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The following represent additions to UpToDate from the past six months that were considered by the editors and authors to be of particular interest. The most recent What's New entries are at the top of each subsection.
SLEEP-RELATED BREATHING DISORDERS
US Preventive Services Task Force recommendations on screening for obstructive sleep apnea (January 2017)
The value of predictive tools (eg, questionnaires) as a way to screen for obstructive sleep apnea (OSA) was recently reviewed by The US Preventive Services Task Force. Among the 110 studies evaluated, there were no randomized trials comparing screening with no screening in asymptomatic individuals [1,2]. Although severe OSA could be predicted by some questionnaires, this was only in high-risk populations. The task force identified a need for randomized trials in asymptomatic individuals and concluded that there was insufficient evidence to make a recommendation on screening for OSA in the community. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Screening questionnaires'.)
Continuous positive airway pressure and sleep apnea outcomes (January 2017)
A meta-analysis of 35 randomized trials comparing continuous positive airway pressure (CPAP) with sham CPAP in patients with obstructive sleep apnea (OSA) found that CPAP reduced sleep-related apneas and hypopneas (ie, the apnea-hypopnea index) and improved daytime sleepiness, blood pressure (systolic and diastolic), and sleep-related quality of life . There was no demonstrable mortality benefit for CPAP, although cohort studies have demonstrated an association between the apnea-hypopnea index and all-cause mortality. CPAP should be the mainstay of therapy for OSA. (See "Management of obstructive sleep apnea in adults", section on 'Efficacy'.)
Diagnosis of OSA using limited data from a sleep study (January 2017)
In patients with suspected obstructive sleep apnea (OSA), a recent randomized trial compared diagnostic and functional outcomes when sleep physicians were presented with only limited polysomnographic data (simulating data provided by in-home studies) or the complete polysomnographic data set . There was no difference in the distribution of initial diagnoses or functional outcome with limited or full testing. However, testing that was limited to oxygen saturation and heart rate was associated with lower physician diagnostic confidence and less continuous positive airway pressure use. While this study supports in-home testing, the studies were not performed in the home, which was a major limitation. Further validation comparing in-home testing with the gold standard of polysomnography is needed. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Home sleep apnea testing'.)
CPAP in obstructive sleep apnea does not reduce cardiovascular events (August 2016)
Whether continuous positive airway pressure (CPAP) therapy can reduce the increased risk of cardiovascular morbidity and mortality associated with obstructive sleep apnea (OSA) is unknown. The largest trial to address this issue randomized 2717 patients with moderate to severe OSA and established cardiovascular disease to CPAP therapy plus usual care or usual care alone (eg, education, risk factor modification) and followed patients for 3.7 years . Despite adequate control of OSA, there was no difference in cardiovascular events (eg, cardiovascular deaths, myocardial infarction, or stroke). However, the exclusion of patients who are among the most likely to benefit from CPAP (eg, patients with “sleepy” OSA) and a low adherence rate to therapy (mean was 3.3 hours per night) may have limited the potential benefit from this therapy. While the cardiovascular benefits are unproven, CPAP should be administered for the associated noncardiovascular benefits (eg, improvement in symptoms and quality of life) and should remain the mainstay of therapy for patients with moderate to severe OSA. (See "Obstructive sleep apnea and cardiovascular disease", section on 'Cardiovascular events'.)
Interactive web-based CBT for chronic insomnia (January 2017)
Cognitive behavioral therapy (CBT) is an effective treatment of chronic insomnia, but access to trained practitioners can be limited. In a randomized trial of 303 adults recruited via the internet, a six-week interactive web-based CBT program resulted in greater improvement in subjective sleep measures than internet patient education alone, and benefits were sustained at one year . Thus, internet-based CBT programs may be an alternative to in-person delivery for motivated, technology-savvy individuals. (See "Treatment of insomnia", section on 'Cognitive behavioral therapy'.)
CENTRAL DISORDERS OF HYPERSOMNOLENCE
Flumazenil in patients with refractory hypersomnolence (December 2016)
Preliminary data suggest that compounded preparations of flumazenil, a gamma-aminobutyric acid type A receptor antagonist, may benefit some patients with hypersomnolence of central origin. In a case series of 153 patients with refractory hypersomnolence due to idiopathic hypersomnia, obstructive sleep apnea, or other disorders, compounded sublingual or transdermal flumazenil was well tolerated and associated with sustained improvement in subjective sleepiness in 39 percent of patients . These results suggest that controlled studies of flumazenil in this patient population are warranted. (See "Idiopathic hypersomnia", section on 'Pharmacotherapy'.)
PARASOMNIAS AND SLEEP-RELATED MOVEMENT DISORDERS
Complications of dopaminergic therapy for restless legs syndrome (August 2016)
The main complication of long-term dopaminergic therapy for restless legs syndrome/Willis-Ekbom disease (RLS/WED) is “augmentation,” or an increase in symptom severity with increasing doses of medication. This may present as earlier onset of symptoms during the day, increased intensity of symptoms, or spread to previously uninvolved body parts (eg, arms, trunk). New consensus-based guidelines on the identification and management of augmentation recommend avoiding dopaminergic drugs as first-line therapy for RLS/WED when possible, screening patients on dopaminergic therapy for augmentation as part of routine clinical follow-up (table 1), and using the lowest doses possible to control symptoms . Treatment options for augmentation reviewed in the guideline include altering the dopaminergic dosing schedule, switching to an extended release preparation, and transitioning to an alpha-2-delta calcium channel ligand (eg, gabapentin enacarbil, pregabalin). In addition, alternative causes of worsening symptoms should be sought, such as low iron stores, sleep deprivation, and certain drugs such as serotonergic antidepressants. (See "Treatment of restless legs syndrome/Willis-Ekbom disease and periodic limb movement disorder in adults", section on 'Augmentation'.)
PEDIATRIC SLEEP MEDICINE
Sleep duration in preschool children and progression to obesity (August 2016)
Increasing evidence supports an association between shortened sleep duration and obesity in children. In a recent large longitudinal study, the risk of adolescent obesity in preschool children with early bedtimes (8:00 PM or earlier) was about half that of preschool children with late bedtimes (9:00 PM or later), after adjustment for several confounding variables, including maternal obesity, education, and income level . (See "Definition; epidemiology; and etiology of obesity in children and adolescents", section on 'Sleep'.)
GENERAL SLEEP MEDICINE
Inadequate sleep and adverse cardiometabolic outcomes (December 2016)
The adverse health outcomes of inadequate sleep duration (<7 hours per night) and quality are increasingly recognized. A new scientific statement from the American Heart Association reviews data linking sleep restriction with adverse cardiometabolic outcomes and recommends that healthy sleep behavior be addressed in public health campaigns to promote ideal cardiac health, alongside blood pressure, cholesterol, diet, blood glucose, physical activity, weight, and smoking cessation . (See "Insufficient sleep: Definition, epidemiology, and adverse outcomes", section on 'Cardiovascular morbidity'.)
- Jonas DE, Amick HR, Feltner C, et al. Screening for Obstructive Sleep Apnea in Adults: Evidence Report and Systematic Review for the US Preventive Services Task Force. JAMA 2017; 317:415.
- US Preventive Services Task Force, Bibbins-Domingo K, Grossman DC, et al. Screening for Obstructive Sleep Apnea in Adults: US Preventive Services Task Force Recommendation Statement. JAMA 2017; 317:407.
- Chai-Coetzer CL, Antic NA, Hamilton GS, et al. Physician Decision Making and Clinical Outcomes With Laboratory Polysomnography or Limited-Channel Sleep Studies for Obstructive Sleep Apnea: A Randomized Trial. Ann Intern Med 2017.
- McEvoy RD, Antic NA, Heeley E, et al. CPAP for Prevention of Cardiovascular Events in Obstructive Sleep Apnea. N Engl J Med 2016; 375:919.
- Ritterband LM, Thorndike FP, Ingersoll KS, et al. Effect of a Web-Based Cognitive Behavior Therapy for Insomnia Intervention With 1-Year Follow-up: A Randomized Clinical Trial. JAMA Psychiatry 2017; 74:68.
- Trotti LM, Saini P, Koola C, et al. Flumazenil for the Treatment of Refractory Hypersomnolence: Clinical Experience with 153 Patients. J Clin Sleep Med 2016; 12:1389.
- Garcia-Borreguero D, Silber MH, Winkelman JW, et al. Guidelines for the first-line treatment of restless legs syndrome/Willis-Ekbom disease, prevention and treatment of dopaminergic augmentation: a combined task force of the IRLSSG, EURLSSG, and the RLS-foundation. Sleep Med 2016; 21:1.
- Anderson SE, Andridge R, Whitaker RC. Bedtime in Preschool-Aged Children and Risk for Adolescent Obesity. J Pediatr 2016; 176:17.
- St-Onge MP, Grandner MA, Brown D, et al. Sleep Duration and Quality: Impact on Lifestyle Behaviors and Cardiometabolic Health: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e367.