New definition, diagnostic criteria, and diagnostic workflows for patients with suspected COMISA

The co-occurrence of insomnia and sleep apnea was first reported in 1973; however, precise definition, diagnostic criteria, and diagnostic workflows have not been provided until now. As more studies have been conducted, this has led to heterogeneous patient classifications and increased variability in results obtained from these studies.

Through a narrative review including randomized controlled trials, as well as retrospective and prospective studies-we aimed to address the variations in diagnostic criteria. Additionally, we examined reviews, editorials, and other published letters to confirm that no clear definition nor criteria have been established.

The proposed definition and corresponding diagnostic criteria are provided to facilitate clinical practice. The terminology we propose is "COMISA-DYAD" to better reflect the interaction between insomnia and obstructive sleep apnea. We propose structured diagnostic workflows applicable to both primary and non-primary care settings. The workflow in non-primary care settings includes initial assessment, preliminary and final diagnosis stages. The workflow in primary care settings integrates a brief sleep history, questionnaires, sleep testing, referral and follow-up to support diagnostic refinement across different resource levels.

We propose a clear definition and diagnostic criteria for COMISA, offering structured diagnostic workflows to facilitate closer attention to this condition. The diagnostic framework we provided supports personalized assessment and treatment decisions and allows for the comparision of findings across studies in patients with COMISA. The framework is intended to guide clinical decision-making and research stratification rather than to establish a definitive single-etiology diagnosis.