New Guidelines Address Management of Chronic Insomnia, OSA

By Will Boggs MD

February 18, 2020

NEW YORK (Reuters Health) - New guidelines from the US Department of Veterans Affairs (VA) and Department of Defense (DoD) address the management of chronic insomnia disorder and obstructive sleep apnea (OSA).

"We expect the guidelines to be far-reaching and lead to necessary changes in clinical practice while helping to determine what clinical and research questions will need to be addressed in military personnel and veterans," Dr. Vincent Mysliwiec from the Long School of Medicine at The University of Texas Health Science Center at San Antonio, San Antonio, Texas told Reuters Health by email. "Whereas in the past, problems with sleep disorders have been discounted, there is growing recognition of the importance of sleep health and treating sleep disorders."

Chronic insomnia disorder affects as many as 10% of US adults, and the prevalence of OSA is as high as 38% in the general population. Sleep disorders appear to be more prevalent in military personnel and veterans.

Dr. Mysliwiec and colleagues summarize the key recommendations of the 2019 VA/DoD clinical practice guidelines in their report in Annals of Internal Medicine.

They recommend using the STOP questionnaire to stratify risk for OSA and the Insomnia Severity Index or the Athens Insomnia Scale as part of a comprehensive assessment of patients with suspected insomnia disorder, along with a careful history.

OSA patients should be treated with positive airway pressure. For those at high risk of poor adherence to such treatment, the guideline recommends educational, behavioral, and supportive interventions

Other recommendations depend upon the degree of OSA, the presence of anatomical obstruction, and the response to treatment.

Oxygen therapy as a stand-alone treatment for patients with OSA who cannot tolerate other therapies is not recommended, and topical nasal steroids should not be used for the sole purpose of improving positive airway pressure adherence in patients without nasal congestion. [p. 4, table, "16" and "17"]

For chronic insomnia disorder, the guidelines strongly recommend cognitive behavioral therapy for insomnia (CBT-I) and weakly favors CBT-I over pharmacotherapy as first-line treatment.

There was insufficient evidence to recommend either for or against mindfulness meditation, acupuncture, aerobic exercise, tai chi, yoga, and other complementary and integrative treatments for chronic insomnia disorder. The authors found weak evidence against sleep hygiene education as a stand-alone treatment.

Weak evidence argues against the use of over-the-counter treatments (diphenhydramine, melatonin, valerian, and chamomile), and there is strong evidence to recommend against the use of kava in this setting.

Based on weak evidence, the guidelines recommend offering short-course doxepin or a non-benzodiazepine benzodiazepine receptor agonist for chronic insomnia disorder, and they recommend against the use of antipsychotic drugs, benzodiazepines, or trazodone.

The article also includes three algorithms: one addresses screening for sleep disorders, one addresses management of chronic insomnia disorder, and one addresses management of OSA.

"Military service is an established risk factor for sleep disorders, which are considerably more prevalent in military personnel and veterans than in the general U.S. population," Dr. Mysliwiec said. "These populations also have high rates of traumatic brain injury, posttraumatic stress disorder (PTSD), and other mental health disorders, which combined with insomnia and/or sleep apnea complicate treatment of affected military personnel and veterans."

"The 'VA/DoD Clinical Practice Guideline for the Management of Chronic Insomnia Disorder and Obstructive Sleep Apnea' is based on evidence-based and effective therapies for military personnel and veterans with chronic insomnia disorder and sleep apnea, while including evidence from civilian studies," he said. "The VA/DoD work group's 41 recommendations in the clinical practice guideline are relevant to all military, VA, and civilian providers who treat patients with sleep disorders."

SOURCE: Annals of Internal Medicine, online February 17, 2020.