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SOLRIAMFETOL TITRATION AND ADMINISTRATION: PHYSICIAN TITRATION STRATEGIES IN A HYPOTHETICAL PATIENT WITH OSA

      TOPIC: Sleep Disorders
      TYPE: Original Investigations
      PURPOSE: Solriamfetol (Sunosi®) is a dopamine/norepinephrine reuptake inhibitor approved (US and EU) to treat excessive daytime sleepiness (EDS) in adults with narcolepsy (75-150 mg/d) or obstructive sleep apnea (OSA) (37.5-150 mg/d). Titration strategies for a hypothetical patient were analyzed to understand factors physicians consider when initiating solriamfetol.
      METHODS: This virtual, descriptive, cross-sectional, qualitative survey of solriamfetol titration and administration (START) enrolled US-based physicians treating patients with EDS due to OSA/narcolepsy. Responses to 4 open-ended questions on a hypothetical patient were recorded. Patient scenario: 48-year-old man with OSA, obesity (BMI=35), and hypercholesterolemia who uses continuous positive airway pressure ≥6 hours/night and has taken modafinil (400 mg/d) for 2 years which no longer controls his EDS (Epworth Sleepiness Scale [ESS]=13). Content analysis of recordings identified themes in responses; a trained linguist captured language patterns.
      RESULTS: Twenty-six physicians (7 neurologists; 7 internists; 6 pulmonologists; 5 psychiatrists; 1 otolaryngologist) treating OSA for 16.3±6.5 years and representing 781 patients stable on solriamfetol participated; 73% were board-certified in sleep medicine. All physicians thought the patient would be appropriate for solriamfetol, citing lack of EDS symptom control (65%), high modafinil dose (31%), and ESS level (27%). To start solriamfetol, most suggested switching from modafinil (21 [81%]); 4 (15%) would add solriamfetol to modafinil and 1 (4%) felt it depended on other factors. Fourteen (54%) would not titrate solriamfetol per the label, of whom 86% would start at 75 mg. Ten (39%) would discontinue modafinil abruptly; others would taper while (5 [19%]) or before starting solriamfetol (5 [19%]), taper and discontinue while starting solriamfetol (4 [15%]), or use another approach (2 [8%]). Current modafinil dose (23%), likelihood of adverse reaction (15%), similar mechanism of action (12%), EDS severity (4%), and other (12%) influenced physicians' titration decisions; 42% cited no factors influencing their decision. If the patient was not taking modafinil, 11 (42%) physicians would titrate solriamfetol per the label starting at 37.5 mg; 15 (58%) would use alternative approaches. Controlled hypertension would not change most physicians' (81%) approaches.
      CONCLUSIONS: Most physicians cited lack of symptom control on modafinil as the rationale for recommending solriamfetol in this scenario. Most physicians considered specific factors when titrating (most commonly the dose of prior medication). Most would not change their approach due to controlled hypertension.
      CLINICAL IMPLICATIONS: Response to and dose of prior EDS medication were commonly considered by physicians recommending solriamfetol for a patient with OSA.
      DISCLOSURES: Consultant relationship with Jazz Pharmaceuticals Please note: 6/2020-8/2020 Added 04/07/2021 by Elizabeth Baldys, source=Web Response, value=Consulting fee
      Employee relationship with Jazz Pharmaceuticals Please note: 11/2019 till now Added 04/30/2021 by Abby Chen, source=Web Response, value=Salary
      Employee relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Salary
      Stock Holder relationship with Jazz Pharmaceuticals Please note: 2014 - current Added 04/13/2021 by Danielle Hyman, source=Web Response, value=Ownership interest
      Consultant relationship with Stratevi Please note: Aug 2018 - Apr 2021 Added 04/01/2021 by Diane Ito, source=Web Response, value=Consulting fee
      Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary
      Removed 04/13/2021 by Gregory Parks, source=Web Response
      Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Salary
      Employee relationship with Jazz Pharmaceuticals Please note: 4/2019-Present Added 04/13/2021 by Gregory Parks, source=Web Response, value=Ownership interest
      Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=Salary
      Employee relationship with Jazz Pharmaceuticals Please note: current Added 04/26/2021 by Gregory Parks, source=Web Response, value=stock options
      No relevant relationships by Haramandeep Singh, source=Web Response
      Advisory Committee Member relationship with Jazz Pharmaceuticals Please note: 3000 Added 04/01/2021 by Michael Thorpy, source=Web Response, value=Consulting fee