Real-world effectiveness and tolerability of wake-promoting agents for residual sleepiness in treated obstructive sleep apnea.

Residual sleepiness despite effective positive airway pressure (PAP) therapy remains a persistent clinical problem in obstructive sleep apnea (OSA). This retrospective study evaluated real-world use, effectiveness, and tolerability of modafinil, armodafinil, and solriamfetol in 50 adults with OSA and residual sleepiness. Most patients received modafinil (80%) as their initial agent. Complete, partial, and poor responses occurred in 26%, 44%, and 30% of patients, respectively. Adverse events were reported in 38%-predominantly neurologic and psychiatric-and led to discontinuation in ten cases. Response did not correlate with apnea severity, body mass index, or PAP adherence, and no single agent demonstrated superior benefit. These findings contrast with the stronger efficacy and tolerability reported in randomized controlled trials, underscoring the need for individualized therapy and realistic counseling about benefits and side effects when prescribing wake-promoting agents in clinical practice.