SURMOUNT-OSA Shows Tirzepatide is Effective for Treating Sleep Apnea

Atul Malhotra, MD, professor of pulmonology critical care and sleep medicine at the University of California San Diego, discusses the results of SURMOUNT-OSA on the weight loss drug tirzepatide (Mounjaro, Zepbound; Eli Lilly) for treating sleep apnea. The study found that tirzepatide significantly improved patients' apnea hypopnea index, a measure of sleep apnea severity, compared to placebo. Secondary outcomes like blood pressure, C-reactive protein levels, and patient-reported symptoms also significantly improved. While CPAP is still the first-line treatment, Malhotra notes tirzepatide is also an effective option and can help patients achieve weight loss and management of both conditions.

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Q: The SURMOUNT-OSA trials investigated the use of tirzepatide for treating obstructive sleep apnea in adults with obesity. Can you elaborate on the primary endpoints and the key findings presented at the ADA conference?

Atul Malhotra: The apnea hypopnea index is the number cessations plus reductions in breathing per hour of sleep, and that's the usual standard for measuring sleep apnea severity. The more avenues and hypopnea they have, the more disrupted sleep you have, and the more complications you have, but as I mentioned, it's a loose predictor of complications, you can have mild sleep apnea and have severe complications, you can have severe sleep apnea and have no symptoms at all, and everything in between. There's a general consensus that you have to hypopnea index is good, but not great. It's the best we have, but i's not perfect. It's also not patient centered, and since it doesn't capture symptoms, it doesn't capture susceptibility to disease risk and these kinds of things. That was our primary outcome, and it did significantly improve with tirzepatide versus placebo. But quite reassuringly, the secondary outcomes improved concurrently, and so hypoxic burden, C reactive protein, systolic blood pressure, patient reported outcomes, all these things got better, quite markedly suggesting we're not just making a number look better, but we're actually improving the health of the patient.

Q: Many patients struggle with adherence to PAP therapy. Could a medication like tirzepatide offer a more accessible or convenient option for managing OSA?

Atul Malhotra: There are 2 arms of the study: study 1 included patients who were not on CPAP, either because they refused or didn't tolerate it. And study 2 included CPAP patients. In both cases, they're randomized either to tirzepatide or placebos. So, even though it's tempting to make the comparisons, there's no direct comparison between tirzepatide and CPAP. And so it's not comparative effective research, we're comparing two active therapies to see which one's better. So I believe the standard of care hasn't changed. CPAP is still first line therapy for sleep apnea, even though we now have compelling evidence that there's tirzepatide is also good treatment for sleep apnea and associated cardio-metabolic complications. Here's the CPAP is actually quite good. We published about 5 years ago, big data analysis from the cloud, suggesting that up to 87% of patients are adherent with CPAP based on us Medicare criteria, and blows away most other chronic medical therapies be inhaler use asthma, and I think a defeatist attitude about CPAP is really not justified. On the other hand, there are many people who were in the CPAP machines ignoring body weights. I think, as I say, for some time, it's been standard of care to treat both sleep apnea and body weight. And we now have a more effective way of addressing them. Diet and exercise, these things have always been recommended, but not always adhered to, and so with tirzepatide treatment, improvements and body weight are consistently achievable.

Q: Sleep apnea often co-occurs with other conditions like diabetes. Are there plans to investigate the combined effects of tirzepatide on both OSA and diabetes?

Atul Malhotra: We didn't study that. I don't know if their future studies planned in that context. You're right, diabetics were excluded from this particular study, and so the improvements we're seeing patients with sleep apnea and obesity are relevant to that population without diabetes, for whatever reason patients with diabetes with tirzepatide or any GLP-1 therapy, usually less than diabetics versus non diabetics. The reasons for that are unclear. I'm married to an endocrinologist deep into revenue hold, we try to figure this out together, the answers I don't know. There are variety theories about why there's less weight loss in people with diabetes and without but the answer right now is no.