Comparable, Sustained Efficacy Observed With HNS vs PAP Therapy in OSA

Hypoglossal nerve stimulation (HNS) may be as effective, and in some cases superior, to standard-of-care positive airway pressure (PAP) therapy in the treatment of patients with obstructive sleep apnea (OSA), according to study findings published in JAMA Otolaryngology Head & Neck Surgery.

Although PAP therapy has been associated with improved symptoms of insomnia and even reduced blood pressure in patients with OSA, uptake has remained a significant issue. The researchers note that adherence reports estimate that 40% to 70% of patients prescribed PAP use the therapy less than is recommended for substantial therapeutic benefit.

As another FDA-approved therapeutic option for OSA, HNS has been shown to improve several OSA metrics and patient-reported outcomes (PROs), including sleep propensity and functional outcomes related to sleep.

“To our knowledge, the effect of HNS on comorbid insomnia and depression, which are often underrecognized in OSA, has not been reported or compared with that of PAP,” said the study authors.

They conducted a retrospective cohort study of data from patients with OSA treated at Cleveland Clinic to examine the long-term efficacy of HNS on patient-reported sleepiness, insomnia, and depression symptoms, and how these benefits compare with PAP treatment.

Participants were matched 3:1 based on age, body mass index (BMI), sex, and apnea hypopnea index (AHI) to receive either HNS (n = 85; mean [SD] age, 62.8 [9.5] years; 59 men [69.4%]; 77 White patients [90.6%]; mean [SD] BMI, 28.8 [3.1]), from November 1, 2015, to September 31, 2018, or PAP (n = 217; mean age, 62.1 [9.9] years; 157 men [72.4%]; 173 White patients [81.2%]; mean [SD] BMI, 29.5 [3.1]), from January 1, 2010, to December 31, 2014, for OSA.

OSA PROs of both groups were measured by AHI and the Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), Insomnia Severity Index (ISI), and Patient Health Questionnaire-9 (PHQ-9; depression) scores.

In their findings, significant improvements were observed in PHQ-9 scores for HNS vs PAP (least-square means [LSM], −4.06 [95% CI, −5.34 to −2.79] vs −2.58 [95% CI, −3.35 to −1.82]; mean difference, −1.48 [95% CI, −2.78 to −0.19]) in the 3-month follow-up compared with baseline scores. Further comparable improvements were seen between HNS and PAP for ESS, FOSQ, and ISI scores:

• ESS scores: Clinically meaningful differences were seen in 42 of 65 HNS group patients (64.6%) vs 118 PAP group patients (54.5%)
• FOSQ scores: Clinically meaningful differences were seen in 29 of 49 HNS group patients (59.2%) vs 67 of 217 PAP group patients (30.9%)
• PHQ-9 scores: Clinically meaningful differences were seen in 14 of 48 HNS group patients (29.2%) vs 53 of 217 PAP group patients (24.4%)
• ISI scores: Clinically meaningful differences were seen in 23 of 49 HNS group patients (46.9%) vs 79 of 217 PAP group patients (36.4%)

Statistically significant improvements with HNS therapy were maintained after 1 year for ESS in 17 of 28 patients (60.7%), FOSQ in 11 of 20 patients (55.0%), PHQ-9 in 7 of 23 patients (30.4%), and ISI in 11 of 25 patients (44.0%).

“In this cohort study of patients with OSA, sustained improvements in PROs were observed 1 year after HNS and were comparable to those for PAP at 3 months,” concluded the researchers. “These findings suggest that HNS is a viable treatment for improving insomnia and depression in patients with OSA.”

Reference

Pascoe M, Wang L, Aylor J, et al. Association of hypoglossal nerve stimulation with improvements in long-term, patient-reported outcomes and comparison with positive airway pressure for patients with obstructive sleep apnea. JAMA Otolaryngol Head Neck Surg. Published online November 11, 2021. doi:10.1001/jamaoto.2021.2245