New Guidelines on Obstructive Sleep Apnea

Pauline Anderson

September 24, 2013

Doctors should encourage obese patients with obstructive sleep apnea (OSA) to lose weight and recommend continuous positive airway pressure (CPAP) as initial therapy for all patients with OSA, or mandibular advancement devices (MADs) if adverse effects with CPAP occur, according to new clinical guidelines from the American College of Physicians (ACP).

Clinicians "should encourage weight loss in obese patients because obesity is associated with increased risk of OSA, and weight loss may reduce OSA symptoms and has many other health benefits," write the authors of the guidelines, led by Amir Qaseem, MD, PhD, director of clinical policy at ACP, in Philadelphia, Pennsylvania.

According to the guidelines, published online September 24 in Annals of Internal Medicine, surgery and pharmaceutical therapy are not recommended for patients with OSA.

More than 18 million US adults have sleep apnea, which is a leading cause of excessive daytime sleepiness. The most common type of sleep apnea is OSA, in which the airway collapses or becomes blocked during sleep. The evidence shows that the incidence of OSA is rising, likely because of the increasing rates of obesity.

Doctors should target evaluation and treatment of OSA to patients with unexplained daytime sleepiness, say the guideline authors.

CPAP devices deliver compressed air into the airway to keep it open, but adherence to wearing these devices is low because of issues such as discomfort, skin irritation, noise, and claustrophobia. An alternative is dental devices or MADs. In addition to these approaches and weight loss, other treatments include surgical intervention to remove obstructive tissue and pharmacologic treatment.

Prioritized Outcomes

The clinical guidelines committee of the ACP searched the literature for relevant studies on OSA treatments and rated the resulting evidence. To guide their recommendations, they prioritized outcomes on the basis of clinical importance, starting with death and including cardiovascular outcomes such as congestive heart failure, hypertension, stroke, and myocardial infarction.

Other outcomes of interest included sleep study measures, such as the apnea-hypopnea index (AHI), a measure of the number of apnea and hypopnea episodes per hour of sleep; measures of cardiovascular status, such as blood pressure; measures of diabetes status, such as hemoglobin A1c levels; and quality of life. The group deemed the evidence to be of high, moderate, or low quality and rated each recommendation as strong (the benefits clearly outweigh the risks and burden, or the risks and burden clearly outweigh the benefits) or weak (the benefits are finely balanced with the risks and burdens).

Overall, the evidence showed that some intensive weight loss programs may effectively reduce signs and symptoms of OSA in obese patients with or without diabetes. The recommendation to encourage patients to lose weight was strong but with low-quality evidence.

CPAP is the most extensively studied therapy for OSA. The research showed that this treatment improves scores of the Epworth Sleepiness Scale (ESS), a self-administered questionnaire; reduces AHI and arousal index scores; and increases oxygen saturation. However, CPAP has not been shown to increase quality of life, and the evidence on its effect on cardiovascular disease, hypertension, and type 2 diabetes was insufficient, the authors conclude.

The data show that CPAP modifications, such as fixed and auto-CPAP and C-Flex (Philips Healthcare), have similar adherence and efficacy, but the data are insufficient to determine the comparative efficacy of other CPAP modifications. Greater AHI and ESS scores were generally associated with better adherence to CPAP.

Patient Preference

The recommendation that CPAP be initial therapy for OSA was strong, with moderate-quality evidence. Clinicians should keep patient preferences and adherence, specific reasons for nonadherence, and costs in mind before initiating CPAP treatment, note the authors.

Although the evidence to suggest which patients would benefit most from the alternative MADs was insufficient, the authors say that these devices can be considered in patients with adverse effects or for those who do not tolerate or adhere to CPAP. The recommendation to use MADs was weak and based on low-quality evidence.

Pharmacologic therapy is not currently supported by the evidence and should not be prescribed for OSA treatment, say the authors.

Current evidence evaluating surgical treatments, which are associated with risks and serious adverse effects, was limited and insufficient to show benefit, and surgery should not be used as initial treatment for OSA, they conclude.

Asked to comment on the new ACP guidelines for OSA, the American Academy of Sleep Medicine (AASM) issued a statement noting that OSA is a "chronic disease that drastically impacts health and well-being, and effective treatment can be life-changing."

The AASM supports the ACP's guideline recommendation of weight loss for overweight or obese OSA patients, the statement said. "However, it is important to emphasize that weight loss should be combined with another OSA treatment such as CPAP, because of the low success rate of dietary programs and the low cure rate by weight loss alone," the AASM cautions.

The new ACP recommendations for CPAP as first line and oral appliance therapy as a treatment alternative "are in line with the AASM's previously published clinical guideline," the AASM told Medscape Medical News.

"The AASM encourages individuals with OSA to consult with a board certified sleep medicine physician to evaluate their treatment options. Patient education, treatment instruction and long-term follow-up care should be provided by the sleep team at an AASM accredited sleep disorders center," the statement concludes.

Dr. Qaseem has disclosed no relevant financial relationships.

Ann Intern Med. 2013;159:471-483. Published online September 24, 2013. Abstract

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