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Guidelines for obstructive sleep apnea and insomnia from the US Departments of Defense and Veteran Affairs
Clinical Question
How should presumed obstructive sleep apnea or chronic insomnia be diagnosed and managed?
Bottom line
Obstructive sleep apnea (OSA) can be identified using the STOP questions (see the synopsis) and confirmed in most people using at-home testing. Positive airway pressure is the mainstay of OSA. For chronic insomnia, avoid medications; use cognitive behavioral therapy, brief behavioral therapy, or auricular acupuncture using seeds (ask an acupuncturist for a description) instead. Medicines can be used in the short term but should be limited to doxepin or nonbenzodiazepine receptor agonists such as zolpidem (Ambien). The complete guideline, which includes an algorithm, can be found at https://bit.ly/3atD31b. 5
Reference
Study design: Practice guideline
Funding: Government
Setting: Various (guideline)
Synopsis
This working group, which represented a wide range of stakeholders, based their 41 recommendations on a systematic search and analysis of existing research. Only one member of the group (who was the lead author) had a financial conflict of interest. They focused on outcomes of importance to patients. The research quality was graded and the recommendations labeled with the quality of the evidence. Here is a broad and incomplete synopsis of their recommendations: To diagnose OSA and insomnia: (1) Consider assessing for sleep disorder in patients with cardiovascular and cerebrovascular events, heart failure, and long-term opioid use (weak evidence) (2) Begin with the STOP questions (Snoring/Tiredness/Observed stopped breathing/blood Pressure); they are easier to answer and provide similar accuracy as the STOP-BANG questions (which adds Body mass index, Age, Neck size, and Gender) (weak evidence) (3) Test at home for OSA first, followed by repeat home testing or laboratory testing if nondiagnostic (strong evidence) Management of OSA: (1) Positive airway pressure is the primary treatment for OSA (strong evidence) (2) Do not use oxygen therapy (weak against) Management of chronic insomnia: (1) Sleep hygiene education should not be used alone for insomnia (weak evidence) (2) Consider cognitive behavioral therapy (strong evidence) or brief behavioral therapy (weak evidence) (3) Consider auricular acupuncture (weak evidence) (4) If considering pharmacotherapy, consider short-term, low-dose doxepin or a nonbenzodiazepine such as zolpidem; do not use benzodiazepines or trazodone (weak evidence) (5) Avoid diphenhydramine, melatonin, valerian, chamomile (weak evidence), and kava (strong evidence)
Reviewer
Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA