RSSDI clinical practice recommendations for screening, diagnosis, and treatment in type 2 diabetes mellitus with obstructive sleep apnea
Bidirectional association between Type 2 diabetes mellitus (T2DM) and obstructive sleep apnea (OSA) is well established with growing evidence. In India, these conditions also constitute strong risk factors for cardiovascular diseases, the known cause of premature deaths and morbidity. However, due to lack of awareness, variability in treatment approach, and limited diagnostic facilities, OSA remains an underdiagnosed condition in Indian patients with T2DM. Hence, Vijay Viswanathan and colleagues published a research paper in International Journal of Diabetes in Developing Countries under title “RSSDI clinical practice recommendations for screening, diagnosis,and treatment in type 2 diabetes mellitus with obstructive sleep apnea”. The summary of this paper is given below:
Objective:
To provide evidence based recommendation for treating OSA in T2DM patients.
Method:
This paper consolidates evidence-based clinical practice recommendations. It also outlines an optimized care pathway for patients with OSA and T2DM, as per consensus multidisciplinary observations and clinical experiences.
Findings:
Signs and Symptoms of OSA
Nocturnal Symptoms
Snoring, Choking or gasping at night, Observed episodes of breathing cessation during sleep, Night sweats, Maintenance insomnia, Erectile dysfunction, Nocturia, Heartburn, Awakening with nocturnal chest pain, Awakening with a dry mouth or sore throat.
Day Time Symptoms
Excessive day time sleepiness, Neurocognitive impairment, Heartburn, Morning headaches, Awakening with chest pain, Difficulty in concentrating during the day, Mood changes such as depression or irritability, High blood pressure.
Physical Examination
Obesity, Enlarged neck circumference, Crowded upper airway, Hypertension, Accentuated P2 heart sounds (pulmonary hypertension), Retrognathia/overjet, Nasal obstruction, Decreased oxygen saturation, S3 heart sound (congestive heart failure), Lower extremity edema (heart failure)
Diagnosis of obstructive sleep apnea
Clinical History Questionnaires
Epworth Sleepiness Scale (ESS), STOP Questionnaire (Snoring, Tiredness, Observed Apnea, High Blood Pressure), STOP-Bang Questionnaire (STOP Questionnaire plus BMI, Age, Neck Circumference, and Gender), Berlin questionnaire, Wisconsin Sleep Questionnaire.
Physical Examination- Risk Factors
Body mass index (BMI), Reduced distance and increased angles from the chin to the thyroid cartilage, Narrow oropharyngeal opening
Polysomnography Portable Monitor
Quantify the apnea-hypopnea index (AHI), AHI= adding all apnea and hypopnea and then dividing by total sleep time
Current treatment options for OSA
Lifestyle modifications, Continuous positive airway pressure (CPAP), Oral devices such as tongue-retaining devices and mandibular advancement devices (MAD), Nasal surgeries, palatal surgeries, and tongue-based surgeries in some cases.
Study directs that there is bidirectional relationship between OSA and T2DM i.e. OSA is a risk factor for T2DM and vice versa. Obesity is an important cofounder for the association between T2DM and OSA.
Recommendations for screening of patients for OSA for diabetologists
Patients presenting with the following signs and symptoms are considered as high risk and should be screened for OSA:
Patients complaining of sleepiness, non-restorative sleep, fatigue or symptoms of insomnia, waking up with gasping or choking, habitual snoring, interruptions in breathing
Upper airway evaluation showing retrognathia, high arched palate, macroglossia, tonsillar hypertrophy, enlarged uvula, and nasal abnormality
Patients who demonstrate PSG or level 3 portable sleep test or home-based cardiorespiratory sleep tests with five or more obstructive respiratory events per hour of sleep OR with fifteen or more obstructive respiratory events per hour of sleep in the absence of symptoms
Existing comorbidities such as hypertension, prediabetes or overt T2DM, congestive heart failure, atrial fibrillation, coronary artery disease, and cognitive dysfunction
Patients with BMI > 22–25 kg/m2 [119]
Abdominal obesity (cm) in the range of > 90 for males and > 80 for females (Asian population) and waist circumference men: 78 cm, women: 72 cm
Neck circumference—women: > 16 in.; men: > 17 in.
Body fat cut—men: 25%, women: 30%
Fasting plasma glucose (FPG) ≥ 100 mg/dL
Hypertension (mmHg) ranging in ≥ 130/≥ 85
High triglycerides levels of ≥ 150 and low levels of high density lipoprotein (HDL)men: < 40; women: < 50
Subjecs for bariatric surgery and individuals on high-risk jobs (machine operators, pilots, truck or bus drivers) experiencing excessive daytime drowsiness should be screened for possible OSA.
Recommendations for diagnosis of T2DM in patients with OSA
Prediabetes can be diagnosed based on the following criteria:
Impaired fasting glucose (IFG): FPG 100 mg/dL to 125 mg/dL, Impaired glucose tolerance (IGT): 2-h plasma glucose (2-h PG) during 75-g, oral glucose tolerance test
(OGTT) 140 mg/dL to 199 mg/dL or HbA1c levels ranging from ≥ 5.7%–6.4%
The diagnosis of T2DM should follow the following criteria:
FPG ≥ 126 mg/dL or FPG ≥ 126 mg/dL and/or 2-h PG ≥ 200 mg/dL using 75-g
OGTT, Random plasma glucose ≥ 200 mg/dL in the presence of classical diabetes symptoms
Diagnosis of OSA in patients with T2DM
The diagnosis of OSA is to be confirmed if one of the two conditions exist:
≥15 events of apnea, hypopnea, or increased respiratory effort leading to sleep arousals per hour of sleep in asymptomatic patient, with >75% of apnea/hypopnea events being obstructive
≥5 events of apnea, hypopnea, or increased respiratory effort leading to sleep arousals per hour of sleep in patients with signs and symptoms of disturbed sleep, with >75% of apnea/hypopnea events being obstructive
The AHI cut-offs for diagnosis of OSA measured on the PSG are as follows:
Mild OSA: 5 to 15 episodes/h
Moderate OSA: 15–30 episodes/h
Severe OSA: ≥ 30 episodes/h
Recommendations for treatment of OSA in prediabetes and T2DM.
The treatment options for OSA in patients with T2DM who are at CVD risk include lifestyle modification, pharmacotherapy, and medical management, which include devices such as positioning therapy, CPAP therapy or dental appliances, and surgical interventions.
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