Importance of Evaluation for Obstructive Sleep Apnea in Obese Patients with Type 2 Diabetes
September / October 2009
Specialists at the Penn Sleep Centers are encouraging
physicians treating obese patients with diabetes, particularly
those with higher waist circumferences (truncal
obesity), to be evaluated for obstructive sleep apnea (OSA).
Data from epidemiologic and clinical studies now suggests
that OSA places patients at increased risk for the development
of altered glucose metabolism, and could thus be a
contributing cause of type 2 diabetes.1 In studies comparing
obese OSA patients with weight-matched non-OSA
controls, the combination of OSA and obesity was found
to increase insulin resistance.2
According to a recent report,3 the prevalence of undiagnosed
OSA among obese patients with type 2 diabetes is greater than 85%
(Figure 1). Importantly, many of the patients in the study had no
symptoms of sleepiness or snoring, and reported symptoms (such as
sleepiness and snoring) did not predict which patients were likely to
have sleep apnea. More than half of the patients with OSA
had moderate or severe sleep apnea, a factor shown in recent
population-based as well as longitudinal studies to be an independent
risk factor for all-cause mortality.
Some studies4,5 have shown that diabetic patients with OSA
who receive sustained, regular treatment with continuous positive
airway pressure (CPAP) can improve insulin sensitivity and
glycaemic control. CPAP treatment has been demonstrated to reduce
systolic blood pressure and heart rate and to improve left ventricular
ejection fraction in patients with OSA.
Case Study
Mr. E, a 35-year-old man, presented to his primary care physician
for routine follow-up care. His medical history was significant for type
2 diabetes, hypertension and obesity. Outpatient medications included
metformin 1000mg twice daily, lisinopril 10mg once daily and amlodipine
10mg once daily. The patient had no specific complaints during
the visit but, when asked by his physician, admitted that his wife had
urged him to visit because she could no longer tolerate his snoring. He
denied excessive daytime sleepiness. Clinical examination was significant
only for obesity (body mass index = 37.2kg/m2) and an elevated blood
pressure of 145/94, despite antihypertensive medications.
An outpatient
sleep study was ordered to investigate for obstructive sleep apnea (OSA).
The polysomnogram revealed severe obstructive sleep apnea with an
apnea hypopnea index of 42 events per hour and an oxyhemoglobin
nadir of 80%. The patient was referred for a titration polysomnogram, which established a CPAP pressure of 10 cm of water as the optimal
pressure needed to treat Mr. E's severe OSA. CPAP therapy was
initiated using a nasal mask interface.
Mr. E returned to his primary care
provider three months later. His blood pressure was within
optimal range (128/74) without change in his antihypertensive
regimen. His wife reported his snoring had been abolished with the
use of his CPAP unit. In addition, Mr. E noted that he now feels more
energized and rested on waking in the morning.
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"Given that OSA may complicate diabetes in the obese, it's
important that physicians treating obese patients with type 2
diabetes consider the possibility of OSA, even in the absence of
symptoms. This is especially true of those with higher waist
circumference and higher BMI levels."
Allan I. Pack, MB, ChB, PhD
Chief, Division of Sleep Medicine
Professor of Medicine
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References
- Tasali E, Mokhlesi B, Van Cauter E. Chest. 2008;133:496-506.
- Tassone F, Lanfranco F, Gianotti L, et al. Clin Endocrinol (Oxf).
2003;59:374-379.
- Foster GD, Sanders MH, Millman R, et al. In press. Diabetes Care. 2009.
- Schachin SP, Nechanitzky T, Dittel C, et al. Med Sci Monit. 2008;14:
CR117-CR121.
- Harsch IA, Schahin SP, Radespiel-Tröger M, et al. Am J Resp Crit Care Med.
2004;169:156-162.
Our Team of Faculty
The Penn Sleep Center is comprised of a multidisciplinary team of
clinicians from the departments of medicine, neurology, psychiatry,
otorhinolaryngology and oral and maxillofacial surgery-a concentration
of expertise that permits a comprehensive approach to the diagnosis and
treatment of sleep disorders and their comorbidities. One of only three
sleep centers in the United States designated by the National
Institutes of Health as a specialized center for research in sleep, the Penn
Sleep Center is fully accredited by the American Academy of Sleep
Medicine. With seven locations in the Philadelphia area, the Sleep
Center currently performs more than 5,000 sleep studies each year.
Allan I. Pack, MB, ChB, PhD
Chief, Division of Sleep Medicine
Professor of Medicine
Charles R. Cantor, MD, DABSM
Medical Director, Penn Sleep Centers
Clinical Associate Professor of Neurology
Maria Antoniou, MD, DABSM
Assistant Professor of Clinical Medicine
Eliot Friedman, MD
Instructor in Medicine
Philip Gehrman, PhD, CBSM
Assistant Professor of Psychiatry
Nalaka S. Gooneratne, MD, DABSM
Assistant Professor of Medicine
Indira Gurubhagavatula, MD, MPH
Assistant Professor of Medicine
Nirav Patel, MD
Assistant Professor of Clinical Medicine
Grace W. Pien, MD, MSCE, DABSM
Assistant Professor of Medicine
David M. Raizen, MD, PhD, DABSM
Assistant Professor of Neurology
Ilene M. Rosen, MD, MSCE, DABSM
Assistant Professor of Clinical Medicine
Sharon L. Schutte-Rodin, MD, DABSMD
Clinical Associate Professor of Medicine
Richard J. Schwab, MD, DABSM
Professor of Medicine
Sigrid C. Veasey, MD, DABSM
Associate Professor of Medicine
Mark Wu, MD, PhD
Instructor in Neurology
Access
Patient appointments are available at:
Penn Sleep Center
Hospital of the University of Pennsylvania***~
11th Floor, Gates Building
3400 Spruce Street
Philadelphia, PA 19104
Penn Sleep Center*~
3624 Market Street, Suite 201
Philadelphia, PA 19104
Pennsylvania Hospital*
800 Spruce Street
Philadelphia, PA 19107
Penn Medicine at Radnor**~
250 King of Prussia Road
2nd Floor
Radnor, PA, 19087
Penn Sleep Center at the Sheraton University City Hotel***~
36th & Chestnut Streets
Philadelphia, PA 19104
Penn Sleep Center at the Pavilion at Doyestown Hospital***
599 West State Street, Suite 101
Doylestown, PA 18901
Penn Sleep Center at the Hilton Homewood Suites***~
681 Shannondell Blvd.
Audubon, PA 19403
~ A facility of the Hospital of the University of Pennsylvania
* Indicates overnight sleep study site and sleep specialist site
** Indicates sleep specialist site
*** Indicates overnight sleep study site
To refer a patient and/or consult with a doctor:
Call 800-789-PENN (7366) or refer
a patient online.
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