Management of Chronic Insomia Disorder and Obstructive Sleep Apnea (Insomia/OSA) (2019)

Publication Date: January 1, 2019
Last Updated: March 14, 2022

Recommendations

Diagnosis and Assessment of Obstructive Sleep Apnea and Insomnia Disorder

1. For patients who report sleep complaints, we suggest using the STOP questionnaire to stratify the risk of obstructive sleep apnea. (Weak for)
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2. We suggest that providers assess for sleep disordered breathing in patients with a history of cardiovascular or cerebrovascular events, congestive heart, and chronic prescription opioid use. (Weak for)
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3. Among patients with a high pretest probability for obstructive sleep apnea, we suggest a manually-scored type III home sleep apnea test (unattended portable monitor) using an event index (i.e., respiratory disturbance index, apnea-hypopnea index) ≥15 events per hour to establish the diagnosis of moderate to severe obstructive sleep apnea. (Weak for)
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4. For patients with a high pretest probability for obstructive sleep apnea and a non-diagnostic home sleep apnea test (i.e., technically inadequate or apnea-hypopnea index <5), we recommend repeat (home sleep apnea testing or lab-based polysomnography) testing for obstructive sleep apnea. (Strong for)
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5. For evaluating patients suspected of having insomnia disorder, we suggest using the Insomnia Severity Index or Athens Insomnia Scale as part of a comprehensive sleep assessment. (Weak for)
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6. There is no available evidence to recommend for or against additional diagnostic testing for patients with chronic insomnia disorder who do not respond to cognitive behavioral therapy for insomnia (CBT-I) or pharmacotherapy. ()
(Neither for nor against)
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Treatment and Management of Obstructive Sleep Apnea

7. We recommend that patients with obstructive sleep apnea on positive airway pressure therapy use this treatment for the entirety of their sleep period(s). (Strong for)
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8. We suggest continuing positive airway pressure therapy for patients with obstructive sleep apnea even if the patient is using this treatment for <4 hours per night. (Weak for)
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9. In patients with obstructive sleep apnea, including those at highrisk for poor positive airway pressure adherence, such as those with posttraumatic stress disorder, anxiety, or insomnia, we recommend educational, behavioral, and supportive interventions to improve positive airway pressure adherence. (Strong for)
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10. We suggest that patients with obstructive sleep apnea and concurrent diagnoses/symptoms of posttraumatic stress disorder, anxiety, or insomnia be offered interventions to improve positive airway pressure adherence upon initiation of therapy. (Weak for)
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11. In appropriate patients with mild to moderate obstructive sleep apnea (apnea-hypopnea index <30 per hour), we suggest offering mandibular advancement devices, fabricated by a qualified dental provider, as an alternative to positive airway pressure therapy. (Weak for)
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12. Among patients with anatomical nasal obstruction as a barrier to positive airway pressure use, we suggest evaluation for nasal surgery. (Weak for)
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13. For patients with obstructive sleep apnea with an apneahypopnea index of 15 – 65 per hour and a body mass index <32 kg/m2 who cannot adhere to positive airway pressure therapy, we suggest evaluation for surgical treatment with hypoglossal nerve stimulation therapy. (Weak for)
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14. For patients with severe obstructive sleep apnea who cannot tolerate or are not appropriate candidates for other recommended therapies, we suggest evaluation for alternative treatment with maxillomandibular advancement surgery. (Weak for)
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15. For patients with obstructive sleep apnea who cannot tolerate or who have declined all other recommended treatments, we suggest offering alternative/salvage therapies. (Weak for)
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16. We suggest against oxygen therapy as a standalone treatment for patients with obstructive sleep apnea who cannot tolerate other recommended therapies. (Weak against)
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17. For patients without nasal congestion, we suggest against the routine use of topical nasal steroids for the sole purpose of improving positive airway pressure adherence. (Weak against)
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18. Due to the lack of clinically significant benefit, we cannot recommend for or against:
• auto-titrating positive airway pressure when compared to fixed positive airway pressure, or
• the use of flexible pressure delivery (e.g., C-Flex®, expiratory pressure relief) to improve positive airway pressure adherence.
()
(Neither for nor against)
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Treatment and Management of Chronic Insomnia Disorder

19. We recommend offering CBT-I for the treatment of chronic insomnia disorder. (Strong for)
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20. We suggest offering brief behavioral therapy for insomnia (BBT-I) for the treatment of chronic insomnia disorder. (Weak for)
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21. There is insufficient evidence to recommend for or against group versus individual CBT-I for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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22. There is insufficient evidence to recommend for or against internet-based CBT-I as an alternative to face-to-face based CBT-I for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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23. For patients diagnosed with chronic insomnia disorder, we suggest CBT-I over pharmacotherapy as first-line treatment. (Weak for)
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24. We suggest offering CBT-I for the treatment of chronic insomnia disorder that is comorbid with another psychiatric disorder. (Weak for)
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25. There is insufficient evidence to recommend for or against mindfulness meditation for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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26. We suggest against sleep hygiene education as a standalone treatment for chronic insomnia disorder. (Weak against)
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27. We suggest offering auricular acupuncture with seed and pellet for the treatment of chronic insomnia disorder. (Weak for)
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28. There is insufficient evidence to recommend for or against acupuncture other than auricular acupuncture with seed and pellet for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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29. There is insufficient evidence to recommend for or against aerobic exercise, resistive exercise, tai chi, yoga, and qigong for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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30. We suggest against cranial electrical stimulation for the treatment of chronic insomnia disorder. (Weak against)
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31. We suggest against the use of diphenhydramine for the treatment of chronic insomnia disorder. (Weak against)
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32. We suggest against the use of melatonin for the treatment of chronic insomnia disorder. (Weak against)
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33. We suggest against the use of valerian and chamomile for the treatment of chronic insomnia disorder. (Weak against)
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34. We recommend against the use of kava for the treatment of chronic insomnia disorder. (Strong against)
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35. In patients who are offered a short-course of pharmacotherapy for the treatment of chronic insomnia disorder, we suggest use of low-dose (i.e., 3 mg or 6 mg) doxepin. (Weak for)
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36. In patients who are offered a short-course of pharmacotherapy for the treatment of chronic insomnia disorder, we suggest the use of a non-benzodiazepine benzodiazepine receptor agonist. (Weak for)
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37. There is insufficient evidence to recommend for or against the use of ramelteon for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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38. There is insufficient evidence to recommend for or against the use of suvorexant for the treatment of chronic insomnia disorder. ()
(Neither for nor against)
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39. We suggest against the use of antipsychotic drugs for the treatment of chronic insomnia disorder. (Weak against)
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40. We suggest against the use of benzodiazepines for the treatment of chronic insomnia disorder. (Weak against)
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41. We suggest against the use of trazodone for the treatment of chronic insomnia disorder. (Weak against)
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Recommendation Grading

Overview

Title

Management of Chronic Insomia Disorder and Obstructive Sleep Apnea (Insomia/OSA) (2019)

Authoring Organization

Veterans Health Administration / Department of Defense

Endorsing Organization

American Academy of Sleep Medicine

Publication Month/Year

January 1, 2019

Last Updated Month/Year

January 23, 2024

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Inclusion Criteria

Female, Male, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care

Intended Users

Social worker, respiratory therapist, physician, nurse, nurse practitioner, physician assistant

Scope

Assessment and screening, Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D020181 - Sleep Apnea, Obstructive

Keywords

obstructive sleep apnea, Chronic Insomia

Supplemental Methodology Resources

Project Plan, Methodology Supplement

Methodology

Number of Source Documents
210
Literature Search Start Date
January 1, 2008
Literature Search End Date
May 15, 2018