REBUTTAL FROM DRS. DAVIES AND STRADLING

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We agree there is debate about the efficacy of treatment for minor obstructive sleep apnea (OSA) and large studies capable of accurately defining the cost/health benefit ratio for treating mild disease are clearly required. However, this does not weaken the argument for the treatment of substantial disease, any more than the absence of evidence for treating minor bronchial hyperreactivity weakens the case for treating clinically overt asthma. The evidence relevant to the treatment of substantial disease comes from trials in clinic patients and not from epidemiological surveys, as Drs. Wright and Sheldon imply. Such trials establish that the excessive daytime sleepiness and quality of life impairment are due to the OSA and improve substantially with nasal continuous positive airway pressure (nCPAP) treatment, and that this is not a placebo effect. It is also wrong to suggest that robust trials have examined only "fairly severe" OSA. Trials using tablet placebos have been performed in patients with mild disease and, although these could be complemented by sham nCPAP studies, the best available evidence currently favors efficacy in these patients.

We agree that clarifying the roles of differing therapeutic modalities is important (and such clarification is indeed happening), and support the call for appropriately trained specialists capable of giving balanced "evidence-based" advice.

Weight loss does have a role and, resources allowing, it should be part of any sleep apnea clinic. However, it is at best a slowly active therapy and thus an inappropriate first choice for patients with disabling symptoms, impaired driving skills, and an increased risk of motor accidents. These problems rapidly improve with nCPAP and the alternative, to remove a patient's driving license and perhaps their livelihood for a year or two while dieting, is not good health economics. Such a clinical response would also tend to dissuade professional drivers from seeking help and thus receiving appropriate therapy.

In conclusion, we agree there are important questions still to be answered about OSA, although this is also true of almost every other disease. However, this debate is about nCPAP for substantial symptomatic OSAS, where the case for efficacy is unassailable.