Eszopiclone Improves Overnight Polysomnography and Continuous Positive Airway Pressure Titration: A Prospective, Randomized, Placebo-Controlled Trial

THE INCREASING AWARENESS OF SLEEP DISORDERED BREATHING HAS CREATED A GROWING DEMAND FOR POLYSOMNOGRAPHY, RESULTING IN EXCESSIVE waiting times in many sleep laboratories.1 Sleep centers, therefore, need to develop methods to improve efficiency, streamline the evaluation process, increase access to care, and reduce costs. Unfortunately, many patients find it difficult to fall asleep in the unfamiliar environment of a laboratory setting (the first-night effect), which may prolong sleep latency and decrease sleep efficiency.2 Likewise, intolerance of continuous positive airway pressure (CPAP) in those initially treated or being titrated to higher levels may disrupt sleep continuity and reduce the quality of polysomnography. Poor quality studies may lead to an inability to establish a diagnosis or titrate CPAP therapy adequately. Unsatisfactory studies may need to be repeated, further adding to the demand for polysomnography. Nonbenzodiazepine hypnotics are commonly used to treat both acute and chronic insomnia. They are effective at reducing sleep latency, increasing total sleep time, and improving sleep efficiency.3–5 These agents have minimal side effects and do not disrupt normal sleep architecture or alter respiratory events.3,5–7 These attributes make these agents ideal for use during polysomnography and, theoretically, could enhance the efficiency of sleep centers. In a recent retrospective review, we found that the use of a nonbenzodiazepine hypnotic prior to polysomnography resulted in significantly shorter sleep latency, improved sleep efficiency, and improved patient tolerance of CPAP titration.8 We concluded that prestudy sedation resulted in improved quality and greater yield of polysomnography. Although promising, these results required validation with a prospective, randomized, placebo-controlled trial. Eszopiclone is a new non-narcotic, nonbenzodiazepine hypnotic agent approved for the treatment of acute and chronic insomnia.9 Clinical trials have found that eszopiclone decreases sleep latency and reduces wake time after sleep onset (WASO), thereby improving sleep efficiency.10–12 Eszopiclone achieves peak plasma levels within 1 hour and has a duration of action of 6–7 h.9,13 Because of its efficacy in promoting sleep onset and sleep maintenance and its favorable safety profile, this agent may be beneficial as a prestudy sedative. Furthermore, its duration of action would be ideal for polysomnography as it would continue to be effective throughout the study period. This would be especially helpful during split-night and CPAP titration studies, in which crucial adjustments in CPAP pressure occur towards the end of the sleep period. We hypothesized that the use of a short-acting hypnotic agent would improve the yield and quality of diagnostic polysomnography and CPAP titration and reduce the rate of studies needing to be repeated.