1. A new clinical practice guideline from the American College of Physicians (ACP) recommends weight loss and continuous positive airway pressure (CPAP) treatment for management of obstructive sleep apnea (OSA) (strong recommendation).
2. The guideline also recommends mandibular advancement devices (MADs) as an alternative to CPAP (weak recommendation).
Evidence Rating Level: 2 (Good)
Study Rundown: OSA is a disease associated with significant morbidity and mortality. The ACP recently performed a systematic review to establish clinical practice guidelines for treatment of OSA. The clinical outcomes identified for the the review were cardiovascular disease, type-II diabetes mellitus, and death, as well as the measures of sleep studies, cardiovascular status, diabetic status, and quality of life. The ACP released three main recommendations based on this review. (1) First, the ACP found evidence to supporting weight loss as an intervention to improve the symptoms of OSA. Despite the low-quality of this evidence, given hat weight loss is also associated with many other health benefits other than OSA, the ACP recommends that all over-weight and obese patients with OSA should be encouraged to lose weight. (2) Regarding, CPAP use, the ACP found moderate-quality evidence demonstrating CPAP was more effective than sham CPAP, despite the lack of randomized trials investigating long-term clinical outcomes and inconclusive changes to quality of life. Furthermore, fixed, auto, and C-Flex CPAP were all found to have only small differences in overall efficacy. Thus, from this evidence, the ACP recommends CPAP as initial therapy for patients diagnosed with OSA. (3) The review of MADs found good evidence supporting its use, although the treatment effect by CPAP was more substantial. Therefore, if patients suffer adverse effects from CPAP, the ACP weakly recommends MADs as an alternative treatment.
In-Depth [systematic review]: The ACP examined three studies investigating the effects of weight-loss intervention, all of which showed improved patient Apnea Hypopnea Index (AHI) [between -4 to -23 events/hour]. Two studies reported changes in Epworth Sleepiness Scale, with only one showing a significant difference in the weight loss group. However, one study found that a low-calorie diet increased the rate of an OSA cure, with an adjusted odds ratio of 4.2. Despite the low quality of the evidence, the ACP strongly recommended weight loss for OSA patients. To review the efficacy of CPAP treatment, 22 studies were evaluated. Among these, there was moderate evidence supporting reduced AHI, increased ESS, and increased minimum oxygen saturation when compared to controls. Quality of life changes could not be determined, as the ten studies that observed changes used differing sub-scales, with most showing no significant improvement due to CPAP. Another study showed no difference in cardiovascular events in those treated with CPAP, but one did demonstrate an increase in the NIH stroke scale in those treated with CPAP (2.3/10 vs 1.4/10 for controls). Seven out of eight observational studies, but no RCTs, showed a significant reduction in mortality associated with CPAP therapy. Five trials showed that MADs reduced AHI and increased minimum oxygen saturation when compared to no treatment, though ten additional studies showed improved efficacy of CPAP vs. MAD treatment. One study did demonstrate increased adherence to MAD when compared to CPAP. Other alternatives, such as positional therapy and surgical options, did not have sufficient evidence to merit a recommendation. Overall, because of its efficacy over no treatment, the ACP recommended MAD for patients with adverse effects to CPAP treatment.
By Sai Folmsbee and Aimee Li, MD
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