© 2003 American Thoracic Society
Rebuttal from Dr. BlackDr. Pollak raises two noteworthy arguments for withholding modafinil in OSA-related sleepiness. The important reasons proffered are: (1) OSA has been shown to be causally related to cardiovascular disease; undoubtedly, treatment of associated sleepiness with modafinil, in lieu of definitive upper airway management, will do nothing to diminish the potential for long-term health consequences; and (2) residual sleepiness in OSA must be evaluated carefully so as to identify known causes (e.g., inadequately treated OSA) such that the cause(s) may be remedied, when possible.To conclude, however, that because modafinil is inappropriate treatment in some instances, no appropriate cases exist, is erroneous. Modafinil treatment, when no other option is meaningful, clearly leads to improved quality of life and would likely lead to a reduction in motor vehicle accidents, to which OSA patients are predisposed at a much higher rate than that of cardiovascular consequences (1, 2). Indeed, as has been established in the previous article, modafinil affords prudent and appropriate management of sleepiness when treatable causes of residual sleepiness in treated OSA are not present. Furthermore, because Dr. Pollak has raised the issue of modafinil in untreated OSA, let me be so bold as to hypothesize that modafinil has a role in treating certain cases of untreated OSA as well. It is well established that approximately 30 to 50% of patients with diagnosed OSA are CPAP noncompliant (3, 4). Even when maximal efforts to optimize compliance are applied, many remain stubbornly CPAP incompatible, often for a variety of legitimate reasons (5). Although surgery or other treatment is viable for some, most go untreated. Such a patient, if treated with modafinil, could be scheduled to see a clinician with each prescription refill. Regular visits would allow for the continued pursuit of effective airway management, to the extent possible, rather than having the patient remain completely and hopelessly untreated. Perhaps many more patients with improved care would result from such an approach. And consider, the next time you're driving the highway on a family vacation, or alone, who would you rather see operating the rig in the oncoming traffic—the concerned, modafinil-awakened, CPAP-intolerant sleep apneic, or his irresponsible, snoozing, modafinil-free counterpart? Think about it. REFERENCES
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