By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is an advisor for Endo, Kowa, Pricara, and Takeda.
Are OSA Outcomes Better in the Hands of Sleep Specialists than Primary Care Clinicians?
Source: Chai-Coetzer CL, et al. Primary care vs specialist sleep center management of obstructive sleep apnea and daytime sleepiness and quality of life: A randomized trial. JAMA 2013;309:997-1004.
The recognition of obstructive sleep apnea (OSA) as a health burden of compelling epidemiologic presence with significant impact on both quality of life and cardiovascular health has been recognized by health care providers of essentially all disciplines. Increasingly, sophisticated sleep laboratory monitoring devices allow ever more detailed (and usually more costly) understanding of sleep dysregulation. At the same time, awareness of the frequency and consequences of OSA among diverse disciplines of medicine has resulted in a sufficiently burgeoning population of individuals who merit screening that sleep labs are often unable to keep pace with the increasing demand.
A proliferation of simpler, home-based tools for the identification and potential management of OSA that can be used by sleep specialists and primary care clinicians alike has prompted the question of whether outcomes for OSA patients attended by sleep specialists (who are usually not primary care clinicians), typically with complex sleep analysis tools (which are most commonly employed in a specific sleep laboratory), are superior to outcomes for patients attended by primary care clinicians with less sophisticated home-based tools.
The authors report on a randomized, controlled, non-inferiority trial of patients with OSA identified and treated either in a university sleep laboratory by sleep specialists or by community primary care practices. The primary outcome was improvement in the Epworth Sleepiness Scale, a commonly used and validated scoring system for monitoring sleepiness associated with OSA.
At the end of the 6-month trial, scores on the Epworth Sleepiness Scales were identical in both groups, and outcomes in the primary care group were determined to be non-inferior to sleep specialist care. Hopefully, primary care clinicians will become more involved in the identification and management of OSA, since equally salutary outcomes are seen in their hands as in the hands of sleep specialists.
Inhaled Steroids Increase Risk of TB in COPD Patients
Source: Kim J, et al. Inhaled corticosteroid is associated with an increased risk of TB in patients with COPD. Chest 2013;143:1018-1024.
Reactivation of Tuberculosis (TB) is an ongoing concern among patients who receive immunosuppressive agents such as TNF-alpha agents for rheumatoid arthritis. Similarly, long-term use of systemic steroids (i.e., ≥ 30 days) in amounts as small as 7.5 mg/day of prednisone increases the risk of TB. Inhaled corticosteroids (ICS) have been associated with systemic effects such as growth retardation (in asthma), reduced bone mineral density, and increased risk of pneumonia (in chronic obstructive pulmonary disease [COPD]). Whether ICS might also be associated with risk for development or reactivation of TB has not been fully clarified.
Kim et al performed a retrospective analysis of COPD patients (n = 620) in a university hospital in South Korea (where the background prevalence of TB is substantially greater than many other nations) to compare the rate of TB activation in persons who had received ICS with controls. To eliminate the confounding factor of systemic steroid use, COPD patients who had received ≥ 7.5 mg for 1 month or more were excluded from the analysis.
There was a substantially greater and statistically significant risk for development of active TB among COPD patients who had been treated with ICS (hazard ratio = 9). In patients whose baseline chest x-ray showed evidence of prior (but quiescent) TB, the hazard ratio for activation of TB was 25!
Although the prevalence of TB is much greater in Korea than in the United States, these data suggest greater vigilance for TB activation in patients chronically using ICS, especially if their x-rays indicate evidence of prior TB.