By Sree Roy
In December 2024, sleep specialists cheered the US Food and Drug Administration (FDA) clearance of Zepbound (tirzepatide) for moderate-to-severe obstructive sleep apnea (OSA) in adults with obesity as the first prescription medicine for OSA. Now comes the challenge of deployment within a sleep medicine practice. Here are six ways to effectively implement glucagon-like peptide-1 agonists (commonly referred to as GLP-1s), including Zepbound, into sleep medicine.
1. Select appropriate patients.
At the risk of stating the obvious, I will say that sleep physicians should start by selecting only appropriate patients for GLP-1s—based on the FDA-approved indications, while screening for contraindications—and talking to those patients who are disappointed about their ineligibility.
Appropriate patients do not include those whose OSA develops for reasons unrelated to obesity, for example, due to anatomical issues.
“Patients might hear about it, but they might have a different endotype of their sleep apnea,” says Mira Tadros, DO, who has developed a new sleep obesity program at Mount Sinai, where she is an assistant professor of medicine (pulmonary, critical care, and sleep medicine) at the Icahn School of Medicine. “I’ve found that if I discuss the likely mechanism behind their sleep apnea—and if it’s not related to weight, then I explain that Zepbound might not be appropriate—these conversations tend to go well.”
For those OSA patients who are Zepbound candidates, the medicine can be a game-changer.
“I’m confident this [new FDA-approved indication] has been helpful to patients, if you choose the right ones,” says Rafael Sepulveda, MD, DABOM, the CEO and medical director of Sleep Fit Medical, a sleep and weight management center in Sonoma, Calif, adding that physicians must be “vigilant” for adverse events, particularly when a person is just starting on incretins.
2. Collaborate with other clinicians.
Because she is boarded in internal medicine, sleep, and obesity medicine, it might be assumed that Tadros would exclusively manage her OSA patients who are on Zepbound. However, Tadros very much collaborates with others. “Use the resources that you have. Talk to the patient’s primary care, their endocrinologist; refer them to a nutritionist,” Tadros says. “A multidisciplinary, patient-centered approach is really key.”
Tadros refers roughly 80% of OSA patients prescribed Zepbound to a nutritionist or dietitian to learn how to modify dietary habits to avoid gastrointestinal side effects. “We can cover this sometimes during the visit as well, but I like for them to have more of a comprehensive assessment with a nutritionist,” Tadros says. For select patients, such as those with limited mobility, she also refers them to a physical therapist to help them incorporate exercise safely.
3. Consider group appointments.
When neurologist-sleep specialist Sarah N. Zallek, MD, FAASM, FANA, FAAN, DipABLM, added lifestyle medication to her board certifications, interactions with the American College of Lifestyle Medicine enlightened her about group appointments.
“You might have a dozen patients or so in a two-hour shared medical appointment,” which works particularly well for cohorts of people implementing behavior change, says Zallek, vice president and chief medical officer for OSF HealthCare St. Joseph Medical Center in Bloomington, Ill. “So a sleep physician could, for example, have a busy sleep practice and add shared medical appointments.” This could be for patients on GLP-1s (or cognitive behavioral therapy for insomnia or any number of other cohorts)—allowing for a favorable reimbursement rate that still facilitates diligent monitoring of patients on GLP-1s and incorporates individual attention via breakout sessions.
4. Plan for follow-up sleep studies.
Though some may dream that GLP-1s mean never needing a device for their OSA, the reality is patients with moderate to severe OSA will simultaneously require another therapy, such as CPAP or an oral appliance, at least until they lose a percentage of their body weight.
Repeat sleep testing facilitates the dynamic process of therapy adjustment. “Sometimes if they feel like their weight has plateaued and they’re curious about their sleep apnea severity, repeating sleep testing to give the patient more information and more data to help them understand what’s going on is helpful,” Tadros says.
Sepulveda also does follow-up sleep testing based on factors including a patient’s baseline severity, clinical symptoms, and percent of total body weight lost (~10% loss is one indicator a repeat sleep study may be in order, he says). “It’s a negotiation and collaboration between the provider and the patient to figure out what’s best for them in the long run,” he says.
The American Academy of Sleep Medicine (AASM) does not have a clinical practice guideline specifically for obesity management in OSA patients. However, a 2021 clinical guidance statement on longitudinal management advises that a follow-up sleep study may be used if clinically significant weight gain or loss—defined as 10% to 20%—has occurred since diagnosis of OSA or initiation of treatment.
5. Add another board certification (if you want to).
While not essential, pursuing an extra professional development pathway is worthwhile for those interested in learning more about weight loss and OSA, according to several sleep specialists who have recently passed an additional board exam.
Zallek used the continuing medical education pathway to become boarded in lifestyle medicine while working “more than full-time” running a sleep center and being a hospital’s chief medical officer. “It was quick,” she says, noting she completed the entire process in nine months. She adds, “It would be really nice to have a cohort of sleep professionals there.”
Internal medicine-sleep specialist Sepulveda became board-certified in obesity medicine when he felt a gap between his weight loss recommendations to patients versus his self-described incomplete understanding of weight and OSA. “It’s very, very helpful in a lot of ways to have an obesity medicine certification,” Sepulveda says. Benefits include a better understanding of nutritional planning options; patients’ physical activities, capabilities, and goals; and behavioral modification, as well as strategies to avoid and manage adverse events linked to anti-obesity drugs.
6. Leverage physician education resources.
As having an FDA-approved drug therapy for OSA is a milestone achievement in sleep medicine, sleep specialists have the opportunity to leverage a slew of physician education resources on the trending topic.
This spring, the AASM plans to appoint a task force on obesity management to help develop practical resources and guidance for members. Its education committee will also host a webinar on novel drugs for OSA.
As the marketer of Zepbound, Eli Lilly also has numerous educational opportunities planned. Lilly will be at sleep conferences, including SEC Sleep and Wellness, ATS, AASM-SLEEP, AAO-HNS, ISSS, CHEST, and will host product theaters to educate healthcare providers on Zepbound.
Additionally, Lilly launched a site for healthcare providers about getting patients started with Zepbound and has a faculty of sleep thought leaders who will deliver peer-to-peer presentations to sleep health care providers.
“Lilly is committed to providing health care professionals with the necessary resources, so they can provide informed recommendations on available treatment options to better treat patients,” says Rhonda Pacheco, group vice president of Lilly cardiometabolic health, US.
It has been only a few months since Zepbound’s FDA approval for OSA. Now is an optimal time to learn how to deploy it appropriately to benefit sleep patients.
ID 296792907 © Oleschwander | Dreamstime.com
