to the editor: The article¹ on the diagnosis and treatment of obstructive sleep apnea (OSA) provided an excellent overview. However, I would like to add a few additional considerations.

As Dr. Victor suggested,¹ family physicians should be able to identify the symptoms of OSA and initiate appropriate treatment. Although the article¹ briefly discussed the risk of mortality associated with OSA, it did not mention some of the other serious problems associated with OSA (such as hypertension, coronary artery disease, myocardial infarction, stroke, psychiatric problems, impotence, cognitive dysfunction, memory loss, and death)^2,3 that should be considered when discussing the disorder.

Another significant issue concerns the short-term dangers associated with OSA-related symptoms, particularly the risks of engaging in certain activities while impaired by excessive sleepiness. Excessive sleepiness is the primary symptom, and often the most debilitating feature, associated with OSA.^3,4 It is reported by approximately 90 percent of patients with OSA and may be incapacitating, resulting in job loss, accidents, self injury, marital and family problems, and poor school or work performance. If the urge to fall asleep during waking hours is uncontrollable and occurs at inappropriate times, it can have the same consequences as inability to sleep at night. Retrospective studies⁵ show that the rate of traffic accidents among persons with sleep apnea is three to four times the rate among persons without sleep apnea.⁵ In addition, 50 percent of accidents at work and 25 percent of accidents at home are caused by excessive sleepiness. The individual and societal implications of excessive sleepiness should not be overlooked, and special consideration should be given to managing this symptom as well as the underlying disease disorder.

The author noted that continuous positive airway pressure (CPAP) therapy can reduce problems of excessive sleepiness in patients with OSA. However, despite the use of nasal CPAP, many patients continue to experience residual excessive sleepiness.⁶ Residual excessive sleepiness may persist in patients with OSA who have insufficient sleep syndrome of a coexisting sleep disorder. In some patients, the underlying sleep-generating mechanisms may be permanently altered as a result of many years of sleep disturbance. These patients may require other therapies such as surgery, additional devices, or medications.

In January 2004, the U.S. Food and Drug Administration approved modafinil (Provigil) as the first and only drug to be used as an adjunct treatment to CPAP to improve wakefulness in patients with residual excessive sleepiness associated with OSA. Clinical studies have shown that patients with OSA who receive treatment with modafinil and CPAP may have significant improvements in daytime wakefulness, sleep-related functional status, overall clinical condition, and quality of life.⁶ Modafinil is well tolerated and has been used safely for the treatment of excessive sleepiness associated with narcolepsy since 1998. While CPAP remains integral to the nighttime treatment of OSA, the management of the coexisting morbidities and daytime symptoms associated with this disorder must be prioritized as well.