Obstructive sleep apnoea and type 2 diabetes: Whose disease is it anyway?

14 December 2010

OSA• What is it?• Why is it important for diabetes?• What have we been doing?

What are the symptoms• Snoring• Restless , unrefreshing sleep• Waking with choking or gasping• Morning headaches• Nocturia• Difficulty concentrating• Impotence• RefluxPLUS• Difficult to control H/T• Poor control of diabetes

Sleepiness or fatigue?

• SleepinessInability to remain fully awake when you should be

• FatigueSubjective lack of physical or mental energy that interferes with activitiesCLOSE CALL

Who is at risk• 25% of adult population at high risk• increases with age• Men>women• OBESITY, particularly neck measurement• Smokers (current have x3 incidence)• Blocked nose (x2)

Why does it matter• Severe untreated OSA increases all cause mortality by x 3 to

x 6Associated with • systemic H/T• CAD• Arrhythmias• Ischaemic stroke• Heart failure• RTA• Pre-operative complications• Diabetes and insulin resistance

Do Surre

y

Residents

Really

Snore?

Pilot study To give us a rough idea of prevalence of OSA in local population to help with forward planning

Cedar Centre SD Dr Chris Hands Academic F2

Sleep TeamDenise Daley ConsultantKatherine Marshall physiotherapist

Case Study Mr R M

Age 71BMI 33HBA1C 10.3BP 132/61Comorbidities

Urinary retentionTKR 2007 (Post op neuropathic pain)Dual chamber pacemakerHypertensionRenal stonesType 2 diabetes (1986)Renal stones/stents

• Never smoker• Min ETOH• Snorer, Witnessed apnoeas• Nocturesis• Poor control diabetes• No nasal trauma /symptoms

Drug history

• Allopurinol 400mg• Humalog 50/55/60• Aspirin 5mg• Metformin 500mg• Effercitrate • Insulin• Gabapentin 300mg tds• Amitryptyline 50mg nocte• Simvastatin 40mg• Valsartan 80mg • Bisoprolol 2.5mg• Nitrofurantoin 50mg• Amlodipine 5mg• Furosemide 40mg• Cocodamol30/500

• CPAP 31/05/2011

• TKR 14/06/2011• Epworth came down (15 to 8)• 6+hours CPAP per night

The kit

Cedar Pilot study• Information and questionnaire given to

patients on arrival at clinic• No patient selection (T1/T2, fat/thin etc)

Cedar Pilot study

• Information and questionnaire given to patients on arrival at clinic

• No patient selection (T1/T2, fat/thin etc)• Patients put completed questionnaires put in a

box in the waiting area• Scored later

SCORE positive if:

Scored 9 or more on the Epworth Scale

Those with observed pauses in breathing

Snorers with a BMI over 30

65 questionnaires

given out

62Returned =95%

34 positive55%

*20 Epworth>9*14 snorers

BMI>30*6 observed

pauses

28 negative

RESULTS

*Not mutually exclusive

Summary3 clinics

65 patients

54% screen positive

17 studied

4 mild OSA5 severe OSA

62 unselected patients

with diabetes

5 with severe sleep apnoea

What are the implications for our clinical practice?

What nextScreen every oneScreen no one

COSTS

Outpatient appointmentIncludes overnight home sleep study if needed

£250

Treatment

CPAP equipmentLasts 5-10years

£350

Consumables £140 approx

POTENTIAL BENEFITS

Improved glycaemic control

Reduced risk of stroke

Reduced risk of road accidents

Improved quality of life

Divorce stats??

What next?

Screen all pts with diabetes?Screen all patients with type 2?Screen all those with BMI >?Opportunistic screening?Nothing?

VOTE NOW!

Summary Questionnaires 62For screening 34Declined Ax 7Did not make an appointment 10

Sleep studies 17Negative 8Mild, D/C with advice 3

Mild, lifestyle changes FU 6/12 1

CPAP trial DC 1On CPAP 4

Hi Sue,

 Please find the picture attached.  It is in a word file as it was in a presentation.

 Data from our clinics:

  Hope this makes sense.  Let me know if not or if you have any queries.  There were 8 negative studies and 9 positive of which 4 are on CPAP, one tried CPAP but didn't get on with it, one is having a repeat sleep study in 6 months as he attempts to lose weight and 3 others were mild and D/C with advice.

 

Sleep disordered breathing

Sleep disordered breathing (adults)

Apnoeas hypopnoeas

OSA

Centraleg Cheynes Stokes

Others!

•AI number of apnoeas per hour of sleep•AHI total number of apnoeas and hypopnoeas per hour of sleep

Who was Epworth?

Epworth near Melbourne

34 screen positive

7 declined appointment

10 no response 17 studied

8 negative 4 mild

3 discharged 1 restudy in 6/12

5 severe

4 on CPAP

RESULTS

• Screening people with type 2 diabetes for OSA is more complex, however they should be screened particularly when they present with classical symptoms such as witnessed apnoeas, heavy snoring or daytime sleepiness.