Rethinking Obstructive Sleep Apnea Care in Obesity: Continuous Positive Airway Pressure, Incretin‐Based Therapy, or Both?

Obesity is a primary driver of obstructive sleep apnea and contributes substantially to its associated cardiovascular morbidity and mortality. Although continuous positive airway pressure remains the standard treatment, its efficacy is often limited by suboptimal patient adherence and its impact on cardiovascular outcomes has yet to be consistently established in major clinical trials. Treatments aimed at the underlying problem, excess adiposity, are therefore needed. Weight loss, whether achieved through lifestyle interventions or bariatric surgery is well-known to improve obstructive sleep apnea. The recent introduction of highly effective weight loss medications, most notably incretin-based agents, now offers a pharmacological approach to accomplish the same result. Recent randomized controlled trials in patients with obesity demonstrated that these medications significantly decrease the apnea-hypopnea index and enhance oxygen saturation, with a significant proportion of disease remission. In light of these findings, we propose a therapeutic algorithm stratifying treatment according to symptoms and body mass index. For asymptomatic patients with obesity and obstructive sleep apnea, we suggest incretin-based therapy as a first-line option to concurrently address excessive weight and obstructive sleep apnea. Conversely, in individuals with impaired sleep-related quality of life combining continuous positive airway pressure and incretin therapy may be more appropriate, pairing immediate symptom control with longer-term weight loss. This integrated strategy, prioritizing weight management alongside symptom relief, may offer a comprehensive approach to treat obesity-related obstructive sleep apnea and decrease its associated cardiovascular risks.