Reconsidering COMISA: Theoretical Inconsistencies of Wake-Promoting Drug Use from the Perspective of Insomnia Theory

Comorbid insomnia and obstructive sleep apnea (COMISA) has recently been described as if it represents a novel disease entity. However, this paper argues that the insomnia component of COMISA can be fully explained by established insomnia theory, including hyperarousal, conditioning, and learning models, without invoking any new pathophysiological mechanisms. We examine current clinical practice in which wake-promoting agents are frequently prescribed to patients with COMISA, whereas similar interventions are generally avoided in patients with primary insomnia. We argue that this discrepancy does not reflect differences in underlying pathology, but rather arises from diagnostic conventions and treatment decisions driven by presenting complaints. We conclude that the first-line treatment for COMISA should target the sleep side—specifically insomnia—and that the early use of wake-promoting agents is theoretically inconsistent with established insomnia models.