Benefits of continuous positive airway pressure on glycaemic control and insulin resistance in patients with type 2 diabetes and obstructive sleep apnoea: A meta-analysis

[Relationship between obstructive sleep apnea and type 2 diabetes mellitus]

INTRODUCTION

The association between obstructive sleep apnea (OSA) and glucose metabolism remains controversial. This study investigates the relationship between OSA and incident type 2 diabetes (DM) and prediabetes (preDM), as well as the effect of long-term CPAP (continuous positive airway pressure) treatment.

METHODS

Follow-up study in a retrospective clinical cohort of patients with OSA and randomly selected controls. Data on incident DM and preDM as well as CPAP were obtained from hospital records. The relationship between baseline OSA and incident DM was examined using COX regression models.

RESULTS

Three hundred and fifty-six patients, 169 with OSA and 187 controls were followed for a median of 98 months; 47 patients (13.2%) developed DM and 43 (12.1%) developed preDM. The 5-year cumulative incidence of DM was 10.7% (6.5-13.9%). 87% of subjects with preDM in the baseline sample progressed to incident DM. It is shown that body mass index (BMI), nocturnal hypoxia and apnea hypopnea index (AHI) are risk factors for the development of DM and that CPAP reduces this risk.

CONCLUSIONS

Patients with OSA have a higher risk of developing DM. The risk factors involved are BMI, nocturnal hypoxia and AHI. Regular long-term CPAP use was associated with a decreased risk.

Polysomnographic features of insomnia occurring in major depressive disorder, generalized anxiety disorder and bipolar mania: Comparison with primary insomnia and association with metabolic indicators

BACKGROUND

Insomnia is very common in psychiatric disorders, but the polysomnographic (PSG) characteristics of insomnia in various psychiatric disorders are still not agreed upon. This study aimed to investigate the characteristics of PSG and its relationship with metabolic indicators in insomnia patients with affective disorders and primary insomnia (PI) patients.

METHODS

A total of 38 patients with PI, 44 major depressive disorder patients with insomnia (DI), 49 generalized anxiety disorder patients with insomnia (GI), and 19 bipolar mania patients with insomnia (BI) were included. PSG was used to detect sleep problems in subjects, and biochemical indicators were also collected.

RESULTS

The results of this study found that subjects with BI were lower on REM sleep latency (RL), awakenings number (AN), number of microarousals (NM), and apnea-hypopnea index (AHI) than those with DI and GI, and lower on RL and AN than those with PI. Subjects with PI had lower NM and AHI than those with DI and GI. Patients with DI had a higher RL than those with GI. All results passed Bonferroni correction (p < 0.00078). No differences in biochemical indices were found among the four groups of subjects. Also, AHI was found to be positively correlated with free triiodothyronine (FT3) and fasting blood glucose in subjects.

CONCLUSION

This study suggests that various psychiatric disorders may have their characteristics in terms of PSG parameters, which prompted us to focus on the PSG characteristics of these disorders when assessing them, as well as to focus on their biochemical indicators.

Effects of different treatments on metabolic syndrome in patients with obstructive sleep apnea: a meta-analysis

Background

Obstructive sleep apnea (OSA) and metabolic syndrome (MetS) often coexist, and the causal relationship between them is not yet clear; treatments for OSA include continuous positive airway pressure (CPAP), mandibular advancement device (MAD), surgery, and lifestyle intervention and so on. However, the effects of different treatments on metabolic syndrome in OSA patients are still under debate.

Objectives

Review the effects of different treatments on metabolic syndrome in OSA patients by meta-analysis.

Methods

we searched articles in PubMed, Embase, Cochrane Library, CNKI, CBM, and Wanfang data from database construction to Feb. 2024.RevMan5.4 and Stata software were used to conduct a meta-analysis of 22 articles.

Results

A total of 22 articles were finally included. The results showed that CPAP treatment could reduce the prevalence of metabolic syndrome in OSA patients in randomized controlled trials (RCTs) (RR = 0.82 [95% CI, 0.75 to 0.90]; p < 0.01) and single-arm studies (RR = 0.73 [95% CI, 0.63 to 0.84]; p < 0.01). As for metabolic syndrome components, CPAP treatment reduces blood pressure, fasting glucose (FG), triglycerides (TG), and waist circumference (WC) but can't affect high-density lipoprotein cholesterol (HDL-C) levels. Lifestyle intervention could significantly reduce the prevalence of metabolic syndrome in OSA patients (RR = 0.60 [95% CI, 0.48 to 0.74]; p < 0.01) and can lower blood pressure, fasting glucose, and waist circumference but can't affect the lipid metabolism of OSA patients. Upper airway surgery can only reduce TG levels in OSA patients (MD = -0.74 [95% CI, -1.35 to -0.13]; p = 0.02) and does not affect other components of metabolic syndrome. There is currently no report on the impact of upper airway surgery on the prevalence of metabolic syndrome. No study has reported the effect of MAD on metabolic syndrome in OSA patients.

Conclusion

We confirmed that both CPAP and lifestyle intervention can reduce the prevalence of MetS in OSA patients. CPAP treatment can lower blood pressure, fasting glucose, waist circumference, and triglyceride levels in OSA patients. Lifestyle intervention can lower blood pressure, fasting glucose, and waist circumference in OSA patients. Upper airway surgery can only reduce TG levels in OSA patients.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42022326857.

Continuous Positive Airway Pressure Effect on Progression of Retinal Disease in Patients with Sleep Apnea and Nonproliferative Diabetic Retinopathy: A Randomized Clinical Trial

Rationale: Obstructive sleep apnea (OSA) is associated with impaired glycemic control and a higher risk of vascular complications, such as diabetic retinopathy. However, the effect of apnea-hypopnea suppression on retinal disease progression is unclear. Objectives: To evaluate the efficacy and safety of continuous positive airway pressure (CPAP) for the reduction of retinal lesions in patients with non-proliferative diabetic retinopathy (NPDR) and OSA. Methods: This open-label, parallel-group, randomized controlled trial was conducted between October 2016 and February 2020 at a university hospital in Spain. The date of final follow-up was March 2, 2021. Eighty-three patients with OSA and mild to moderate NPDR receiving stable treatment were randomized to receive CPAP and usual care (43 patients with 79 available eyes) or usual care alone (40 patients with 67 available eyes) for 52 weeks. The primary outcomes were the change in the percentage of eyes with retinal exudates and the number of retinal microhemorrhages from baseline to week 52. We also assessed the effects of both interventions on retinal thickness by means of optical coherence tomography, serum concentrations of glycated hemoglobin, blood pressure, lipid concentrations, sleepiness, and quality of life. Results: Fifty-two weeks of CPAP treatment was associated with reductions from baseline in the percentage of eyes with hard exudates (overall difference, -21.7%; P = 0.035) and in optical coherence tomography indices of retinal edema, including central subfield thickness and cube volume. However, in patients who met prespecified criteria for CPAP adherence, treatment was also associated with a higher number of retinal microhemorrhages at 52 weeks (intergroup adjusted difference, 6.0 [95% confidence interval, 0.6-11.5]; P = 0.029), which was directly related to prescribed pressure levels. CPAP treatment also improved glycemic control, sleepiness, and general health-related quality of life. Conclusions: In patients with OSA and NPDR, long-term CPAP treatment in addition to usual care may result in slower progression of retinal disease, although it could also induce an increase in retinal microhemorrhages. Clinical trial registered with www.clinicaltrials.gov (NCT02874313).

Adaptive responses to chronic intermittent hypoxia: contributions from the European Sleep Apnoea Database (ESADA) Cohort

Obstructive sleep apnoea (OSA) is a common disease in the general population, and is associated with increased cardiovascular risk and several comorbidities. Obesity favours upper airway collapsibility, but other pathophysiological traits have been identified, i.e. upper airway muscle activity, modulation of the respiratory drive, and the arousal threshold. OSA causes chronic intermittent hypoxia, inflammatory activation and autonomic imbalance with diurnal and nocturnal sympathetic hyperactivity. Disentangling so many components to investigate the pathogenesis of OSA's consequences is very hard clinically. However, albeit imperfect, clinical medicine constitutes a major source of inspiration for basic research, and a mutual exchange of information is essential between clinicians and physiologists to improve our understanding of disease states. OSA is no exception, and this narrative review will summarize the results of clinical studies performed over the years by the European Sleep Apnoea Database (ESADA) Study Group, to explore the variables linked to markers of intermittent hypoxia as opposed to the traditional assessment of OSA severity based on the frequency of respiratory events during sleep (the Apnoea Hypopnoea Index). The results of the clinical studies indicate that intermittent hypoxia variables are associated with several comorbidities, although evidence of a cause-effect relationship is still missing in many cases. It is also possible that adaptive rather than maladaptive responses could be evoked by intermittent hypoxia. The intensity, duration and frequency of intermittent hypoxia episodes causing adaptive rather than maladaptive responses, and their clinical implications, deserve further investigation.

Characterization of sleep apnea among a sample of adults from Samoa

Sleep apnea is a public health concern around the world, but little research has been dedicated to examining this issue in low- and middle-income countries, including Samoa. Using data collected through the Soifua Manuia ("Good Health") study, which aimed to investigate the impact of the body mass index (BMI)-associated genetic variant rs373863828 in CREB3 Regulatory Factor ( CREBRF ) on metabolic traits in Samoan adults, we examined the sample prevalence and characteristics of sleep apnea using data collected with a validated home sleep apnea device (WatchPAT, Itamar). A total of 330 participants (sampled to overrepresent the obesity-risk allele of interest) had sleep data available. Participants (53.3% female) had a mean (SD) age of 52.0 (9.9) years and BMI of 35.5 (7.5) kg/m 2 and 36.3% of the sample had type 2 diabetes. Based on the 3% and 4% apnea hypopnea indices (AHI) and the 4% oxygen desaturation index (ODI), descriptive analyses revealed that many participants had potentially actionable sleep apnea defined as >5 events/hr (87.9%, 68.5%, and 71.2%, respectively) or clinically actionable sleep apnea defined as ≥15 events/hr (54.9%, 31.5%, and 34.5%, respectively). Sleep apnea was more severe in men; for example, clinically actionable sleep apnea (≥15) based on the AHI 3% definition was observed in 61.7% of men and 48.9% of women. Correction for non-representational sampling related to the CREBRF obesity-risk allele resulted in only slightly lower estimates. Across the AHI 3%, AHI 4%, and ODI 4%, multiple linear regression revealed associations between a greater number of events/hr and higher age, male sex, higher body mass index, higher abdominal-hip circumference ratio, and geographic region of residence. Our study identified a much higher frequency of sleep apnea in Samoa compared with published data from other studies, but similar predictors. Continued research addressing generalizability of these findings, as well as a specific focus on diagnosis and affordable and equitable access to treatment, is needed to alleviate the burden of sleep apnea in Samoa and around the world.

Association of poor sleep and HbA1c in metformin-treated patients with type 2 diabetes: Findings from the UK Biobank cohort study

The American Diabetes Association recommends a glycated haemoglobin target of less than 7% for treating type 2 diabetes mellitus. However, it is still being determined if poor sleep affects this therapeutic goal, despite being treated with the blood-glucose-lowering medication metformin. Thus, we used data from 5703 patients on metformin monotherapy participating in the UK Biobank baseline investigation between 2006 and 2010. We combined self-reported chronotype, daily sleep duration, insomnia, daytime sleepiness and snoring into a multidimensional poor sleep score ranging from 0 to 5, with higher scores indicating a less healthy sleep pattern. With each point increase on the poor sleep score scale, the odds of patients having an glycated haemoglobin of ≥ 7% increased by 6% (odds ratio [95% confidence interval], 1.06 [1.01, 1.11], p = 0.021). When examining the components of the poor sleep score separately, snoring was specifically associated with a glycated haemoglobin of ≥ 7% (1.12 [1.01, 1.25] versus no snoring, p = 0.038). However, adjusting for health and lifestyle conditions, such as body mass index, weekly physical activity level and hypertension status, eliminated the significant associations between the poor sleep score and snoring with glycated haemoglobin of ≥ 7%. Our findings suggest that poor sleep, specifically snoring, a symptom of obstructive sleep apnea, may interfere with the therapeutic goal of achieving a glycated haemoglobin below 7%. However, other factors known to be promoted by poor sleep, such as high body mass index, low physical activity and hypertension, may also contribute to the link between poor sleep and higher glycated haemoglobin levels.

Effects of continuous positive airway pressure therapy on glucose metabolism in patients with obstructive sleep apnoea and type 2 diabetes: a systematic review and meta-analysis

Obstructive sleep apnoea is a highly prevalent chronic disorder and has been shown to be associated with disturbed glucose metabolism and type 2 diabetes. However, the evidence from individual clinical trials on the effect of continuous positive airway pressure (CPAP) treatment on glycaemic control in patients with co-existing obstructive sleep apnoea and type 2 diabetes remains controversial. A systematic review of randomised controlled trials assessing the effect of CPAP on glycaemic control in patients with obstructive sleep apnoea and type 2 diabetes was conducted using the databases MEDLINE, Embase, Cochrane and Scopus up to December 2022. Meta-analysis using a random-effect model was performed for outcomes that were reported in at least two randomised controlled trials. From 3031 records screened, 11 RCTs with a total of 964 patients were included for analysis. CPAP treatment led to a significant reduction in haemoglobin A1c (HbA1c) (mean difference -0.24%, 95% CI -0.43- -0.06%, p=0.001) compared to inactive control groups. Meta-regression showed a significant association between reduction in HbA1c and hours of nightly CPAP usage. CPAP therapy seems to significantly improve HbA1c and thus long-term glycaemic control in patients with type 2 diabetes and obstructive sleep apnoea. The amount of improvement is dependent on the hours of usage of CPAP and thus optimal adherence to CPAP should be a primary goal in these patients.

Investigating the Relationship between Obstructive Sleep Apnoea, Inflammation and Cardio-Metabolic Diseases

Obstructive sleep apnoea (OSA) is a prevalent underdiagnosed disorder whose incidence increases with age and weight. Uniquely characterised by frequent breathing interruptions during sleep-known as intermittent hypoxia (IH)-OSA disrupts the circadian rhythm. Patients with OSA have repeated episodes of hypoxia and reoxygenation, leading to systemic consequences. OSA consequences range from apparent symptoms like excessive daytime sleepiness, neurocognitive deterioration and decreased quality of life to pathological complications characterised by elevated biomarkers linked to endocrine-metabolic and cardiovascular changes. OSA is a well-recognized risk factor for cardiovascular and cerebrovascular diseases. Furthermore, OSA is linked to other conditions that worsen cardiovascular outcomes, such as obesity. The relationship between OSA and obesity is complex and reciprocal, involving interaction between biological and lifestyle factors. The pathogenesis of both OSA and obesity involve oxidative stress, inflammation and metabolic dysregulation. The current medical practice uses continuous positive airway pressure (CPAP) as the gold standard tool to manage OSA. It has been shown to improve symptoms and cardiac function, reduce cardiovascular risk and normalise biomarkers. Nonetheless, a full understanding of the factors involved in the deleterious effects of OSA and the best methods to eliminate their occurrence are still poorly understood. In this review, we present the factors and evidence linking OSA to increased risk of cardiovascular conditions.

Continuous Positive Airway Pressure Effect on Albuminuria Progression in Patients with Obstructive Sleep Apnea and Diabetic Kidney Disease: A Randomized Clinical Trial

Rationale: Obstructive sleep apnea (OSA) is associated with impaired glycemic control and a higher risk of vascular complications, such as diabetic kidney disease (DKD). However, the effect of apnea-hypopnea suppression on DKD progression is unclear. Objectives: To assess the effect of continuous positive airway pressure (CPAP) on the urinary albumin-to-creatinine ratio (UACR) in patients with DKD and OSA. Methods: In a 52-week, multicentric, open-label, parallel, and randomized clinical trial, 185 patients with OSA and DKD were randomized to CPAP and usual care (n = 93) or usual care alone (n = 92). Measurements and Main Results: UACR, estimated glomerular filtration rate, serum concentrations of creatinine and glycated hemoglobin, insulin resistance, lipid concentrations, sleepiness, and quality of life. A 52-week change in UACR from baseline did not differ significantly between the CPAP group and the usual-care group. However, in per-protocol analyses that included 125 participants who met prespecified criteria for adherence, CPAP treatment was associated with a great reduction in UACR (mean difference, -10.56% [95% confidence interval, -19.06 to -2.06]; P = 0.015). CPAP effect on UACR was higher in nonsleepy patients with more severe OSA, worse renal function, and a more recent diagnosis of DKD. CPAP treatment also improved glycemic control and insulin resistance, as well as sleepiness and health-related quality of life. Conclusions: In patients with OSA and DKD, the prescription of CPAP did not result in a statistically significant reduction in albuminuria. However, good adherence to CPAP treatment in addition to usual care may result in long-term albuminuria reduction compared with usual care alone. Clinical trial registered with www.clinicaltrials.gov (NCT02816762).

Obesity does not modify the effect of continuous positive airway pressure on insulin resistance in adults with obstructive sleep apnoea

This study found no evidence that obesity significantly modifies the effect of 4 months of CPAP treatment on HOMA-IR. Longer duration of CPAP treatment may be needed in order to reduce insulin resistance and determine whether obesity modifies the effect. https://bit.ly/3CtX7jZ.

Association between positive airway pressure therapy adherence and health care resource utilization in patients with obstructive sleep apnea and type 2 diabetes in the United States

STUDY OBJECTIVES

There is a complex interplay between obstructive sleep apnea (OSA) and type 2 diabetes. There are minimal data regarding the effects of treating OSA with positive airway pressure (PAP) therapy on outcomes and health care resource utilization (HCRU) in patients with OSA and type 2 diabetes. We investigated the impact of PAP adherence on HCRU and costs in this population.

METHODS

A retrospective analysis was conducted with a cohort of OSA patient from a US administrative claims dataset linked to objective device data (AirView, ResMed Corp., San Diego, California). Propensity score matching was used to control for potential imbalance in baseline covariates between PAP-adherent and -nonadherent patients. Newly diagnosed patients with OSA aged ≥ 18 years with type 2 diabetes were included. PAP adherence was defined as meeting Centers for Medicare and Medicaid Services compliance criteria in all 8 90-day periods over 2 years. HCRU was based on the number of all-cause doctor visits, emergency room visits, inpatient hospitalizations, and PAP equipment and supplies.

RESULTS

In years 1 and 2 of PAP therapy, HCRU was significantly lower in adherent vs nonadherent patients (number/patient for emergency room visits 0.68 ± 1.47 vs 0.99 ± 1.91 [year 1], 0.69 ± 1.43 vs 0.95 ± 1.89 [year 2]; for hospitalizations 0.16 ± 0.58 vs 0.22 ± 0.62 [year 1], 0.15 ± 0.51 vs 0.21 ± 0.74 [year 2]; all P < .001). Changes in estimated total 24-month payments were higher for nonadherent patients ($2,282, 95% confidence interval: $1,368, $3,205).

CONCLUSIONS

Consistent use of PAP therapy over 2 years was associated with decreased HCRU in patients with OSA and type 2 diabetes, strongly suggesting a role for screening and treating OSA in type 2 diabetes.

CITATION

Sterling KL, Cistulli PA, Linde-Zwirble W, et al. Association between positive airway pressure therapy adherence and health care resource utilization in patients with obstructive sleep apnea and type 2 diabetes in the United States. J Clin Sleep Med. 2023;19(3):563-571.

Effect of Continuous Positive Airway Pressure on Glucose and Lipid Profiles in Patients With Obstructive Sleep Apnoea: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

BACKGROUND AND AIM

Continuous Positive Airway Pressure (CPAP) is the most effective therapy for symptomatic obstructive sleep apnoea (OSA). However, uncertainty remains about the effectiveness of CPAP in improving OSA-related metabolic dysregulation. This meta-analysis of randomized controlled trials (RCTs) aimed to investigate whether CPAP, compared to other control treatments, could improve glucose or lipid metabolism in OSA patients.

METHODS

Relevant articles were searched in three different databases (MEDLINE, EMBASE and Web of Science) from inception to 6th Feb 2022 through specific search terms and selection criteria.

RESULTS

From a total of 5553 articles, 31 RCTs were included. CPAP modestly improved insulin sensitivity as determined by mean fasting plasma insulin and Homeostasis Model Assessment of Insulin Resistance reduction of 1.33mU/L and 0.287, respectively. In subgroup analyses pre-diabetic/type 2 diabetic patients as well as those with sleepy OSA showed a greater response to CPAP. Regarding lipid metabolism, CPAP was associated with a mean total cholesterol reduction of 0.064mmol/L. In subgroup analyses, the benefit was higher in patients that showed more severe OSA and oxygen desaturations at the baseline sleep study as well as in younger and obese subjects. Neither glycated haemoglobin nor triglycerides, HDL- and LDL-cholesterol were reduced by CPAP.

CONCLUSION

CPAP treatment may improve insulin sensitivity and total cholesterol levels in OSA patients but with low effect size. Our results suggest that CPAP does not substantially improve metabolic derangements in an unselected OSA population, but the effect may be higher in specific subgroups of OSA patients.

Non-dipping blood pressure pattern is associated with higher risk of new-onset diabetes in hypertensive patients with obstructive sleep apnea: UROSAH data

OBJECTIVE

Impairment of circadian blood pressure (BP) patterns has been associated with cardiovascular risks and events in individuals with hypertension and in general populations, which are more likely to be found in obstructive sleep apnea (OSA). The aim of this study was to investigate the association of non-dipping BP pattern with new-onset diabetes in hypertensive patients with OSA, based on Urumqi Research on Sleep Apnea and Hypertension (UROSAH) data.

MATERIALS AND METHODS

This retrospective cohort study included 1841 hypertensive patients at least 18 years of age, who were diagnosed with OSA without baseline diabetes and had adequate ambulatory blood pressure monitoring (ABPM) data at enrollment. The exposure of interest for the present study was the circadian BP patterns, including non-dipping and dipping BP pattern, and the study outcome was defined as the time from baseline to new-onset diabetes. The associations between circadian BP patterns and new-onset diabetes were assessed using Cox proportional hazard models.

RESULTS

Among 1841 participants (mean age: 48.8 ± 10.5 years, 69.1% male), during the total follow-up of 12172 person-years with a median follow-up of 6.9 (inter quartile range: 6.0-8.0) years, 217 participants developed new-onset diabetes with an incidence rate of 17.8 per 1000 person-years. The proportion of non-dippers and dippers at enrollment in this cohort was 58.8% and 41.2%, respectively. Non-dippers were associated with higher risk of new-onset diabetes compared with dippers (full adjusted hazard ratio [HR]=1.53, 95% confidence interval [CI]: 1.14-2.06, P=0.005). Multiple subgroup and sensitivity analyses yielded similar results. We further explored the association of systolic and diastolic BP patterns with new-onset diabetes separately, and found that diastolic BP non-dippers were associated with higher risk of new-onset diabetes (full adjusted HR=1.54, 95% CI: 1.12-2.10, P=0.008), whereas for systolic BP non-dippers, the association was nonsignificant after adjusted the confounding covariates (full adjusted HR=1.35, 95% CI: 0.98-1.86, P=0.070).

CONCLUSIONS

Non-dipping BP pattern is associated with an approximately 1.5-fold higher risk of new-onset diabetes in hypertensive patients with OSA, suggesting that non-dipping BP pattern may be an important clinical implication for the early prevention of diabetes in hypertensive patients with OSA.

Obstructive Sleep Apnoea and Lipid Metabolism: The Summary of Evidence and Future Perspectives in the Pathophysiology of OSA-Associated Dyslipidaemia

Obstructive sleep apnoea (OSA) is associated with cardiovascular and metabolic comorbidities, including hypertension, dyslipidaemia, insulin resistance and atherosclerosis. Strong evidence suggests that OSA is associated with an altered lipid profile including elevated levels of triglyceride-rich lipoproteins and decreased levels of high-density lipoprotein (HDL). Intermittent hypoxia; sleep fragmentation; and consequential surges in the sympathetic activity, enhanced oxidative stress and systemic inflammation are the postulated mechanisms leading to metabolic alterations in OSA. Although the exact mechanisms of OSA-associated dyslipidaemia have not been fully elucidated, three main points have been found to be impaired: activated lipolysis in the adipose tissue, decreased lipid clearance from the circulation and accelerated de novo lipid synthesis. This is further complicated by the oxidisation of atherogenic lipoproteins, adipose tissue dysfunction, hormonal changes, and the reduced function of HDL particles in OSA. In this comprehensive review, we summarise and critically evaluate the current evidence about the possible mechanisms involved in OSA-associated dyslipidaemia.

American Association of Clinical Endocrinology Clinical Practice Guideline: Developing a Diabetes Mellitus Comprehensive Care Plan-2022 Update

OBJECTIVE

The objective of this clinical practice guideline is to provide updated and new evidence-based recommendations for the comprehensive care of persons with diabetes mellitus to clinicians, diabetes-care teams, other health care professionals and stakeholders, and individuals with diabetes and their caregivers.

METHODS

The American Association of Clinical Endocrinology selected a task force of medical experts and staff who updated and assessed clinical questions and recommendations from the prior 2015 version of this guideline and conducted literature searches for relevant scientific papers published from January 1, 2015, through May 15, 2022. Selected studies from results of literature searches composed the evidence base to update 2015 recommendations as well as to develop new recommendations based on review of clinical evidence, current practice, expertise, and consensus, according to established American Association of Clinical Endocrinology protocol for guideline development.

RESULTS

This guideline includes 170 updated and new evidence-based clinical practice recommendations for the comprehensive care of persons with diabetes. Recommendations are divided into four sections: (1) screening, diagnosis, glycemic targets, and glycemic monitoring; (2) comorbidities and complications, including obesity and management with lifestyle, nutrition, and bariatric surgery, hypertension, dyslipidemia, retinopathy, neuropathy, diabetic kidney disease, and cardiovascular disease; (3) management of prediabetes, type 2 diabetes with antihyperglycemic pharmacotherapy and glycemic targets, type 1 diabetes with insulin therapy, hypoglycemia, hospitalized persons, and women with diabetes in pregnancy; (4) education and new topics regarding diabetes and infertility, nutritional supplements, secondary diabetes, social determinants of health, and virtual care, as well as updated recommendations on cancer risk, nonpharmacologic components of pediatric care plans, depression, education and team approach, occupational risk, role of sleep medicine, and vaccinations in persons with diabetes.

CONCLUSIONS

This updated clinical practice guideline provides evidence-based recommendations to assist with person-centered, team-based clinical decision-making to improve the care of persons with diabetes mellitus.

Genetic determinants of cardiometabolic and pulmonary phenotypes and obstructive sleep apnoea in HCHS/SOL

BACKGROUND

Obstructive Sleep Apnoea (OSA) often co-occurs with cardiometabolic and pulmonary diseases. This study is to apply genetic analysis methods to explain the associations between OSA and related phenotypes.

METHODS

In the Hispanic Community Healthy Study/Study of Latinos, we estimated genetic correlations ρ_g between the respiratory event index (REI) and 54 anthropometric, glycemic, cardiometabolic, and pulmonary phenotypes. We used summary statistics from published genome-wide association studies to construct Polygenic Risk Scores (PRSs) representing the genetic basis of each correlated phenotype (ρ_g>0.2 and p-value<0.05), and of OSA. We studied the association of the PRSs of the correlated phenotypes with both REI and OSA (REI≥5), and the association of OSA PRS with the correlated phenotypes. Causal relationships were tested using Mendelian Randomization (MR) analysis.

FINDINGS

The dataset included 11,155 participants, 31.03% with OSA. 22 phenotypes were genetically correlated with REI. 10 PRSs covering obesity and fat distribution (BMI, WHR, WHRadjBMI), blood pressure (DBP, PP, MAP), glycaemic control (fasting insulin, HbA1c, HOMA-B) and insomnia were associated with REI and/or OSA. OSA PRS was associated with BMI, WHR, DBP and glycaemic traits (fasting insulin, HbA1c, HOMA-B and HOMA-IR). MR analysis identified robust causal effects of BMI and WHR on OSA, and probable causal effects of DBP, PP, and HbA1c on OSA/REI.

INTERPRETATION

There are shared genetic underpinnings of anthropometric, blood pressure, and glycaemic phenotypes with OSA, with evidence for causal relationships between some phenotypes.

FUNDING

Described in Acknowledgments.

Benefits of plasma exchange on mortality in patients with COVID-19: a systematic review and meta-analysis

OBJECTIVE

The COVID-19 pandemic continues, and the death toll continues to surge. This systematic review and meta-analysis aimed to determine the efficacy of therapeutic plasma exchange (TPE) on mortality in patients with COVID-19.

METHODS

A systematic search was made of PubMed, Embase, Cochrane Library, and clinicaltrials.gov, without language restrictions. Controlled clinical trials on treatment of COVID-19 with TPE, compared with standard of care, were reviewed. Studies were pooled according to risk ratios (RRs) and weighted mean differences, with 95% confidence intervals (CIs).

RESULTS

A total of six trials (enrolling 343 participants) met the inclusion criteria. Therapeutic plasma exchange showed significant effect on mortality (RR 0.41, 95% CI 0.24 to 0.69; P = 0.0008).

CONCLUSION

TPE significantly reduced mortality in hospitalized patients with moderate-to-critical COVID-19. Plasma exchange therapy should be considered for patients with COVID-19.

Benefits of tolvaptan on early dyspnea relief in patients with acute heart failure: A meta-analysis

Considering the prevalence of dyspnea in acute heart failure (AHF), its reduction is important to both patients and caregivers. This meta‐analysis was performed to determine the efficacy and safety of tolvaptan on early dyspnea relief in patients with AHF. A systematic search was made of PubMed, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials (RCTs) on treatment of AHF with tolvaptan, compared with placebo or blank, were reviewed. Studies were pooled to relative risk (RR), with 95% confidence interval (CI). Five RCTs (enrolling 4857 participants) met the inclusion criteria. Tolvaptan presented significant effects on 12 h dyspnea relief (RR: 1.98; 95% CI: 1.24−3.15; p = .004), 24 h/day 1 dyspnea relief (RR: 1.15; 95% CI: 1.07−1.24; p = .0003), 48 h dyspnea relief (RR: 1.20; 95% CI: 1.06−1.36; p = .004), and 72 h dyspnea relief (RR: 1.18; 95% CI: 1.02−1.37; p = .03). No significant increase was noticed in the incidence of worsening renal function in tolvaptan group (RR: 1.10; 95% CI: 0.87−1.39; p = .43). Tolvaptan treatment significantly improved patient‐assessed dyspnea early and persistently in patients with AHF.

Obstructive sleep apnea, prediabetes and progression of type 2 diabetes: A systematic review and meta-analysis

AIMS/INTRODUCTION

Obstructive sleep apnea (OSA) is related to prediabetes and diabetes. Whether patients with OSA have a higher risk of prediabetes/diabetes remains unclear. We aimed to carry out a meta-analysis of published studies to evaluate the relationships between OSA and prediabetes and diabetes, and the impact of the severity of OSA on diabetes.

MATERIALS AND METHODS

The PubMed, EMBASE and Cochrane databases were searched from January 2011 to July 2021. The associations between OSA and impaired fasting glucose, impaired glucose tolerance, impaired glucose regulation and diabetes mellitus were analyzed. We estimated the pooled odds ratios using fixed or random effects models. We included 25 studies comprising a total of 154,948 patients with OSA and risk factors for prediabetes/diabetes (20 and 16, respectively) in the analysis.

RESULTS

OSA was associated with a higher risk of impaired fasting glucose, impaired glucose tolerance, impaired glucose regulation and diabetes mellitus in the cohort studies and cross-sectional studies. The pooled odds ratios were 2.34 (95% confidence interval [CI] 1.16-4.72), 1.58 (95% CI 1.15-2.15), 1.65 (95% CI 1.12-2.42), 2.15 (95% CI 1.68-2.75) and 3.62 (95% CI 2.75-4.75), respectively. Subgroup analyses were based on the proportions of men and women. The results showed that OSA was a risk factor, and there was no significant difference between the two groups. The risk of diabetes increased with the severity of OSA.

CONCLUSIONS

The risk of developing prediabetes and diabetes was higher in patients with OSA.

Benefits of continuous positive airway pressure on blood pressure in patients with hypertension and obstructive sleep apnea: a meta-analysis

This meta-analysis was performed to determine the effects of continuous positive airway pressure (CPAP) on blood pressure (BP) in patients with systemic hypertension and obstructive sleep apnea (OSA). A systematic search was conducted using PubMed, Embase, Web of Science, Cochrane Library, and clinicaltrials.gov, without language restrictions. Randomized controlled trials on the treatment of hypertension and OSA with CPAP, compared with sham CPAP or no CPAP, were reviewed. Studies were pooled to obtain weighted mean differences (WMDs) with 95% confidence intervals (CIs). Nineteen trials (enrolling 1904 participants) met the inclusion criteria. CPAP had significant effects on 24-h systolic blood pressure (SBP) (WMD -5.01 mmHg, 95% CI -6.94 to -3.08; P < 0.00001), 24-h diastolic blood pressure (DBP) (WMD -3.30 mmHg, 95% CI -4.32 to -2.28; P < 0.00001), daytime SBP (WMD -4.34 mmHg, 95% CI -6.27 to -2.40; P < 0.0001), daytime DBP (WMD -2.97 mmHg, 95% CI -3.99 to -1.95; P < 0.00001), nighttime SBP (WMD -3.55 mmHg, 95% CI -5.08 to -2.03; P < 0.00001), nighttime DBP (WMD -2.33 mmHg, 95% CI -3.27 to -1.40; P < 0.00001), office SBP (WMD -3.67 mmHg, 95% CI -5.76 to -1.58; P = 0.0006), office DBP (WMD -2.61 mmHg, 95% CI -4.25 to -0.97; P = 0.002), and heart rate (WMD -2.79 beats/min, 95% CI -4.88 to -0.71; P = 0.009). CPAP treatment was associated with BP reduction in patients with systemic hypertension and OSA, except when the follow-up period was shorter than 3 months.

Effect of Continuous Positive Airway Pressure on Lipid Profiles in Obstructive Sleep Apnea: A Meta-Analysis

BACKGROUND

Obstructive sleep apnea (OSA) is associated with dyslipidemia. However, the effects of continuous positive airway pressure (CPAP) treatment on lipid profiles are unclear.

METHODS

PubMed/Medline, Embase and Cochrane were searched up to July 2021. Randomized controlled trials (RCTs) of CPAP versus controls with ≥4 weeks treatment and reported pre- and post-intervention lipid profiles were included. Weighted mean difference (WMD) was used to assess the effect size. Meta-regression was used to explore the potential moderators of post-CPAP treatment changes in lipid profiles.

RESULTS

A total of 14 RCTs with 1792 subjects were included. CPAP treatment was associated with a significant decrease in total cholesterol compared to controls (WMD = -0.098 mmol/L, 95% CI = -0.169 to -0.027, p = 0.007, I² = 0.0%). No significant changes in triglyceride, high-density lipoprotein nor low-density lipoprotein were observed after CPAP treatment (all p > 0.2). Furthermore, meta-regression models showed that age, gender, body mass index, daytime sleepiness, OSA severity, follow-up study duration, CPAP compliance nor patients with cardiometabolic disease did not moderate the effects of CPAP treatment on lipid profiles (all p > 0.05).

CONCLUSIONS

CPAP treatment decreases total cholesterol at a small magnitude but has no effect on other markers of dyslipidemia in OSA patients. Future studies of CPAP therapy should target combined treatment strategies with lifestyle modifications and/or anti-hyperlipidemic medications in the primary as well as secondary cardiovascular prevention models.

Postprandial glucose and HbA1c are associated with severity of obstructive sleep apnoea in non-diabetic obese subjects

INTRODUCTION

Obstructive sleep apnoea (OSA) is an underdiagnosed condition frequently associated with glycaemic control impairment in patients with type 2 diabetes.

AIM

To assess the relationship between glycometabolic parameters and OSA in obese non-diabetic subjects.

METHODS

Ninety consecutive subjects (mean age 44.9 ± 12 years, mean BMI 42.1 ± 9 kg/m²) underwent polysomnography and a 2-h oral glucose tolerance test (OGTT).

RESULTS

OSA was identified in 75% of subjects, with a higher prevalence of males compared to the group of subjects without OSA (62% vs 32%, p = 0.02). Patients with OSA had comparable BMI (42.8 kg/m² vs 39.4 kg/m²), a higher average HbA1c (5.8% vs 5.4%, p < 0.001), plasma glucose at 120 min during OGTT (2 h-PG; 123 mg/dl vs 97 mg/dl, p = 0.009) and diastolic blood pressure (81.1 mmHg vs 76.2 mmHg, p = 0.046) than obese subjects without OSA. HbA1c and 2 h-PG were found to be correlated with the apnoea-hypopnoea index (AHI; r = 0.35 and r = 0.42, respectively) and with percent of sleep time with oxyhaemoglobin saturation < 90% (ST90; r = 0.44 and r = 0.39, respectively). Further, in a linear regression model, ST90 and AHI were found to be the main determinants of 2 h-PG (β = 0.81, p < 0.01 and β = 0.75, p = 0.02, respectively) after controlling for age, sex, waist circumference, physical activity, and C-reactive protein. Similarly, ST90 and AHI persisted as independent determinants of HbA1c (β = 0.01, p = 0.01 and β = 0.01, p = 0.01, respectively).

CONCLUSION

Beyond the traditional clinical parameters, the presence of a normal-high value of 2 h-PG and HbA1c should raise suspicion of the presence of OSA in obese subjects.