Pharmacists, Help People Stop Snoring!
Pharmacists, train to screen snorers and signpost to appropriate care.
Why do Anything About Snoring?
Obstructive Sleep Apnoea
Within the context of concurrent cardiovascular, obesity and T2DM epidemics, it might perhaps be forgivable to consider ‘snoring’, an irrelevance.
However, when you appreciate that metabolic syndrome is exacerbated by obstructive sleep apnoea (OSA)1 – a symptom of which is snoring, you may wish to reconsider.
Indeed, snoring without OSA is far from benign.
“Pharmacies are often the first port of call for snorers, or their desperate domestic partners.”
Alan Nathan, Pharmaceutical Journal.2
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 during long journeys on public transport and the consequent ridicule and embarrassment
mean snorers deserve valid help.
With an estimated 40% of the UK population reporting regular snoring3 this is a sizeable problem.
Snoring is commonly trivialised and sales of OTC snore ‘cures’ that encourage the unwary to self-diagnose and self-treat (in order to profit from their misery) commonplace.
Yet the snorer with untreated sleep apnoea can expect to:
Die 20 years sooner4
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.
Screening and signposting for sleep apnoea are fulfilling roles for the community pharmacist that support the healthy living and better care agenda5.
Our Unique Offering
Our free, online snoring course for UK pharmacists is divided into three chapters, each with a short assessment.
The final examination has a minimum pass mark of 80% to satisfy planned learning CPD requirements and to ensure pharmacists are educated sleep professionals.
Our proprietary Snorer.me Signposting™ software is a CE marked Clinical Decision Support System (CDSS) utilising industry recognised pre-treatment screening tools.
We do NOT make/sell treatment devices. We have no vested interest in the outcome of signposting.
Snorer.com ranks on Google’s first page for commonly searched for snoring keywords and phrases.
We direct snorers and their long-suffering partners to consult a pharmacist (or GP).
Designed for Distanced Delivery #ddd
We created our software with distanced delivery in mind. While face-2-face assessment would be ideal, circumstances (and covid19) may not permit.
So our online services are: “Designed for Distanced Delivery” meaning snorers and pharmacists can speak via Zoom, Teams, Meet etc. as preferred.
How Does it Work?
Three Steps to Heaven-ly Sleep for your patients:
Learn about sleep & breathing and evidence-based care
Integrate the latest evidence into decision making for snoring and sleep apnoea patients
Screen and recognise snorers with sleep apnoea symptoms
Identify at risk patients using our evidence-based software tool in line with the most up to date recommendations
Signpost appropriately utilising your new knowledge
Incorporate patient-centred considerations when making clinical recommendations based upon recognised protocols
In the (13 mins) video below, Adrian Zacher provides an overview of the developing role of the sleep-trained pharmacist:
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.
What does Signposting look like?
Adrian Zacher established Snorer.com after 18 years in the sleep industry.
Initially, Adrian was satisfied just to disrupt the pseudo-scientific marketing, commonly used to exploit snorers and their partners.
This grew into creation of our online signposting software and comprehension that pharmacists are the appropriate professional to deliver it.
Snorer.com is proudly independent of any sleep business and NOT part of an affiliate scheme.
What Can Pharmacists do to Advise Snorers?
Screening, Recognising and Signposting
An abundance of Over-The-Counter (OTC) products for snoring exist.
However, they generally have little, if any, objective evidence of effect.
As a sleep-trained pharmacist you will be able to advise snorers in a more informed way.
Once trained, you will be able to:
- Recognise OSA symptoms that merit further investigation
- Use our signposting tool to:
- Assess snoring and contributory factors
- Screen and connect patients to NICE recommended treatment6, for both anti-social snoring and sleep apnoea
- Discuss evidence-based help that may extend their healthy life
- Use our home sleep apnoea testing service to improve the patient’s likelihood of onward referral to secondary care, and potentially reduce their time to treatment
Signposting ‘snorers’ to appropriate care pathways is a key role for the pharmacist 6.
Does the Evidence Support the Pharmacists’ Sleep Role?
A Public Health Benefit
In a systematic review of pharmacists performing OSA screening services7 the authors observed that:
“Pharmacists are the most accessible and underutilized healthcare resource in the community and can have a significant role in screening patients for OSA.”
Thus, it could reasonably be argued a public health benefit, for pharmacists to recognise snorers with symptoms of Obstructive Sleep Apnoea Syndrome (OSAS) and particularly where those patients have relevant history and/or comorbidities e.g.:
- T2DM (type II diabetes mellitus)
- Hypertension (high blood pressure)
- CVD (heart disease)
- CVA (stroke)
Such comorbid snorers should be referred to their GP1 with comprehension that referral uptake may be poor if left to the individual to action,8 ideally a note made on the patient’s Electronic Health Record or Summary Care Record for the GP’s attention9.
Current NICE Guidelines6 state that mandibular advancement devices (custom-made, prescription ‘mouthguards’) are first-line therapy for snoring and mild OSA, when the snorer is not drowsy during their normal awake time (hypersomnolent) and has no relevant comorbidities.
Such patients should be directed to a sleep-trained dentist, for the dentist to determine the patient’s suitability for a custom-made, prescription mandibular advancement device.
Our online ‘pharmacist driven’ signposting tool10 (Snorer.me Signposting™) gives you the option of referring those you have screened as not needing further investigation, to our network of sleep-trained dentists. Particularly useful when a GP referral would be unlikely to result in a secondary care referral and serve only to:
Unnecessarily consume GP clinical time
Waste the snorer’s time
And in the worse case scenario, unnecessarily consume diagnostic capacity in secondary care
We created our signposting tool (CDSS) to develop the primary care network, and connect snorers to pharmacists so they may accelerate sufferers to valid, evidence-based and effective treatment.
Benefits & Outcomes
The snorer has been:
- Assessed by a sleep-trained professional
- Screened for symptoms of OSA
- Signposted appropriately
The snorer knows:
- Why they snore
- What to do about it
- Where to go to stop
The patient now has a comprehensive, actionable, personal report.
They have been accelerated to the most appropriate care.
Why Work With Us?
25+ Years Snoring & Sleep Apnoea Experience
Experience built over decades working with sleep experts
Pioneering Online Signposting Software
Our online, pharmacist ‘driven’ signposting tool (CDSS), assists you with sleep patient assessment and signposting
Optimising use of GP time and NHS capacity
We understand the vital role the healthcare professional team play to optimise NHS resource utilisation
Independent, Professional Education
We’ve been teaching healthcare professionals since 2005 WITHOUT a product sales agenda
Make a difference to snorers’ and partners’ lives:
What Others Say
Thank you for the opportunity to train as a sleep trained pharmacist. Your training platform was simply superb - well thought out, engaging and highly informative for all things snoring and OSA. I can't wait to utilise my new-found knowledge and help the many people out there lead a healthier life. In fact now that I know how important this field is I may even save a few lives in the process. Thank you again and I hope every pharmacist takes up this opportunity!!
How much does it cost?
Training is completely free and without any obligation. When successfully completed you will gain a digital course certificate (3 valuable CPD hours).
We charge when:
- You use our software tool
- You provide home sleep apnoea testing
We use a Pay-Per-Use pricing model, where you only pay when you have a customer. We consider that fairer.
As you would imagine, a contract and SOPs apply.
Get in touch and we can set up a time to discuss on the phone or via most video meeting apps.
How long will it take?
We estimate the online course will take ~ 3 hours to complete.
Further reading is highly recommended, and you should expect to spend some time becoming familiar with the signposting software (we consider this intuitive) and the Home Sleep Apnoea Testing equipment.
Can I discuss this with you?
Drop us an email [firstname.lastname@example.org] and we can setup a time that suits us both.
Our contact details
Tel: 01235 364121
2 Baynards Green Farm Cottage
Make a difference to snorers’ and partners’ lives:
- IDF. Consensus Statements. Int Diabetes Fed. 2008;51(5):i-ii. oi:10.1159/000480305 ↗ Accessed January 14, 2020.
- Snoring and the evidence behind the various treatments available Pharmaceutical Journal, Feb 2010 ↗ Accessed 15th Oct 2020.
- Ohayon MM, Guilleminault C, Priest RG, Caulet M. Snoring and breathing pauses during sleep: Telephone interview survey of a United Kingdom population sample. Br Med J. 1997;314(7084):860-863. doi:10.1136/bmj.314.7084.860 https://pubmed.ncbi.nlm.nih.gov/9093095/ ↗ Accessed January 14, 2020.
- Finn L, Young T. Sleep Disordered Breathing and Mortality: Eighteen-Year Follow-up of the Wisconsin Sleep Cohort. Year Pulm Dis. 2009;2009:291-292. doi:10.1016/s8756-3452(08)79181-3 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2542952/ ↗ Accessed January 14, 2020.
- Pharmacy in England: Building on Strengths – Delivering the Future – Great Britain. Department of Health – Google Books. ↗ Accessed January 14, 2020.
- NICE CKS. Obstructive sleep apnoea syndrome. Clinical knowledge summaries. https://cks.nice.org.uk/obstructive-sleep-apnoea-syndrome ↗ Accessed 30th June 2020.
- Cawley MJ, Warning WJ. A systematic review of pharmacists performing obstructive sleep apnea screening services. Int J Clin Pharm. 2016;38(4):752-760. doi:10.1007/s11096-016-0319-0 https://link.springer.com/article/10.1007/s11096-016-0319-0?shared-article-renderer ↗. Accessed January 13, 2020.
- Fuller JM, Wong KK, Grunstein R, Krass I, Patel J, Saini B. A Comparison of Screening Methods for Sleep Disorders in Australian Community Pharmacies: A Randomized Controlled Trial. Baradaran HR, ed. PLoS One. 2014;9(6):e101003. doi:10.1371/journal.pone.0101003 https://pubmed.ncbi.nlm.nih.gov/24978952/ ↗ Accessed 30th June 2020.
- Summary Care Record (SCR) in community pharmacy – NHS Digital. https://digital.nhs.uk/services/summary-care-records-scr/summary-care-record-scr-in-community-pharmacy ↗. Accessed January 13, 2020.
- Zacher A, Easton E. P076 Signposting for snoring: does it optimise use of GP time? Online surveys of patients and sleep-trained dentists. BMJ Open Respir Res. 2019;6(Suppl 1):A47-A48. doi:10.1136/bmjresp-2019-bssconf.76 https://bmjopenrespres.bmj.com/content/6/Suppl_1/A47.2 ↗ Accessed 30th June 2020.
Snorer Pharmacy™ is a pending trademark.
Snorer.me Signposting™ is a CE marked clinical decision support system (CDSS) software as a medical device (SaMD).
The manufacturer is Snorer.com Ltd. ｜Page created by Adrian Zacher. All rights reserved. Copyright 2020. ｜ Last updated 25th Nov 2020.