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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
Guideline on obstructive sleep apnea diagnosis and treatment in commercial drivers (May 2017)
The American Academy of Sleep Medicine (AASM) has released consensus-based recommendations on screening, diagnosis, and management of obstructive sleep apnea (OSA) in commercial drivers . The AASM recommends that drivers meeting any of the following high-risk criteria be referred to a sleep medicine specialist for clinical sleep evaluation and diagnostic testing:
●Body mass index (BMI) ≥40 kg/m2
●Fatigue or sleepiness during the duty period or involvement in a sleepiness-related crash or accident
●BMI ≥33 kg/m2 and either hypertension requiring two or more medications to control or type 2 diabetes
The document also provides guidance on determining when to restrict driving certification based on OSA severity, symptoms, and adherence with positive airway pressure therapy. (See "Drowsy driving: Risks, evaluation, and management", section on 'Special considerations in commercial drivers'.)
Adaptive servoventilation in adults with central sleep apnea and heart failure (April 2017)
A previous randomized trial (SERVE-HF) found that adaptive servoventilation (ASV), a modified method of positive airway pressure ventilation, increased cardiovascular mortality in patients with central sleep apnea (CSA) due to symptomatic heart failure with reduced ejection fraction. In the CAT-HF trial, 126 hospitalized patients with heart failure and moderate-to-severe CSA were randomly assigned to ASV plus optimized medical therapy or medical therapy alone . While the trial showed no difference between the groups in a combined endpoint (death, cardiovascular hospitalizations, and timed walk distance), the confidence intervals were wide and there was a suggestion of increased harm in the ASV group (HR 1.06, 95% CI 0.75-1.51). The trial was stopped early, in part due to results of SERVE-HF. Although this limits interpretation of the CAT-HF results, we continue to recommend against use of ASV in patients with CSA and heart failure with reduced ejection fraction. (See "Sleep-disordered breathing in heart failure", section on 'Adaptive servoventilation' and "Central sleep apnea: Treatment", section on 'Patients with ejection fraction ≤45 percent'.)
AASM guideline on diagnostic testing for obstructive sleep apnea (March 2017)
The American Academy of Sleep Medicine (AASM) issued guidelines for diagnostic testing in patients with suspected obstructive sleep apnea (OSA) . Compared with prior iterations, emphasis was placed on formal evaluation by certified sleep experts. In addition, recommendations were made regarding patient selection for in-laboratory polysomnography (PSG), PSG split-night testing, or home sleep testing using a technically adequate device. The AASM also recommended against the use of clinical tools, questionnaires, or prediction algorithms. These guidelines should help standardize testing in patients with suspected OSA. (See "Clinical presentation and diagnosis of obstructive sleep apnea in adults", section on 'Indications for diagnostic testing'.)
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 [4,5]. 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'.)
AASM guideline on pharmacotherapy for chronic insomnia in adults (March 2017)
The American Academy of Sleep Medicine (AASM) has released a new clinical practice guideline on the pharmacologic treatment of chronic insomnia in adults . The guideline reviews evidence of effectiveness for a variety of medications (including benzodiazepines, nonbenzodiazepine hypnotics, ramelteon, doxepin, and suvorexant) and notes limitations and potential biases to the evidence, leading to low confidence in the overall estimation of risk-to-benefit ratio. The potential short-term benefits of pharmacologic therapy need to be balanced with the risk of side effects and dependence with long-term use. We continue to prefer behavioral therapy, rather than pharmacotherapy, as an initial treatment approach in most patients. (See "Treatment of insomnia in adults", section on 'Choice of an agent'.)
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 in adults", section on 'Cognitive behavioral therapy'.)
CENTRAL DISORDERS OF HYPERSOMNOLENCE
Pitolisant for cataplexy in adults with narcolepsy type 1 (May 2017)
Pitolisant, a novel histamine H3 receptor inverse agonist, may be an effective treatment for cataplexy as well as daytime sleepiness in patients with narcolepsy. In a randomized trial of 106 adults with narcolepsy type 1, pitolisant was more effective than placebo at reducing weekly cataplexy rates (75 versus 35 percent relative reduction from baseline) and Epworth Sleepiness Scale scores as well as hallucinations and objective sleepiness . Adverse effects were generally mild, aside from one case of severe nausea. Pitolisant has been approved for use in the European Union but is not available in the United States. (See "Treatment of narcolepsy in adults", section on 'Pitolisant'.)
Psychiatric comorbidities in patients with narcolepsy (March 2017)
Small studies have found an increased rate of depression in patients with narcolepsy, but the risk of other psychiatric comorbidities has not been well established. In a population-based case-control study that included 9312 adults with narcolepsy and more than 45,000 age- and gender-matched controls, a broad range of psychiatric disorders were more common in patients with narcolepsy; the most prevalent were depressive disorders and anxiety, which were three to four times more common than in controls . Thus, recognition and treatment of psychiatric disorders is an important component of the care of patients with narcolepsy. (See "Clinical features and diagnosis of narcolepsy in adults", section on 'Other features'.)
PEDIATRIC SLEEP MEDICINE
Predictive tool for sleep apnea in children with Down syndrome (March 2017)
Polysomnography or pulse oximetry monitoring during sleep is recommended in all children with Down syndrome by four years of age because of their increased risk of obstructive sleep apnea (OSA). A predictive model using a validated sleep questionnaire, medication history, patient age, anthropometric measurements, vital signs, and physical exam findings had a high negative predictive value for moderate to severe OSA . If confirmed in validation studies, this tool could decrease the number of diagnostic sleep studies needed in children with Down syndrome. (See "Down syndrome: Management", section on 'Sleep apnea'.)
- Gurubhagavatula I, Sullivan S, Meoli A, et al. Management of Obstructive Sleep Apnea in Commercial Motor Vehicle Operators: Recommendations of the AASM Sleep and Transportation Safety Awareness Task Force. J Clin Sleep Med 2017; 13:745.
- O'Connor CM, Whellan DJ, Fiuzat M, et al. Cardiovascular Outcomes With Minute Ventilation-Targeted Adaptive Servo-Ventilation Therapy in Heart Failure: The CAT-HF Trial. J Am Coll Cardiol 2017; 69:1577.
- Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical Practice Guideline for Diagnostic Testing for Adult Obstructive Sleep Apnea: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017; 13:479.
- 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; 166:332.
- Sateia MJ, Buysse DJ, Krystal AD, et al. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med 2017; 13:307.
- 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.
- Szakacs Z, Dauvilliers Y, Mikhaylov V, et al. Safety and efficacy of pitolisant on cataplexy in patients with narcolepsy: a randomised, double-blind, placebo-controlled trial. Lancet Neurol 2017; 16:200.
- Ruoff CM, Reaven NL, Funk SE, et al. High Rates of Psychiatric Comorbidity in Narcolepsy: Findings From the Burden of Narcolepsy Disease (BOND) Study of 9,312 Patients in the United States. J Clin Psychiatry 2017; 78:171.
- Skotko BG, Macklin EA, Muselli M, et al. A predictive model for obstructive sleep apnea and Down syndrome. Am J Med Genet A 2017; 173:889.