A systematic review of the pharmacological approaches against snoring: can we count on the chickens that have hatched? - Sleep and Breathing

Background

Snoring is the sound produced by the vibration of the soft tissues caused by the air passing through a narrow upper airway during sleep. It is usually associated with the conditions that increase upper airway resistance, but can occur in their absence too (primary snoring). Considering its sheer prevalence, the associated comorbidities, like carotid atherosclerosis and the social disorder that it can represent, treatment for snoring must be considered even in the absence of any other medical condition. Treatment options include conservative approaches like weight reduction, smoking and alcohol cessation, sleep positioning, mechanical nasal dilators, and continuous positive airway pressure (CPAP) to more radical approaches like surgery. Till date, we have no drugs for treating the primary pathology of snoring.

Methods

A systematic literature search was carried out in PUBMED and EMBASE, and we found only nine randomized control trial’s and one interventional study focusing on the pharmacotherapy of snoring per se, even as the literature is replete with studies evaluating drug therapy for obstructive sleep apnea.

Result

Drugs evaluated include protriptyline, pseudoephedrine and domperidone, mometasone, nasal surfactant, Botulinum toxin type A, and some homeopathic and oil-based nasal sprays. The selected studies showed no strength in data and had a great methodological heterogeneity, so it is impossible to compare the analyzed studies.

Discussion

Even though there are no consistent data to support pharmacologic treatment for primary snoring, through the critical analysis of these studies, we have discussed about the future directions for clinical trials in this area to arrive at a clinically meaningful decision.

1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328(17):1230–1235. doi:10.1056/NEJM199304293281704

   Article  CAS  PubMed  Google Scholar 

2. Deary V, Ellis JG, Wilson JA, Coulter C, Barclay NL (2014) Simple snoring: not quite so simple after all? Sleep Med Rev. doi:10.1016/j.smrv.2014.04.006

   PubMed  Google Scholar 

3. Lugaresi E, Cirignotta F, Coccagna G, Piana C (1980) Some epidemiological data on snoring and cardiocirculatory disturbances. Sleep 3(3–4):221–224

   CAS  PubMed  Google Scholar 

4. Norton PG, Dunn EV (1985) Snoring as a risk factor for disease: an epidemiological survey. Br Med J (Clin Res Ed) 291(6496):630–632

   Article  CAS  Google Scholar 

5. Koskenvuo M, Kaprio J, Telakivi T, Partinen M, Heikkila K, Sarna S (1987) Snoring as a risk factor for ischaemic heart disease and stroke in men. Br Med J (Clin Res Ed) 294(6563):16–19

   Article  CAS  Google Scholar 

6. Beninati W, Harris CD, Herold DL, Shepard JW Jr (1999) The effect of snoring and obstructive sleep apnea on the sleep quality of bed partners. Mayo Clin Proc 74(10):955–958. doi:10.4065/74.10.955

   Article  CAS  PubMed  Google Scholar 

7. Beninati W. Treatment of adults with snoring. In: UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessed on August 4, 2014)

8. Downs SH, Black N (1998) The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. J Epidemiol Community Health 52(6):377–384

   Article  PubMed Central  CAS  PubMed  Google Scholar 

9. Hoffstein V, Mateiko S, Halko S, Taylor R (1987) Reduction in snoring with phosphocholinamin, a long-acting tissue-lubricating agent. Am J Otolaryngol 8(4):236–240

   Article  CAS  PubMed  Google Scholar 

10. Series F, Marc I (1993) Effects of protriptyline on snoring characteristics. Chest 104(1):14–18

    Article  CAS  PubMed  Google Scholar 

11. Lipman D, Sexton G, Schlesser J (1999) A randomized double-blind placebo-controlled evaluation of the safety and efficacy of a natural over-the-counter (otc) medication in the management of snoring. Sleep Breath 3(2):53–56. doi:10.1007/s11325-999-0053-0

    Article  PubMed  Google Scholar 

12. Ulfberg J, Nystrom B (2001) Treatment of snorers with a volatile oil: a randomized, double-blind, placebo-controlled trial. ORL J Otorhinolaryngol Relat Spec 63(5):298–301

    Article  CAS  PubMed  Google Scholar 

13. Morrell MJ, Arabi Y, Zahn BR, Meyer KC, Skatrud JB, Badr MS (2002) Effect of surfactant on pharyngeal mechanics in sleeping humans: implications for sleep apnoea. Eur Respir J 20(2):451–457

    Article  CAS  PubMed  Google Scholar 

14. Prichard AJ (2004) The use of essential oils to treat snoring. Phytother Res 18(9):696–699. doi:10.1002/ptr.1360

    Article  CAS  PubMed  Google Scholar 

15. Wijewickrama RC, Blalock D, Mims JW (2004) Study of lubricant-induced changes in chronic snorers (SLICCS). Otolaryngol Head Neck Surg 131(5):606–609. doi:10.1016/j.otohns.2004.05.024

    Article  PubMed  Google Scholar 

16. Larrain A, Hudson M, Dominitz JA, Pope CE 2nd (2006) Treatment of severe snoring with a combination of pseudoephedrine sulfate and domperidone. J Clin Sleep Med 2(1):21–25

    PubMed  Google Scholar 

17. Kuhnel TS, Schulte-Mattler W, Bigalke H, Wohlfarth K (2008) Treatment of habitual snoring with botulinum toxin: a pilot study. Sleep Breath 12(1):63–68. doi:10.1007/s11325-007-0136-8

    Article  CAS  PubMed  Google Scholar 

18. Hultcrantz E, Harder L, Harder H, Zetterlund EL, Roberg K (2010) To treat snoring with nasal steroids—effects on more than one level? Acta Otolaryngol 130(1):124–131. doi:10.3109/00016480902934211

    Article  CAS  PubMed  Google Scholar 

19. Cho JG, Witting PK, Verma M, Wu BJ, Shanu A, Kairaitis K, Amis TC, Wheatley JR (2011) Tissue vibration induces carotid artery endothelial dysfunction: a mechanism linking snoring and carotid atherosclerosis? Sleep 34(6):751–757. doi:10.5665/SLEEP.1042

    PubMed Central  PubMed  Google Scholar 

20. Hoffstein V (1994) Blood pressure, snoring, obesity, and nocturnal hypoxaemia. Lancet 344(8923):643–645

    Article  CAS  PubMed  Google Scholar 

21. Lee SA, Amis TC, Byth K, Larcos G, Kairaitis K, Robinson TD, Wheatley JR (2008) Heavy snoring as a cause of carotid artery atherosclerosis. Sleep 31(9):1207–1213

    PubMed Central  PubMed  Google Scholar 

22. Yeboah J, Redline S, Johnson C, Tracy R, Ouyang P, Blumenthal RS, Burke GL, Herrington DM (2011) Association between sleep apnea, snoring, incident cardiovascular events and all-cause mortality in an adult population: MESA. Atherosclerosis 219(2):963–968. doi:10.1016/j.atherosclerosis.2011.08.021

    Article  PubMed Central  CAS  PubMed  Google Scholar 

23. Hagander L, Harlid R, Svanborg E (2009) Quantitative sensory testing in the oropharynx: a means of showing nervous lesions in patients with obstructive sleep apnea and snoring. Chest 136(2):481–489. doi:10.1378/chest. 08-2747

    Article  PubMed  Google Scholar 

24. Fenik V, Kubin L, Okabe S, Pack AI, Davies RO (1997) Differential sensitivity of laryngeal and pharyngeal motoneurons to iontophoretic application of serotonin. Neuroscience 81(3):873–885

    Article  CAS  PubMed  Google Scholar 

25. Veasey SC, Panckeri KA, Hoffman EA, Pack AI, Hendricks JC (1996) The effects of serotonin antagonists in an animal model of sleep-disordered breathing. Am J Respir Crit Care Med 153(2):776–786. doi:10.1164/ajrccm.153.2.8564132

    Article  CAS  PubMed  Google Scholar 

26. Goldstein JA (1983) Possible therapy for snoring. West J Med 138(2):270

    PubMed Central  CAS  PubMed  Google Scholar 

27. Kamm RD, Schroter RC (1989) Is airway closure caused by a liquid film instability? Respir Physiol 75(2):141–156

    Article  CAS  PubMed  Google Scholar 

28. Liu MY, Wang LM, Li E (1985) Enhorning G (1991) Pulmonary surfactant will secure free airflow through a narrow tube. J Appl Physiol 71(2):742–748

    Google Scholar 

29. Tangel DJ, Mezzanotte WS (1985) White DP (1991) Influence of sleep on tensor palatini EMG and upper airway resistance in normal men. J Appl Physiol 70(6):2574–2581

    Google Scholar 

30. Douglas NJ, Polo O (1994) Pathogenesis of obstructive sleep apnoea/hypopnoea syndrome. Lancet 344(8923):653–655

    Article  CAS  PubMed  Google Scholar 

31. Mason M, Welsh EJ, Smith I (2013) Drug therapy for obstructive sleep apnoea in adults. Cochrane Database Syst Rev 5, CD003002. doi:10.1002/14651858.CD003002.pub3

    PubMed  Google Scholar 

Download references

Authors and Affiliations

1. Department of Pharmacology, Postgraduate Institute of Medical Education and Research (PGIMER), 4th Floor, Research Block B, Chandigarh, India

   Shyambalaji Achuthan & Bikash Medhi

Corresponding author

Correspondence to Bikash Medhi.