Jaw Device, CPAP Similar for BP Reduction in Sleep Apnea

December 02, 2015

The use of continuous positive airway pressure (CPAP) and mandibular advancement devices (MADs) in the treatment of sleep apnea showed similar effects on blood pressure reduction, according to a new network meta-analysis.

"CPAP is regarded as the best treatment for sleep apnea, and MADs are not used much because there is little data on their effectiveness," senior author, Malcolm Kohler, MD, from University Hospital Zurich, Switzerland, commented to Medscape Medical News. "Previous individual studies of MADs to date have shown contradictory results on their effect on blood pressure. But when we put all the data together we did show an effect."

Dr Kohler noted that another meta-analysis by his group published a few weeks ago suggested that MADs were also similar to CPAP in reducing daytime sleepiness in patients with sleep apnea patients.

"These two meta-analyses together suggest that MADs are a viable alternative to CPAP and may be preferable to many patients who find CPAP too difficult to use."

Their report was published in the December 1 issue of JAMA.

He added: "CPAP involves wearing a mask attached to a machine while sleeping. It is quite cumbersome and noisy and some patients complain that they can't sleep with it. In contrast a MAD is like wearing a brace — it is a device that advances the jaw forward, producing more space at the back of the throat, so it is less likely the pharynx will collapse. It is easier to use and much less obtrusive."

The current network meta-analysis, included 51 studies in 4888 patients. Of these, 44 studies compared CPAP with an inactive control; 3 compared MADs with an inactive control; 1 compared CPAP with a MAD; and 3 compared CPAP, MADs, and an inactive control.

Compared with an inactive control, CPAP was associated with a reduction in systolic blood pressure of 2.5 mmHg and in a reduction in diastolic blood pressure of 2.0 mmHg. A 1-hour-per-night increase in mean CPAP use was associated with an additional reduction in systolic blood pressure of 1.5 mmHg and an additional reduction in diastolic blood pressure of 0.9 mmHg.

Compared with an inactive control, MADs were associated with a reduction in systolic pressure of 2.1 mmHg and in diastolic pressure of 1.9 mmHg.

There was no significant difference between CPAP and MADs in their association with change in systolic (–0.5 mmHg) or diastolic (–0.2 mmHg) pressure.

However, secondary analyses found a greater effect of CPAP when used for longer periods. A 1-hour-per-night increase in mean CPAP use was associated with an additional reduction in systolic blood pressure of 1.5 mmHg and an additional reduction in diastolic pressure, of 0.9 mmHg.

"With CPAP, the best effect is seen if patients use it for the whole night as opposed to those who start the night with it but take if off after a few hours," Dr Kohler noted.

"My message would be that for a highly compliant patient, CPAP is the best option," he added. "But if a patient is struggling to adjust to using CPAP, MADs are a viable alternative."

Alternatively, patients may use CPAP most nights but could find it easier to use a MAD on occasion, such as when they are away from home for a few days.

"Unlike CPAP devices, a MAD is small and would fit easily in hand luggage, and doesn't need an electricity supply," he noted.

Dr Kohler believes these new results could lead to resurgence in the use of MADs. He reported that the sleep apnea treatment market is heavily weighted toward CPAP (about 95% CPAP vs 3% MAD).

"But after these two meta-analyses there should be more balanced use of the two treatments," he said.

This research was supported by a grant from the Swiss National Science Foundation and by funding from the University of Zurich Clinical Research Priority Program Sleep and Health. The authors have disclosed no relevant financial relationships.

JAMA. 2015;314:2280-2293. Abstract

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