Thursday, February 20, 2020

Evidence-based guidance for two sleep disorders in adults

- Kenny Lin, MD, MPH

At an American Family Physician editors' meeting several years ago, a colleague, who marveled at amount of academic and clinical activities that I cram into a typical workweek, asked half-seriously, "Do you sleep?" Yes, I answered, not only do I need at least seven hours of uninterrupted sleep each night, I don't feel the least bit guilty about making it a priority. As Dr. Jennifer Middleton wrote in a previous AFP Community Blog post, the negative health consequences of chronic sleep deprivation are legion. Unfortunately, a recent survey found that nearly half of U.S. military personnel report poor sleep quality. From 2003 to 2011, the incidence of insomnia and obstructive sleep apnea (OSA) in active duty U.S. Army soldiers increased by 652% and 600%, respectively.

Concerns about these two common sleep disorders led the U.S. Departments of Veterans Affairs (VA) and Defense (DoD) to develop a joint clinical practice guideline for their diagnosis and management; a synopsis was published this week in Annals of Internal Medicine. Key recommendations for treating chronic insomnia (insomnia occurring for three or more nights per week for three or more months) generally agree with those from a 2016 American College of Physicians guideline and Agency for Healthcare Research and Quality review: offer cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, and reserve short-term pharmacologic therapy (low-dose doxepin or nonbenzodiazepine benzodiazepine receptor agonists) for patients who are unable to access or complete CBT-I.

The VA/DoD panel suggests not using antipsychotic drugs, benzodiazepines, or trazodone for chronic insomnia due to harms outweighing benefits or lack of benefit. It also advises against two common ingredients in over-the-counter sleep aids, diphenhydramine and melatonin. The panel suggests that clinicians not use sleep hygiene education as a standalone treatment due to its limited effectiveness and potential to discourage patients from pursuing the more effective CBT-I.

For OSA, the VA/DoD guideline suggests using the STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure) to stratify risk in patients who report sleep symptoms and performing home sleep apnea testing rather than in-laboratory polysomnography in patients with a high pretest probability of OSA. Although continuous positive airway pressure (PAP) therapy is recommended for persons with severe OSA, mandibular advancement devices may be used as an alternative in mild or moderate cases. The VA/DoD panel did not evaluate positional therapy (techniques to promote side sleeping) for OSA. However, a recent Cochrane review found that patients are more likely to tolerate and adhere to positional therapy than PAP, compensating somewhat for the former's lower effectiveness.