Pharmacy teams, Help People Stop Snoring!

Community pharmacists are the frontline healthcare professional. The public recognise community pharmacy as such, and expect community pharmacy to be accessible.

It is – and has been throughout the pandemic.

Recently, HRH Prince Charles, while celebrating the National Pharmacy Association’s centenary, summed up community pharmacy’s role by saying:

“Pharmacies are one of those places where science and society meet”

“An approachable and accessible first port of call for medicines and advice”

In 2021, I pulled together a group of forward thinking pharmacy and sleep experts, and we launched The British Society of Pharmacy Sleep Services ↗ We began by surveying Community Pharmacy’s knowledge of sleep disorders and their interactions with patients with suspected sleep disorders.

The BSPSS research found that Community Pharmacists:

• frequently encounter patients with symptoms of sleep disorders
• their confidence and training in dealing with these is lacking

The BSPSS research, presented to the British Sleep Society 2021 conference, and published in the BMJ Open Respiratory Research journal) ↗ highlighted the need for specialist sleep training for pharmacists and the development of pharmacy-based services to support and improve patient outcomes.

Snoring and Obstructive Sleep Apnoea the pharmacists developing role.

Within the context of concurrent cardiovascular obesity and type 2 diabetes epidemics it might perhaps be forgivable to consider snoring an irrelevance.

However when you appreciate that metabolic syndrome is exacerbated by Obstructive Sleep Apnoea, a symptom of which is snoring, you might wish to reconsider.

Indeed snoring without OSA is far from benign.

The social consequences alone: sleeping apart, relationship disharmony, no holidays because of enforced sleep disruption when sharing a hotel room, fear of travelling due to concern over falling asleep on public transport and the consequent ridicule and embarrassment, mean that snorers deserve valid help.

With an estimated 40 percent of the UK population reporting regular snoring, this is a sizable problem and one that the pharmacists can actually help with.

Did you know the snorer with untreated sleep apnoea can actually expect to die 20 years sooner than the average lifespan, independent of age, sex and BMI? Which is disappointing when diagnosis and treatment is available from the NHS that could significantly extend their healthy life.

So then, how is snoring related to Obstructive Sleep Apnoea?

Well snoring noise is created by vibrating tissue in the upper airway. In the oropharyngeal and hypopharyngeal areas, as the airway loses rigidity due to reduction in dilator muscle tone, as you go to sleep. Snoring and obstructive sleep apnoea (OSA) exist along a spectrum from otherwise benign anti-social snoring to severe OSA with the physiological and neurological consequences of recurrent hypoxic events.

But what is Obstructive Sleep Apnoea you might ask?

Well OSA consists of repetitive breathing pauses during sleep known as apnoeaic episodes. The unconscious individual’s airway has relaxed to such an extent that their snoring leads to partial or complete airway collapse. These episodes of airway collapse are the silent pauses between snores. This is when no air gets to their lungs despite continued efforts to breathe. Now the partner might notice the chest wall going up and down, they’ll notice the periods of silence in between snores.

Well there comes a point where the increased inspiratory effort arouses the sleeping brain and a breath is finally taken. Sleep as a result becomes highly fragmented and the sufferer experiences excessive daytime sleepiness because they crave sleep.

Now during an apnoeaic episode the blood oxygen levels drop dramatically and blood pressure spikes. Adrenaline, noradrenaline and cortisol are released. Apnoeaic episodes may last from several seconds to perhaps two minutes at a time. Now the number and duration of these apnoeaic episodes with larger than four percent drops in Sp02 (the oxygen saturation of the blood) are measures of OSA severity.

OK so then who is commonly affected by snoring and OSA?

Well OSA can affect anyone. However sufferers are most commonly male (two to three fold greater risk) snorers aged less than 50 years. The effect of female hormones has been proposed as an explanation for this gender difference. Yet hormone replacement studies in post-menopausal women does not support this hypothesis. It is thought that upper airway shape, tongue muscle activity and differences between sexes in fat deposition are suggested explanations. OSA is increasingly common and frequently missed in postmenopausal women. A client group likely to consult with a pharmacist.

Let’s talk about prevalence.

Well US data from 2013 not taking into account the obesity epidemic and the differences between the US and the UK (but we’re catching up) estimates prevalence at 13% of men and 6% of women. Now we calculate BMI differently in the in the UK to the US, so there’s always that confounder. Well the British Lung Foundation, in their 2015 OSA toolkit stated “OSA
is a major health challenge in the UK. 85% of people with OSA in the UK are undiagnosed and therefore untreated“. It’s likely that the prevalence of OSA will rise in the coming years particularly due to an increasing prevalence of obesity and the increasing age of the UK population.

I would note that OSA prevalence is higher among those with cardiovascular conditions and death rates from cardiovascular disease are higher for those with untreated OSA the mortality rate increasing with OSA severity.

People don’t die of OSA – they die of other conditions that are aggravated by their Obstructive Sleep Apnoea.

OK so what are the modifiable risk factors?

What lifestyle changes can actually have an impact? Well obesity is the key moderator of the effect of OSA on type 2 diabetes.

So lifestyle and behaviour change advice that includes where appropriate weight loss, alcohol reduction/cessation, increasing exercise and not smoking is helpful. Something well suited to the role of the community pharmacist.

We’ve mentioned diabetes before, but how is OSA related to diabetes? Well the cause/effect relationship between OSA and type 2 diabetes is well documented. Note that there appears to be an association between OSA and the development of insulin resistance.

How is OSAS (that’s obstructive sleep apnoea syndrome) That’s when the individual is sleepy, how is it diagnosed?

OSA syndrome as I said “OSAS”. OSAS is when OSA causes symptoms during the day or normal awake time. The most common of which is excessive sleepiness during the individual’s as I say normal awake time, typically the day. The diagnosis requires at least five episodes of apnoea / hypopnea or both events per hour of sleep. The two validated screening tools that pharmacists may use together are the Epworth Sleepiness Scale and the STOP-Bang.

Now these tools respectively assess for perceived hypersomnolence and the probability of OSA. They’re subjective, there’s obviously room for intelligent interpretation and this is where the pharmacist face-to-face, together ideally with the partner can explain the ESS and the STOP-Bang and apply a little intelligent interpretation perhaps as well.

If the ESS is greater than 10 or there are relevant comorbidities, (and you’ll get to see what the ESS is in this course), if there are relevant co-morbidities or the ESS is greater than 10 now these co-morbidities would be obesity, type 2 diabetes, hypertension or history of stroke, the snorer should be referred for further investigation: a sleep study.

Which is typically carried out at home. Called a home sleep apnoea test (HSAT). Now an important note here is that the OSA sufferer may not appreciate quite how sleepy or drowsy they have become. Which is why face-to-face with the pharmacist and ideally the partner, you can get a little bit of a more accurate representation of the truth.

The HSAT data is scored or assessed by a sleep physiologist who will produce a sleep study report. Now this report together with a patient’s medical history and perceived sleepiness data are reviewed by a specialist respiratory physician. This is their exclusive preserve. The diagnosis of OSAS is not something that a GP can do, it’s not something a pharmacist can do, a dentist can do. This is a secondary care specialist respiratory physician If there’s sufficient evidence the physician may diagnose OSA and also its severity.

“Johnny” he’s now diagnosed with OSA, well what are the prescription therapies?

According to NICE, what are called intraoral devices, otherwise known as custom-made mandibular repositioning devices or MRDs are first line therapy for snoring and mild obstructive sleep apnoea syndrome, but really with normal daytime alertness and second line therapy for moderate to severe OSAS.

So what that means is intra oral devices, these are not “gumshield” self-fit gadgets, these are custom-made discreet, adjustable devices that the dentist would prescribe when they’ve assessed the patient as being appropriate from a dental perspective as well as a respiratory one.

First line therapy for moderate to severe Obstructive Sleep Apnoea Syndrome is what’s called Positive Airway Pressure (I’ll tell you what that is in this course) or PAP therapy. It’s transformative, yet arduous and it’s a lifelong therapy. Consequently patients need support with treatment adherence

I would remind you that GPs are not permitted to prescribe PAP therapy any more than they are allowed to diagnose Obstructive Sleep Apnoea, unless of course they’ve had a special interest in sleep apnoea and their GPSi (GPwER) and they’re working very closely with the sleep unit.

OK so what could pharmacists do to advise patients?

Signposting snorers to appropriate care pathways is a key role for the pharmacist. In a systematic review of pharmacists performing OSA screening services, the authors observed that quote “Pharmacists are the most accessible and underutilised healthcare resource in the community and can have a significant role in screening patients for OSA“. Therefore it could be argued a public health benefit for pharmacists to recognise snorers with symptoms of OSAS and particularly where these patients have relevant history and/or co-morbidities.

I repeat these are: type 2 diabetes, obesity, hypertension, a cardiovascular disease or history of a stroke.

Such comorbid snorers should be immediately referred to their GP with a view to screening for OSA (your HSAT) and obviously with comprehension that referral update might be poor if left to the individual to action, ideally a note made on the patient’s Summary Care Record for the GPs attention.

So let’s sum this up:

Over-the-Counter cures have little if any objective evidence to support their claims. While of course there may be a placebo effect, better options exist that reflect well upon the pharmacist. Now as you know snoring may be a symptom of OSA and the worst thing that could happen would be that the Over-the-Counter “cure” delayed the patient obtaining effective treatment. Such treatment that will extend their healthy life. OSA treatment decreases the patient’s relative risk of having a stroke by 49%, a cardiovascular event by 46% and the risk of them being involved in a road traffic incident by 31%.

The provision of healthy lifestyle advice by community pharmacists such as smoking cessation and weight management, these things are known to improve symptoms of OSAS, (obstructive sleep apnoea syndrome) together with (when sleep trained) signposting snorers to appropriate care pathways specifically targeting those under the age of 50 and/or those with comorbidities and relevant medical history, this would aid identification and subsequent treatment of obstructive sleep apnoea, build capacity and realise the potential of community pharmacy to improve public health.