Letters to the Editor
Obstructive Sleep Apnea Associated with Leg Edema
to the editor: In an otherwise comprehensive review of the causes and treatment of edema in American Family Physician, O'Brien and colleagues1 make no mention of idiopathic edema or sleep apnea. Several years ago, my colleagues and I identified idiopathic edema as the most common cause of bilateral leg edema in the primary care setting.2 More recently, we have shown that idiopathic edema is associated with obstructive sleep apnea in women.3 In addition, treating the obstructive sleep apnea reduces or eliminates the amount of swelling in patients who have obstructive sleep apnea and leg edema.4 This information may or may not have an impact upon the clinical care of patients with edema. The majority of my patients with obstructive sleep apnea and leg edema are not interested in treating the obstructive sleep apnea, primarily because they do not complain of excessive daytime sleepiness. Consequently, I often prescribe a diuretic to treat the leg edema, which is what many physicians do when their patients complain of leg edema with no apparent cause.
REFERENCES
1. O'Brien JG, Chennubhotla SA, Chennubhotla RV. Treatment of edema. Am Fam Physician 2005;71:2111-7.
2. Blankfield RP, Finkelhor RS, Alexander JJ, Flocke SA, Maiocco J, Goodwin M, et al. Etiology and diagnosis of bilateral leg edema in primary care. Am J Med 1998;105:192-7.
3. Blankfield RP, Ahmed M, Zyzanski SJ. Idiopathic edema is associated with obstructive sleep apnea in women. Sleep Med 2004;5:583-7.
4. Blankfield RP, Ahmed M, Zyzanski SJ. Effect of nasal continuous positive airway pressure on edema in patients with obstructive sleep apnea. Sleep Med 2004;5:589-92.
in reply: Idiopathic edema (IE) is a perplexing problem that may represent a contradiction in terms. In an extensive review of IE, Kay and Davis1 note that "no consensus has been reached as to underlying causes, management or even existence of IE." As Blankfield2 and others3 have noted, there are often underlying causes identified that would seem to be at odds with the label "idiopathic." In the study of bilateral leg edema referenced by Dr. Blankfield,2 IE was noted to be the most common cause of edema. However, there is no evidence that the patients identified met the criteria for IE, and the evaluation of the patients was probably not adequate to rule out all other causes. The number of patients in this study was small, and when no obvious cause was identified, the patients were labeled as having IE. We think it likely that what is identified currently as idiopathic edema, when subjected to extensive evaluation, will have discoverable underlying causes. In many instances, periodic, cyclical edema never reaches a threshold that results in an individual seeking medical help. Yet, many patients present with edema that must be treated. Our review recommended an approach that would address all types of edema, whatever the underlying cause.
REFERENCES
1. Kay A, Davis CL. Idiopathic edema. Am J Kidney Dis 1999;34:405-23.
2. Blankfield RP, Finkelhor RS, Alexander JJ, Flocke SA, Maiocco J, Goodwin M, et al. Etiology and diagnosis of bilateral leg edema in primary care. Am J Med 1998;105:192-7.
3. Thorn GW. Approach to the patient with "idiopathic edema" or "periodic swelling." JAMA 1968;206:333-8.
The Clinical Evidence Concise article "Urinary Tract Infection in Children" (September 1, 2005, page 858) contained an error in the editor's note on page 860. The editor's note stated "Co-trimoxazole is called trimethoprim and nitrofurantoin is called sulfamethoxazole in the United States," and should have read "Co-trimoxazole is called trimethoprim/sulfamethoxazole in the United States." The online version of this article has been corrected.
Send letters to Kenny Lin, M.D., Assistant Editor, American Family Physician, e-mail: afplet@aafp.org. Letters submitted via regular mail should be sent (on disk) to: 11400 Tomahawk Creek Pkwy., Leawood, KS 66211-6272.
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