Alternative Therapies for Patients Who Understand But Choose Not to Use CPAP
For patients who understand the benefits of CPAP but choose not to use it, custom-made dual-block mandibular advancement devices should be offered as the first-line alternative therapy, with other options including positional therapy, weight loss, maxillo-mandibular osteotomy, or hypoglossal nerve stimulation based on specific patient factors. 1
First-Line Alternative: Oral Appliance Therapy
Custom Mandibular Advancement Devices
- Custom, titratable oral appliances are superior to non-custom devices for treating OSA 1
- Most effective for patients with mild to moderate OSA
- Reduces AHI, arousal index, and oxygen desaturation index
- Potential side effects include dental changes (decreased overbite and overjet), TMJ pain, and gingival irritation 1
- Requires management by a qualified dentist for proper fit and adjustments
Second-Line Alternatives
Positional Therapy
- Effective for patients with positional OSA (where breathing events occur primarily when sleeping on back)
- Simple interventions include positional alarms or specialized pillows
- Less invasive than surgical options
Weight Loss
- Particularly important for overweight/obese patients
- Can significantly reduce OSA severity or eliminate it entirely in some cases
- Should be recommended alongside other treatments
Surgical Options
Maxillo-Mandibular Osteotomy (MMO)
- The European Respiratory Society conditionally recommends MMO as an alternative to CPAP 1
- Comparable effectiveness to CPAP in reducing AHI (from 56.8 to 8.1 events/h with MMO vs. 50.3 to 6.3 events/h with CPAP)
- Most appropriate for younger patients with high AHI who are willing to undergo surgery
- Requires consideration of potential adverse effects including need for additional orthodontic work 1
Hypoglossal Nerve Stimulation
- Emerging therapy for moderate to severe OSA
- Involves implanting a device that stimulates the hypoglossal nerve during sleep
- Best suited for patients with specific anatomical features
Pharmacological Options
Carbonic Anhydrase Inhibitors
- The European Respiratory Society conditionally recommends carbonic anhydrase inhibitors for adult OSA patients 1
- Medications include acetazolamide, zonisamide, and topiramate
- Can reduce AHI by up to 45% in unselected groups
- Improves oxygenation but limited evidence for effect on daytime sleepiness
Considerations When Selecting Alternatives
Patient Factors That Influence Treatment Selection
- Age: Older patients have higher risk of CPAP intolerance due to nasal/pharyngeal side effects 2
- OSA severity: Patients with less severe OSA are more likely to discontinue CPAP treatment 2
- Previous surgeries: Patients who have undergone UPPP are less likely to experience clinical improvement with CPAP 2
- Anatomical considerations: Facial structure affects suitability for different interventions
Monitoring and Follow-up
- Regular assessment of treatment efficacy is essential regardless of chosen therapy
- Objective monitoring of symptoms and sleep quality
- Evaluation of impact on comorbidities (hypertension, diabetes)
Common Pitfalls to Avoid
- Assuming all alternatives are equally effective: CPAP remains the gold standard, with alternatives generally showing lower efficacy
- Neglecting to address underlying factors: Weight management and sleep hygiene remain important regardless of chosen therapy
- Inadequate follow-up: All alternative therapies require monitoring to ensure adequate treatment of OSA
- Overlooking combination therapy: Some patients may benefit from combining approaches (e.g., oral appliance plus weight loss)
- Failing to reassess: OSA severity can change over time, requiring periodic reevaluation of treatment efficacy
By providing patients who decline CPAP with effective alternatives, clinicians can still significantly reduce the morbidity and mortality associated with untreated obstructive sleep apnea while respecting patient preferences and improving quality of life.