ACP issues recommendations for treating obstructive sleep apnea

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People diagnosed with obstructive sleep apnea (OSA) should not consider surgery, according to new recommendations from the American College of Physicians (ACP). Instead, ACP recommends that patients lose weight and use continuous positive airway pressure (CPAP) as initial therapy. More than 18 million American adults have sleep apnea, which increases the risk of high blood pressure, heart attack, stroke, heart failure, and diabetes and increases the chance of driving or other accidents. Sleep apnea is a leading cause of excessive daytime sleepiness. The most common type of sleep apnea is OSA, a condition in which the airway collapses or becomes blocked during sleep causing shallow breathing or breathing pauses lasting from a few seconds to minutes. The evidence shows that the incidence of OSA is rising, likely because of the increasing rates of obesity. A CPAP machine helps because it uses mild air pressure delivered through a face mask to open airways and keep them from collapsing or becoming blocked. However, for patients who do not tolerate or comply with CPAP treatment, ACP recommends a mandibular advancement device (MAD) as an alternative therapy. The available evidence was limited on treating OSA with surgery, which is associated with serious adverse events and should not be used as initial treatment. ACP developed the guideline based on a systematic evidence review sponsored by the Agency for Healthcare Research and Quality.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. For an interview with an author, contact Steve Majewski at smajewski@acponline.org or 215-351-2514.

Chronic exposure to low to moderate levels of inorganic arsenic is associated with increased incidence of fatal and not-fatal cardiovascular disease. Inorganic arsenic in water and food (particularly rice and grain) is a major global health problem. Research has shown that high arsenic levels in drinking water increase the risk of peripheral artery disease, coronary heart disease, stroke, and carotid atherosclerosis. However, less is known about the cardiovascular effects of low to moderate arsenic levels, an issue that affects most populations around the world. In the United States, people living in small rural communities in the Southwest, Midwest, and Northeast are disproportionately exposed to inorganic arsenic. Researchers analyzed urine samples for 3,575 American Indian men and women living in Arizona, Oklahoma, and North and South Dakota to evaluate the prospective association of chronic low to moderate arsenic exposure with incident cardiovascular disease over almost 20 years follow-up. They found that baseline urine arsenic concentrations were prospectively associated with cardiovascular disease mortality and incidence (1,184 developed fatal and non-fatal cardiovascular disease and 439 developed fatal cardiovascular disease). The researchers conclude that low to moderate arsenic exposure is an important risk factor for cardiovascular disease with no apparent threshold.

Note: For an embargoed PDF, please contact Megan Hanks or Angela Collom. For an interview with an author, please contact Natalie Wood-Wright at nwoodwri@jhsph.edu or 410-614-6029.

The United States Preventive Services Task Force (USPSTF) recommends against using medications such as tamoxifen or raloxifene for reducing the risk of primary breast cancer in average risk women, as the risks associated with these medications outweigh the potential benefits. Doctors should discuss the benefits and harms of these treatments and offer to prescribe them to women who are at high risk for breast cancer and low risk for adverse reactions. In high-risk populations, the benefits may outweigh the risks. This recommendation reaffirms Task Force's 2002 recommendation and provides updated evidence on the risks and benefits of risk-reducing medications for women who are at increased risk for breast cancer. To update its previous recommendations, the Task Force reviewed evidence published through December 2012. In placebo-controlled trials, both tamoxifen and raloxifene reduced the incidence of invasive breast cancer over the five-year treatment period, and both medications reduced fractures. In head-to-head trials, tamoxifen had greater effect at reducing invasive breast cancer than raloxifene, but also was associated with more thromboembolic events, endometrial cancer, and related gynecologic outcomes and cataracts compared with placebo and raloxifene.

Note: For embargoed PDFs please contact Megan Hanks or Angela Collom. For an interview, please contact Nicole Raisch at nicole.raisch@edelman.com or 202-572-2044.

The American College of Physicians (ACP) has written a brief to explain how health exchanges, or health insurance marketplaces, will work when the Affordable Care Act begins to roll out late this year. By 2014, most individuals who do not have health insurance will have to acquire health insurance or pay a fine. The marketplaces were created under the ACA with the hope of enabling individuals to objectively compare private health plans that meet the minimum standards set by the government and also meet their budget and health needs. Legal residents without access to affordable, comprehensive insurance, and business with up to 100 employees can access the marketplaces online, via toll free number, or in person to research and purchase an appropriate health benefits package. To meet government standards, a health package must have services in 10 benefit categories, including hospitalization, outpatient care, prescription drug coverage, and preventive and wellness and chronic disease management. The goal of marketplace-based coverage is to limit out-of-pocket costs and provide essential health benefits without restricting coverage or varying premiums based on health conditions.

Note: For an embargoed PDF or an interview, please contact Megan Hanks or Angela Collom.