1206 Combination of Nasal Steroid and Nasal Oxymetazoline: A Way to Improve PAP Tolerance in OSA Patients with Rhinitis

Introduction Obstructive sleep apnea (OSA) is the most common cause of sleep-disordered breathing, and positive airway pressure (PAP) therapy is the gold standard for treatment. PAP therapy adherence remains a challenge especially in patients with nasal disease. Our case is that of a patient with OSA and long-standing allergic rhinitis who had significant improvement in PAP adherence with the use of daily intranasal oxymetazoline and fluticasone. Report of case(s) A 62-year-old man with history of allergic rhinitis on intranasal fluticasone presented to our sleep clinic for discussion about OSA treatment options because he was intolerant of PAP therapy. He had OSA documented for 18 years and had twice attempted PAP therapy unsuccessfully despite high motivation. Baseline AHI was 25/hr. He had tried a mandibular assist device (MAD) with good control of snoring until he gained more weight and the MAD no longer controlled symptoms. He attempted PAP therapy again and tried nasal oxymetazoline with a nasal steroid and was able to tolerate the use of PAP machine for an entire night and so continued using the combination therapy. He has been tolerant of PAP for a year on this regimen without the development of rhinitis medicamentosa (RM). The presence of rhinitis before or after starting PAP therapy is a strong negative predictor of PAP adherence. Intranasal oxymetazoline is an option for treatment of sinusitis but has been known to cause rhinitis medicamentosa when used alone. Our index patient did not notice any improvement in tolerance of PAP while on intranasal fluticasone, but a combination of intranasal fluticasone and oxymetazoline led to better tolerability in our patient. There are limited studies for long-term use of oxymetazoline. Two studies showed that using oxymetazoline along with a nasal steroid once daily for 4 weeks demonstrated improved effectiveness in relieving nasal symptoms with no development of rebound congestion or rhinitis medicamentosa. Conclusion PAP therapy compliance remains a challenge in patients with allergic rhinitis. Combination therapy of intranasal steroid and intranasal oxymetazoline may be helpful in improving PAP adherence in these patients, and further study is warranted. Support (if any)