ACP's sleep apnea guideline recommends weight loss and CPAP as initial therapies

All overweight and obese patients diagnosed with obstructive sleep apnea (OSA) should be encouraged to lose weight and use continuous positive-airway pressure (CPAP) or, if preferred, mandibular advancement devices, according to a new ACP guideline.

The guideline appeared in the Sept. 24 Annals of Internal Medicine and included the following recommendations:

• Recommendation 1: All overweight and obese patients diagnosed with OSA should be encouraged to lose weight. (Grade: strong recommendation; low-quality evidence)
• Recommendation 2: ACP recommends CPAP as initial therapy for patients diagnosed with OSA. (Grade: strong recommendation; moderate-quality evidence)
• Recommendation 3: ACP recommends mandibular advancement devices as an alternative therapy to CPAP treatment for patients diagnosed with OSA who prefer mandibular advancement devices or for those with adverse effects associated with CPAP treatment. (Grade: weak recommendation; low-quality evidence)

The guideline was based on a literature search from 1966 to 2010, sponsored by the Agency for Healthcare Research and Quality, in which evidence showed that intensive weight-loss interventions reduce Apnea–Hypopnea Index scores and improve OSA symptoms. The reviewers also found moderate-quality evidence that CPAP was more effective than control treatments or sham CPAP but noted the absence of randomized trials evaluating long-term clinical outcomes, such as death or cardiovascular illness. Moderate-quality evidence showed that fixed and auto-CPAP have overall similar efficacy and adherence, and low-quality evidence showed that C-Flex CPAP (a proprietary system that provides pressure relief during active exhalation) and fixed CPAP were similarly efficacious, they noted.

The evidence showed that mandibular advancement devices could effectively lower Apnea–Hypopnea Index scores and reduce sleepiness but that CPAP more effectively reduced Apnea–Hypopnea Index and arousal index scores and increased the minimum oxygen saturation. Because adherence to CPAP is key to its effectiveness, physicians should consider patient preferences, potential reasons for nonadherence and costs before initiating therapy, the guideline advised.

The reviewers also looked at evidence on other OSA interventions, including positional therapy, oropharyngeal exercise, surgical interventions, pharmacologic therapy and atrial overdrive pacing, and found insufficient evidence of their overall or comparative efficacy. The guideline noted that pharmacologic therapy is not supported by evidence, so should not be prescribed, and that surgical treatments are associated with risks and serious adverse effects and thus should not be the initial treatment for OSA.