Water pills confer benefits to overweight, obese OSA patients with hypertension

Diuretics appear to be useful in the treatment of obstructive sleep apnoea (OSA) in overweight or moderately obese patients with hypertension, producing reductions in OSA severity, body weight and blood pressure, as reported in a recent study.

“These findings provide further evidence that fluid redistribution from the legs to the neck during sleep contributes to the severity of OSA in patients with hypertension and may be a significant link between these two conditions. Thus, an association between diuretic use and decreased severity of OSA in overweight or moderately obese and/or hypertensive patients has been shown,” the investigators said.

A propensity score analysis was performed using data from the French national sleep apnoea registry involving 69,564 OSA patients (median age, 56.9 years; 67 percent male; median Apnoea–Hypopnoea Index [AHI], 28 events/h). The matched population comprised 42,565 patients, among whom 8,513 received diuretics and 34,052 did not.

Diuretic treatment had no effect on OSA severity in the overall population. However, it was associated with a lower likelihood of having severe OSA (AHI >30 events/hour) in subgroups of patients who were overweight (body mass index [BMI] 25–30 kg/m²; odds ratio [OR], 0.90, 95 percent confidence interval [CI], 0.82–0.99; p=0.03) or moderately obese (BMI 30–35 kg/m²; OR, 0.91, 95 percent CI, 0.82–1.00; p=0.03) and those with hypertension (OR, 0.84, 95 percent CI, 0.78–0.91; p<0.01). [Chest 2020;doi:10.1016/j.chest.2020.01.050]

The effect was more pronounced in hypertensive patients who were overweight (OR, 0.81, 95 percent CI, 0.71–0.92; p<0.01) or moderately obese (OR, 0.83, 95 percent CI, 0.73–0.95; p<0.01).

Meanwhile, diuretics did not yield any benefits in patients with self-reported low physical activity or heart failure.

“Our results confirm three previous studies reporting an improvement of OSA in hypertensive patients treated by diuretics… In general, in these studies the impact of [the drugs] was moderate with the mean AHI reduction varying from 7 to 17 events/hour,” the investigators noted. [J Hum Hypertens 2010;24:532–537; J Hypertens 2014;32:673–680; Sleep 2018;doi:10.1093/sleep/zsy016]

“A major goal for personalized and precision medicine in the OSA field is to combine therapies appropriate for specific well-defined OSA phenotypes. Combinations of therapies can include continuous positive airway pressure…, lifestyle interventions (weight loss and exercise), and pharmacological interventions targeting OSA-related conditions,” they continued. [Lancet Respir Med 2019;7:456-464; PloS One 2016;11:e0157318]

The investigators called for additional investigations to validate the current findings and identify the specific class of diuretics that provides the most benefit in the following pathophysiological patient phenotype: overweight or moderately obese patients with OSA and hypertension.

The present study had several limitations, including the failure to record the duration, dosage and indication for a diuretic at the time of AHI measurement, as well as the lack of information on renal disease that might have influenced the use of water pills, particularly in subgroups of chronic heart failure patients.