What are the treatment options for sleep apnea?

Treatment of Sleep Apnea

First-Line Therapy

Continuous positive airway pressure (CPAP) is the recommended initial treatment for all patients diagnosed with obstructive sleep apnea (OSA), regardless of severity. 1 CPAP demonstrates superior efficacy in reducing the apnea-hypopnea index (AHI), arousal index, and oxygen desaturation while improving oxygen saturation compared to all other interventions. 2

Weight Loss as Concurrent First-Line Therapy

• All overweight and obese patients with OSA must be strongly encouraged to lose weight as part of their initial management. 1
• Weight reduction addresses the primary modifiable risk factor for OSA and shows a trend toward improvement in disease severity. 2
• For patients with moderate-to-severe OSA (AHI ≥15 events/hour) who have obesity (BMI ≥30) or are overweight (BMI ≥27) with weight-related comorbidities, tirzepatide (Zepbound) is now FDA-approved as the first pharmacologic agent specifically indicated for OSA treatment. 2
• Tirzepatide achieves mean weight loss of 15-20.9% at 72 weeks depending on dose (5-15 mg), substantially greater than other GLP-1 receptor agonists. 2
• Initiate tirzepatide alongside CPAP therapy rather than as monotherapy, since CPAP remains the gold standard for reducing respiratory events. 2

Alternative Therapies for CPAP Intolerance

Mandibular advancement devices (MADs) should be prescribed as first-line alternatives for patients who refuse CPAP, cannot tolerate CPAP due to adverse effects (discomfort, skin irritation, noise, claustrophobia), or prefer oral appliances. 1

• MADs are particularly appropriate for mild to moderate OSA. 2, 3
• Evidence suggests adherence to MADs may be superior to CPAP adherence in some patients. 3
• Recent data indicate MADs may provide similar cardiovascular mortality prevention compared to CPAP, though objective adherence measurement was not available in these studies. 3

Additional Behavioral Interventions

For Central Sleep Apnea Specifically

• Weight reduction is recommended for overweight patients with central sleep apnea. 4
• Avoidance of alcohol and sedatives before bedtime helps manage central sleep apnea. 4

Positional Therapy

• Consider positional therapy only for patients with predominantly positional OSA (apneas occurring primarily in supine position). 5
• Positional therapy is inferior to CPAP and has poor long-term compliance, making it a weak alternative. 2

Surgical Interventions

• Upper airway surgery remains a second- or third-line treatment for moderate to severe OSA after failure of CPAP and MADs. 3
• Maxillomandibular advancement (MMA) shows considerable, statistically significant improvements in AHI in multiple case series. 3
• Exercise great caution with surgical procedures in elderly patients due to increased risk of complications. 5

What NOT to Do

Do not prescribe pharmacologic agents (other than tirzepatide for weight loss) as primary OSA treatments, as they lack sufficient evidence of efficacy. 2

• Antidepressants and respiratory stimulants tested for OSA treatment have been found ineffective or cause tolerance and serious adverse effects. 5
• Acetazolamide may have limited adjunctive use for high-altitude travelers specifically. 3
• Carbonic anhydrase inhibitors are recommended only in research contexts due to limited evidence. 2

Monitoring and Follow-Up

• Regular follow-up with objective monitoring of treatment outcomes is essential to assess treatment efficacy. 4
• Monitoring CPAP adherence is critical for effective OSA treatment and cardiovascular risk reduction. 2
• Objective adherence monitors are now available for oral appliances and should be utilized clinically. 3

Common Pitfalls to Avoid

• Do not rely on lifestyle modifications alone for weight loss in obese OSA patients—historically this has been difficult to achieve and maintain without pharmacologic or surgical intervention. 2
• Do not discontinue tirzepatide once initiated, as discontinuation leads to weight regain (mean 6.9% regain after stopping). 2
• Screen for gallbladder disorders and monitor for cardiac arrhythmia/tachycardia in patients on tirzepatide. 2
• Avoid tirzepatide in patients with gastroparesis due to further delayed gastric emptying. 2
• Consider delayed gastric emptying effects when planning anesthesia in patients on tirzepatide, though aspiration risk with chronic use remains uncertain due to potential tachyphylaxis. 2