MEDPAGE TODAY: Sleep Apnea? Lose Weight, ACP Urges

SOURCE:  MedPage Today (Michael Smith, Sep. 23, 2013)
http://www.medpagetoday.com/pulmonology/sleepdisorders/41803


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Sleep Apnea? Lose Weight, ACP Urges

Published: Sep 23, 2013 | Updated: Sep 25, 2013

By Michael Smith, North American Correspondent, MedPage Today

Reviewed by Robert Jasmer, MD; Associate Clinical Professor of Medicine, University of California, San Francisco and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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Action Points

• The first line of defense against obstructive sleep apnea should be weight loss, according to new guidelines from the American College of Physicians.
• Note that the guidelines recommend CPAP treatment as initial therapy for patients diagnosed with obstructive sleep apnea, and mandibular advancement devices as an alternative therapy for patients who prefer mandibular advancement devices or for those with adverse effects associated with CPAP.

The first line of defense against obstructive sleep apnea should be weight loss, according to new guidelines from theAmerican College of Physicians.

If more treatment is needed, the first choice should be continuous positive airway pressure (CPAP), but so-calledmandibular advancement devices can be used as an alternative therapy, the guidelines suggest.

On the other hand, there is insufficient evidence to say surgery has any benefit and, given its risks, it "should not be used as initial treatment," according to the guidelines published in the Oct. 1 issue ofAnnals of Internal Medicine.

Obstructive sleep apnea is an increasing issue, "probably because of escalating obesity rates," the guidelines noted, so that more and more people are likely to seek treatment.

To assess the evidence, researchers led by Amir Qaseem, MD, PhD, of the ACP in Philadelphia, used a systematic review of available English-language literature from 1966 to September 2010, conducted by Tufts researcher Ethan Balk, MD. He also reviewed information turned up in a supplemental search for studies published through October 2012.

The first recommendation of the guideline committee was that all overweight and obese patients who have obstructive sleep apnea should be encouraged to lose weight.

The investigators concluded that the evidence showed that "some intensive weight-loss programs may effectively reduce signs and symptoms of (obstructive sleep apnea) in obese patients with or without diabetes."

Those signs and symptoms can include the apnea-hypopnea index (AHI), daytime sleepiness, and oxygen saturation.

But in cases where patients are not overweight or where weight-loss interventions fail, the next line of defense should be CPAP, which is the most intensely studied therapy, the committee argued.

The evidence shows that CPAP reduces daytime sleepiness, cuts the AHI and arousal index scores, and increases quality of life, although it has not been shown to improve the latter, they reported.

There was insufficient evidence to say anything about the effect of CPAP on cardiovascular disease, hypertension, and type 2 diabetes, the guidelines committee found.

In patients who are unable or unwilling to use CPAP, mandibular advancement devices can be an alternative to CPAP, they said.

The devices move the lower jaw forward slightly during sleep to tighten the soft tissues of the airway and prevent apnea. The committee noted that evidence shows the devices are better than no treatment in improving AHI scores, arousal index scores, and minimum oxygen saturation.

But the evidence also shows that CPAP does a better job, they found.

Drug therapy has been tried, using a range of medications including such mirtazapine (Remeron), xylometazoline, and fluticasone (Flonase), but evidence was insufficient to conclude that any of them worked.

Seven studies evaluated surgical interventions but each assessed a different approach and outcomes were inconsistent, "making it difficult to ascertain the benefit of surgery," the committee reported.

Support for the development of this guideline came from the operating budget of the American College of Physicians. The systematic evidence review was sponsored by the Agency for Healthcare Research and Quality. Qaseem and co-authors reported no conflicts of interest.