T HREE STRIKES IS ENOUGH Karalyn J Huxhagen B Pharm FPS AACPA Cardiovascular Health Sleep Apnoea Diabetes

O BJECTIVES

A CRONYMS

K EY P RACTICE P OINTS Snoring and interrupted sleep are risk factors for type 2 diabetes Patients suffering from sleep disturbance, daytime drowsiness, who are obese or have diabetes, should be checked for OSA Management should initially focus on weight reduction (for overweight and obese patients), and improved sleep hygiene

K EY P RACTICE P OINTS CPAP may: improve glucose metabolism and glucose control improve blood pressure control in patients with refractory hypertension reduce risk of cardiac arrhythmias and heart failure

OSA IS OFTEN FOUND IN PATIENTS WITH : Cardiovascular disease Insulin resistance Type 2 diabetes Excess weight Central obesity is a strong risk factor for development of OSA

I NTERNATIONAL D IABETES F EDERATION (IDF) C ONSENSUS Screen for OSA in patients with metabolic disorders, as well as investigate patients who present with sleep disturbances for features of the metabolic syndrome. Take action to manage OSA or disrupted sleep.

IDF ESTIMATES Up to 40% of people with OSA will have diabetes Up to 23% of people with diabetes may have OSA Up to 58% of people with diabetes will have some form of SDB

M ETABOLIC S YNDROME People with metabolic syndrome are at higher risk of OSA People with OSA are more likely to have metabolic syndrome

H OW CAN OSA AFFECT GLUCOSE METABOLISM OSA causes intermittent short oxygen in the body (hypoxia) and/or sleep fragmentation This leads to a physiologic stress which may impact on glucose metabolism and enhance the development of insulin resistance

12 Sleep apnoea Hypoxia Inflammation Sleep loss Lifestyle Choices Elevated sympathetic activity Insulin resistance Diabetes Diabetic autonomic neuropathy Obesity Disordered appetite regulation Mechanical airway obstruction Pathways linking sleep loss to insulin resistance and diabetes

OSA AND CARDIOVASCULAR DISEASE OSA is an independent risk factor for the development of : Hypertension Stroke Heart failure Ischaemic heart disease Myocardial infarction

The prevalence of cardiovascular disease increases progressively with the increasing severity of obstructive sleep apnoea. People with known coronary disease and obstructive sleep apnoea have an increased risk of cardiovascular events and death. Hypertension associated with obstructive sleep apnoea may be relatively resistant to drug therapy.

CPAP TREATMENT Mixed results on glucose metabolism Some studies show a significant reduction in HbA 1c in people who had less than optimal control Improvement in CVD management May improve cardiovascular outcomes in people with heart failure

S UMMARY The major cause of OSA is upper airways obstruction The way in which it is manifest is dependent on arousal and respiratory responses The neuromuscular response is usually uniform Central sleep apnoea is due to instability of respiratory control Cardiovascular and metabolic effects of OSA (and CSA) are probably more important then respiratory or neurological effects