Weight loss and bariatric surgery
Obesity is a common, reversible risk factor for OSA. However, not all obese individuals develop OSA (typically those with robust upper airway reflexes). Improvements in weight appear to correlate with reductions in tongue fat, which correlate to AHI reduction. Weight loss also creates lower CPAP requirements for many individuals, conceivably improving tolerability. Ongoing work is seeking to understand whether there are changes in upper airway muscle recruitability as well as other change in endotype traits following weight loss surgery.
Pharmacotherapy for OSA
There is a great deal of promise in tailoring pharmacotherapy to individual sleep traits. Acetazolamide, for instance, results in improvements an AHI for both obstructive and central sleep apnea through changes in chemosensitivity and is generally well-tolerated (Schmickl CN, et al. Physiol Rep. 2021;9[20]:e15071). Eszopiclone has been used to raise the arousal threshold for those who awaken from breathing events too easily. With added time, individuals with a low arousal threshold can more effectively recruit upper airway dilator muscles without waking up. Pharmacotherapy to improve upper airway recruitability with combination noradrenergic stimulation and antimuscarinic activity has limited data thus far but may be a useful part of the sleep armamentarium moving forward.
Summary
OSA is a public health priority, and the current global CPAP shortage emphasizes the need for alternative OSA therapies. The ideal therapy for a given patient requires a careful consideration of their individual traits and will be much more refined when endotyping is available in a routine clinical setting. Individualized sleep apnea treatment is the future of sleep medicine and a one-size fits all approach no longer meets the needs of our patients given the current state of sleep medicine knowledge.
Dr. Nokes, Dr. Schmickl, and Dr. Malhotra are with the University of California, San Diego, Division of Pulmonary, Critical Care, and Sleep Medicine, La, Jolla, CA. Dr. Nokes also is with the Veterans Affairs San Diego Healthcare System, sleep section, San Diego, CA. Dr. Vahabzadeh-Hagh is with the University of California, San Diego, Department of Otolaryngology, San Diego, CA.