Both Promise and Concern for OSA and CPAP with GLP-1s
Will the weight reduction success with glucagon-like peptide-1 (GLP-1) agonists translate into strong reductions in obstructive sleep apnea (OSA)? Will those potential OSA benefits obviate the need in many for continuous positive airway pressure (CPAP)?
“I think it’s a game changer for helping people who are overweight or obese,” Samuel T. Kuna, MD, chief of sleep medicine at the Corporal Michael J. Crescenz VA Medical Center in Philadelphia, said in an interview with CHEST Physician. “I think we’re just starting out on a very exciting new era. We finally have quite effective treatments for this population.” Dr. Kuna’s Sleep AHEAD (Action for Health in Diabetes) 2021 study (doi: 10.1164/rccm.201912-2511OC) found that participants with OSA and type 2 diabetes mellitus receiving intensive lifestyle interventions for weight loss had reduced OSA severity at 10 years, and that OSA remission at 10 years was more common with intensive lifestyle intervention than with diabetes support and education.
Potential for OSA impact
In a JAMA Network Open/Pulmonary Medicine article on a 2022 study (doi: 10.1001/jamanetworkopen.2022.8212) conducted among 89 Spanish male adults with moderate to severe OSA and body mass index of 25 or greater, participants received CPAP therapy with or without 8 weeks of weight loss and lifestyle intervention. The primary endpoint of apnea-hypopnea index at 6 months showed the intervention to yield “clinically meaningful and sustainable improvements in OSA.”
Dr. Kuna stated, “I don’t think these [weight loss] agents eliminate the importance of behavioral modification, of changing diet, of reducing highly processed foods and maintaining a healthy lifestyle.” He acknowledged, however, that behavioral endeavors have been in general disappointing with respect to patients’ ability to achieve weight loss. “These medicines really open up a new strategy to help patients do that,” he added.
Dr. Kuna pointed to a recent (2023) Grunstein et al. perspective article (doi: 10.1093/sleep/zsad224) published in Sleep citing phase 3 trial results showing placebo-subtracted weight loss percentages. With subcutaneous (SC) semaglutide 2.4 mg they were 12.6% in patients with obesity or overweight with one or more weight-related comorbidities (but not type 2 diabetes), and 17.8% with tirzepatide (15 mg, SC, weekly), a combination GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, in a similar population. The authors stated, “These new agents, provided they are available to persons who need them most — who are often socioeconomically disadvantaged — could revolutionize the management of obesity and its many complications, including OSA.” Grunstein et al. also, noted that the number of studies showing improvement in cardiometabolic outcomes (eg, blood pressure) with pre-incretin OSA therapies are “minimal.” They underscored, however, the need for risk/benefit/cost-effectiveness data on incretin therapies, and cited evidence that withdrawal from incretin treatment brings back weight gain and adverse cardiometabolic factors. They also indicated key areas of uncertainty requiring research: gender-based response differences to incretins (women predominate in most weight loss studies, but OSA is more common in men), how CPAP users will adapt to incretin OSA benefits, direct comparisons of impact on OSA with incretins vs mechanical therapy, and understanding which target populations derive the most benefit with incretin therapies.
Despite the unanswered questions, the direction was unequivocally clear for Grunstein et al.: “Ultimately, the focus must shift away from mechanical therapy for obesity-related OSA towards weight loss, the latter which is likely to produce multiple health outcome improvements that are superior, including all-cause mortality.”
Dr. Kuna agreed with the Sleep article authors that one implication of this “incretin revolution” is that sleep physicians will have to broaden their skills to encompass obesity management. “As the field evolves, perhaps we should start training our fellows about how to manage these patients,” Dr. Kuna said.
