepy, again, we want to reduce morbidity and mortality, but it’s important for us to recognize that these individuals are symptomatic and somewhat so that there are FDA-approved drugs, but excitingly there are other drugs in development that address this very relevant problem in our patients in terms of excessive sleepiness and sleep apnea.

What’s your best advice for clinicians treating this patient population?

RB: Based on the survey what we saw was that most patients don’t bring it up to their doctors. They have trouble quantifying how sleepy they are and how tired they are due to the sleepiness, and they don’t bring it up, and even those that brought it up, they had to bring it up with the physicians.

My message to the physicians is that sleepiness can manifest as fatigue and we have to figure out if the fatigue is due to sleepiness which can have neurocognitive effects, mood effects, or attention effects, so it’s up to us as clinicians not only to reduce morbidity and mortality, but to ask our patients if they are sleepy because if we can determine that they are sleepy and there’s something we can do and that something we can do to help with the sleepiness may involve pharmacologic intervention, that something we can do that can have a significant impact in terms of these individuals and their quality of life.

Are there any misconceptions/stigmas that need to be debunked?

RB: I think the big one I hear is, ‘I have sleep apnea and now I’m adequately treated and therefore I’m done,’ and that’s not the case. Sleepiness is a very prevalent symptom in these individuals and even despite adequate treatment, we are concerned that there are patients that have residual sleepiness and often times the patients say, ‘well if I have this disorder, this is how I’m supposed to be,’ and they don’t really quantify it. As I said before, it’s very important for us to recognize that this is a problem.

There’s actually exciting science now that looks at the potential of neuronal injury, so there’s objective evidence now that there is possibility of neuronal injury associated with sleep fragmentation, associated potentially with sleep apnea, or oxidative stress with drops in oxygen levels. This evolving science is now prepping us to potentially understand a possible mechanism of action in some of these individuals and that’s not the sole explanation, but I think it’s important for the patients and the clinicians to that know there’s some evolving science that gives us objective evidence as to why this might be happening.

Is there anything else you think our physician audience should know?

RB: I hate to be redundant, but I think the bottom line is we obviously want to reduce morbidity and mortality and treat patients appropriately, but we have to really recognize the impact of sleepiness in terms of quality of life in these individuals—at work, at home, at social situations, and even workplace performance striving, for example. It’s important for us to not only make sure patients are adherent to their CPAP, but also, we’re addressing these functional impairments.

That’s why the development of this website is so exciting, “A Different Kind of Tired” to try and help patients understand that residual symptoms are there and they need to talk to their doctors about it.

Disclosure: Richard Bogan MD, is a paid consultant for JAZZ, treats patients and has conducted clinical research.

REFERENCE

Jazz Pharmaceuticals Survey Highlights Significant Impact of Excessive Daytime Sleepiness Related to Sleep Apnea [news release]. Dublin, Ireland: Jazz Pharmaceuticals; 2018. https://www.multivu.com/players/English/8390751-jazz-pharmaceuticals-sleep-apnea-survey-results. Accessed Oct. 19, 2018.