Beyond CPAP for OSA

Obstructive Sleep Apnea (OSA) affects an estimated 18 million Americans.1 Until recently, treatments for OSA were limited to lifestyle changes, invasive surgical procedures and the most common and well-known treatment option, Continuous Positive Airway Pressure (CPAP) therapy. Today, there are new diagnostic tools to personalize treatment options as well as new therapies for those who have not responded well to CPAP therapy.

CPAP Adherence
CPAP is the most commonly used method for treating OSA and is considered an effective first-line therapy. While the clinical outcomes for CPAP show significant reductions in sleep apnea events during the night, CPAP adherence is only about 50%.2 In fact, according to the Apnea Positive Pressure Long-Term Efficacy Study (APPLES) published in 2012, CPAP adherence rate was 39 percent at six months. Since CPAP therapy is only effective when used regularly, adherence is a significant issue. But there are new advances in treatment options for OSA that go beyond the traditional methods like lifestyle changes and CPAP.3

Oral Appliances An oral appliance, sometimes known as a mandibular advancement device, is a customized mouthguard created by either a doctor or dentist to treat sleep apnea and snoring. These are used as an alternative to CPAP due to their portable size, comfort and convenience.4 They work by pulling the lower jaw forward in an attempt to keep the airway open. Similar to CPAP, there are many variations available on the market. Oral appliances work well in patients with mild to moderate sleep apnea, but do not work well in those with severe sleep apnea.5 A recent study published in 2015 showed that oral appliance therapy was not associated with improvements in daytime sleepiness or quality of life when compared to a placebo.6 These devices can also cause dental side effects such as mouth dryness, tooth discomfort and jaw pain.7

Surgery for OSA
Traditionally, there have been a few different surgical methods available for treating OSA. These methods, sometimes referred to as anatomy altering surgeries, are intended to make the airway larger by removing certain soft tissues of the airway and sometimes realigning bony structures of the face or jaw. Because these procedures are often painful and require lengthy recovery times, they are typically done as a last resort, only after the patient hasn’t responded to other treatment options. A recent development is that more surgeons are performing a drug-induced sleep endoscopy (DISE) prior to uvulopalatopharyngoplasty (UPPP) to determine where the blockage is occurring. UPPP is the most common type of oropharyngeal surgery for OSA. UPPP removes excess tissue in the throat to make the airway wider. This procedure is sometimes accompanied by a tonsillectomy.8

SEE ALSO: Economic & Social Costs of OSA

Upper Airway Stimulation (UAS) Therapy
New in 2014, UAS therapy represents a major advancement in OSA treatment for patients who are unable or unwilling to use CPAP. UAS, developed by Inspire Medical Systems, utilizes stimulation therapy to keep the airway open during sleep. The small, fully-implanted system delivers mild stimulation to key airway muscles which keeps the airway open during sleep. The system consists of three components: a small generator, a breathing sensor lead and a stimulation lead. A small, handheld remote allows the patient to turn the therapy on before bed and off upon awakening.

In the STAR clinical trial, funded by Inspire Medical Systems, 126 patients across the United States and Europe receiving UAS therapy experienced a 68% reduction in apnea and hypopnea events, a 70% reduction in oxygen desaturation events, and significant improvement in quality of life measures as measured by Epworth Sleepiness Scale (ESS) and Functional Outcomes of Sleep Questionnaire (FOSQ). Additionally, 85 percent of bed partners reported little or no snoring by their partner using UAS.9 These results were published in The New England Journal of Medicine in January 2014. Safety, effectiveness and durability studies have been featured in nine peer-reviewed publications. Durability studies demonstrate that significant reductions in OSA severity and improvements of quality of life measures were maintained at 18 months.10

Patients using UAS therapy demonstrate far more willingness to use the therapy because it is a more natural sleep experience without the mask, hose and noise of a CPAP machine. Recent data show that more than 90% of these patients use the device at least five nights per week.10 UAS therapy is intended for patients who are diagnosed with OSA, are unable or unwilling to use CPAP, and are not significantly overweight.

The Bottom Line
When patients cannot tolerate CPAP, there are new treatment options available. It is important to weigh all factors in deciding which alternative treatment method to try. Since comorbidities related to OSA include stroke, obesity, heart attack and memory loss, it is vital to stress the importance of treating obstructive sleep apnea, regardless of which method is chosen.

1. Paul E. Peppard,* Terry Young, Jodi H. Barnet, et al. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013 May 1; 177(9): 1006-1014.
2. Weaver TE1, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008 Feb 15;5(2):173-8.
3. Kushida CA; Nichols DA; Holmes TH; Quan SF, et al.Effects of continuous positive airway pressure on neurocognitive function in obstructive sleep apnea patients: the Apnea Positive Pressure Long-term Efficacy Study (APPLES). SLEEP 2012; 35(12):1593-1602.
4. Sutherland K, Vanderveken OM, Tsuda H, et al. J Clin Sleep Med. 2014 Feb 15;10(2):215-27.
5. Ramar K, Dort LC, Katz SG, et al. Clinical practice guideline for the treatment of obstructive sleep apnea and snoring with oral appliance therapy: an update for 2015. J Clin Sleep Med. 2015 Jun 11. pii: jc-00186-15.
6. Marklund M, Carlberg B, Forsgren L, Olsson T, et al. Oral appliance therapy in patients with daytime sleepiness and snoring or mild to moderate sleep apnea. JAMA Intern Med. 2015 Aug; 175(8):1278-1285.
7. Fritsch K, Iseli A, Russi E, Bloch K. Side effects of mandibular advancement devices for sleep apnea treatment. Am J Respir Crit Care Med. 2001 Sept 1;164(5):813-818.
8. Friedman M, Ibrahim H, Lee G, Joseph NJ. Combined uvulopalatopharyngoplasty and radiofrequency tongue base reduction for treatment of obstructive sleep apnea/hypopnea syndrome. Otolaryngol Head Neck Surg. 2003;129(6):611-21.
9. Strollo PJ Jr, Soose RJ, Maurer JT, et al. N Engl J Med. 2014;370(2):139-149.
10. Strollo PJ Jr, Gillespie MB, Soose RJ, Maurer JT, et al. Upper airway stimulation for obstructive sleep apnea: durability of the treatment effect at 18 months. Sleep. 2015 Jun 22. pii: sp-00580-14.

Dr. Quan Ni is the vice president of research at Inspire Medical Systems.

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