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Published by Department of Veterans Affairs and Department of Defense · GRADE
This clinical practice guideline provides evidence-based recommendations for the screening, diagnosis, and management of chronic insomnia disorder and obstructive sleep apnea (OSA) in adult patients. It emphasizes objective diagnostic testing, prioritizes cognitive behavioral therapy for insomnia (CBT-I) as a first-line treatment for chronic insomnia, and advocates for positive airway pressure (PAP) and mandibular advancement devices (MAD) as initial therapies for OSA. The guideline heavily incorporates shared decision-making and patient-centered care.
Key Takeaways
Updated Algorithm; Reviewed studies focused on specific outcomes to include critical outcomes of adoption of therapy, insomnia severity, and sleep efficiency; Added nine new recommendations; seven reviewed and replaced, eleven amended, and two no change; Used more rigorous application of GRADE methodology; Updated Provider Guide to Sleep Education; Updated Research Priorities.
For screening of patients with sleep complaints, we suggest using validated screening instruments for both insomnia (e.g., Insomnia Severity Index or Athens Insomnia Scale) and obstructive sleep apnea (e.g., STOP) to identify patients who need further evaluation.
For diagnosis of clinically suspected obstructive sleep apnea, we recommend diagnosis with polysomnography or home sleep apnea testing.
For diagnosis of obstructive sleep apnea in appropriate patients, we suggest home sleep apnea testing as an alternative to in-laboratory polysomnography.
For diagnosis of patients with a non-diagnostic home sleep apnea test, we recommend further sleep testing for obstructive sleep apnea with in-lab polysomnography or HSAT.
For treatment of chronic insomnia disorder, we recommend treatment with CBT-I.
For treatment of chronic insomnia disorder, we suggest treatment with BBT-I.
For treatment of chronic insomnia disorder, we suggest against sleep hygiene education as a stand-alone treatment.
For treatment of chronic insomnia disorder, we suggest CBT-I over pharmacotherapy as first-line treatment.
For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, we suggest the use of one of the following agents: Daridorexant, Doxepin, Eszopiclone, Lemborexant, Suvorexant, Zaleplon, Zolpidem.
For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, we suggest against the use of: Antipsychotic drugs, Benzodiazepines, Diphenhydramine, Trazodone.
For treatment of chronic insomnia disorder in patients who are offered a course of pharmacotherapy, there is insufficient evidence to recommend for or against the use of ramelteon.
For treatment of chronic insomnia disorder, we recommend against the use of kava.
For treatment of chronic insomnia disorder, we suggest against the use of cannabis and/or its derivatives.
For treatment of chronic insomnia disorder, we suggest against the use of: Chamomile, Melatonin, Passionflower, Saffron, Valerian.
For treatment of chronic insomnia disorder, there is insufficient evidence to recommend for or against the use of magnesium.
For treatment of chronic insomnia disorder, there is insufficient evidence to recommend for or against: Aerobic exercise, Mindfulness meditation, Qigong, Resistive exercise, Tai chi, Yoga.
For treatment of obstructive sleep apnea, we recommend one or more of the following evidence-based therapies, depending on patient values and characteristics: Mandibular advancement devices, Positive airway pressure (PAP), Referral for surgical evaluation.
For treatment of mild to moderate obstructive sleep apnea (Event Index <30 per hour), we suggest either mandibular advancement devices or positive airway pressure as first line therapy options.
For treatment of newly diagnosed obstructive sleep apnea, we suggest initiating auto-titrating over fixed continuous positive airway pressure to facilitate usage.
For treatment of obstructive sleep apnea in patients with overweight or obesity, we suggest evidence-based weight management in combination with other treatments for obstructive sleep apnea.
For treatment of positional obstructive sleep apnea, we suggest positional therapy.
For treatment of obstructive sleep apnea in appropriate patients (including with an apnea hypopnea index of 15 or greater per hour) who have not been successful with positive airway pressure therapy, we suggest referral for evaluation for hypoglossal nerve stimulation therapy.
For treatment of obstructive sleep apnea in patients who cannot tolerate other recommended therapies, we suggest against oxygen therapy as a standalone treatment.
For treatment of obstructive sleep apnea, we suggest against atomoxetine or a combination of atomoxetine and oxybutynin.
For treatment of obstructive sleep apnea there is insufficient evidence to suggest for or against these interventions: Expiratory positive airway pressure (EPAP), Inspiratory muscle therapy, Intra-oral negative airway pressure, Myofunctional exercise, Neuromuscular electrical stimulation, Transcutaneous electrical nerve stimulation (TENS).
For treatment of obstructive sleep apnea in patients who are prescribed positive airway pressure therapy, we suggest the use of in-person or telehealth educational, behavioral, and supportive interventions to improve PAP usage.
For treatment of obstructive sleep apnea in appropriate patients, we suggest up to a two-week course of eszopiclone to improve positive airway pressure usage.
For treatment of obstructive sleep apnea in patients with anatomical nasal obstruction as a barrier to positive airway pressure use, we suggest evaluation for nasal surgery.
For treatment of obstructive sleep apnea-related residual excessive daytime sleepiness in patients who are optimally treated with sufficient therapy use, we suggest adding: Armodafinil, Modafinil, Solriamfetol.
Clinical Topic
Chronic Insomnia Disorder and Obstructive Sleep Apnea
Objectives
To provide healthcare providers with a framework by which to evaluate, treat, and manage the individual needs and preferences of patients with sleep disorders, specifically chronic insomnia disorder and obstructive sleep apnea, thereby leading to improved clinical outcomes.
Target Patient Population
Adult patients with chronic insomnia disorder and/or obstructive sleep apnea
Diagnostic Criteria
Chronic insomnia disorder: Difficulty initiating or maintaining sleep at least 3 nights per week for over 3 months, causing daytime impairment. OSA: At least 5 predominantly obstructive respiratory events per hour of sleep (with symptoms) or 15+ events per hour (regardless of symptoms) measured via polysomnography or HSAT.
Target Providers
Therapeutic Area
Sleep MedicineGuideline Scope
Inclusion Criteria
Exclusion Criteria
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Contraindications
Monitoring Guidance
Providers should actively monitor treatment adherence, especially for PAP and MAD therapies (e.g., assessing device data downloads and side effects). If prescribing medications like non-BZD BzRAs or antipsychotics, monitor for metabolic parameters and complex sleep-related behaviors.
Difficulty
advanced
Estimated Read Time
180 minutes
Exam Relevance
Learning Paths