Do you obtain an MSLT or start empiric therapy with modafinil in patients with residual excessive daytime sleepiness despite optimal adherence to PAP therapy?  

In this situation I would start either modafinil, armodafinil, or solriamfetol for residual EDS if the OSA was appropriately controlled without need for MSLT. We have an FDA label for these medications in this situation to support this practice. If I felt like there was concern for a combination of ...

I start empiric therapy unless I suspect narcolepsy or idiopathic hypersomnia with OSA then I order MSLT.

Personally, I am not a strong believer in empiric stimulant use in this context. Usual offenders need to be addressed first: circadian rhythm disorder, behaviorally insufficient sleep, sleep hygiene, exercise, etc. should be the first line. If all that is optimized I would consider MSLT to screen fo...

I recently had a patient in this situation with hypersomnia in spite of great pap compliance. BMI 45. Insurance denied MSLT. Modafinil, Ritalin, and caffeine didn't work. Weight loss surgery solved the issue. There was no evidence of hypercapnia. I think MSLT is helpful in corroborating the patient'...

First, we need to define "optimal adherence." The 4-hour rule used by payers is a minimum threshold and not an optimal use. The study by Weaver et al., PMID 17580592 demonstrates that more patients will achieve normal functioning with longer nightly CPAP durations, but what constitutes adequate use ...