GLP-1 obesity management medications are increasingly used in sleep medicine as new connections are noted between patients’ weight and sleep issues, and clinicians find themselves fielding questions about the ins and outs of a relatively new class of drugs. The American Academy of Sleep Medicine recently hosted a webinar that provided an overview of these factors and explained how healthcare professionals can recognize and mitigate concerns using lifestyle and clinical strategies.
AASM’s webinar, “The Good, the Bad and the Manageable: Practical Pearls for Obesity Pharmacotherapy in Sleep Medicine,” moderated by Dr. Xinhang Tu of the University of Michigan, featured insights from specialists in sleep medicine, obesity and metabolic health: Dr. Mira Tadros of the Icahn School of Medicine at Mount Sinai, Dr. Safia Khan of UT Southwestern Medical Center and Dr. Nicollas Mozart Vieira of Instituto Mozart. The goal was to help other clinicians provide safe, effective care for patients with sleep disorders who use these medications.
Tu began by outlining three main focal points of the webinar – assessing patients before beginning obesity pharmacotherapy, the practical side of treatment, and strategies that clinicians can recommend, including medication.
In the clinic
To illustrate the process of GLP-1 use, Tadros introduced a sample patient, “Alex,” a 50-year-old man who has a body mass index of 40, hypertension, prediabetes and obstructive sleep apnea. He’s doing pretty well on positive airway pressure therapy, and he has tried lifestyle modifications to lose weight, but he always ends up gaining it back. He wants to know if he might be a good candidate for a GLP-1 drug.
This is where the “6 As framework” for obesity management can be used in sleep medicine, Tadros said: 1. Ask the patient for permission to discuss weight; 2. Assess obesity-related health risks; 3. Advise on the benefits of personalized weight loss; 4. Agree on goals and interventions; 5. Assist with multidisciplinary support and pharmacotherapy; 6. Arrange for regular follow-up care.
Tadros said it’s important to ask Alex’s permission before discussing the sensitive topic of weight, even if he brought it up. “Often, patients who have been living with obesity might have had difficult discussions in healthcare, or just have experienced bias and stigma before, so just introducing the topic … is a huge thing,” Tadros said. “If the patients are open for it, then we move on to the second A – assess.” This is where the clinician learns about the person’s family history of weight gain, when it began, and any contributing factors, such as past weight-loss attempts, pregnancy, contraception, sleep patterns, substance use, diet and exercise habits, bariatric surgery, medications and comorbidities.
Next, the clinician can advise on a tailored weight-loss strategy. “Obesity management medications in particular are recommended for patients with a BMI greater than 30, or greater than 27 with one or more weight-related comorbidities,” Tadros said, noting that interventions need to be combined with lifestyle changes in nutrition and exercise. Drug labeling for tirzepatide doesn’t expressly state that baseline bloodwork should be done, but Tadros said she recommends it as a best practice.
Making progress
Patients and clinicians can agree on an appropriate strategy, and individuals should be advised that the medications are meant for consistent use unless issues arise such as severe side effects or plans to get pregnant. “It’s important to frame treatment as long-term, because obesity is a chronic disease,” Tadros noted.
Alex’s clinician should help him understand that a specific weight or BMI level isn’t the main goal of treatment. “I like to focus on other monitoring parameters such as improvement in sleep apnea severity, A1C or lipid profile, or improvement in joint pain,” Tadros said.
Next, Alex’s clinician can help develop a plan for medication use and arrange any needed follow-up care. With tirzepatide, for example, the active weight loss phase tends to last 24 to 36 weeks, depending on starting BMI. Most patients reach a plateau between weeks 60 and 72, and most lose 0.5 to 2 pounds per week. Dosages are adjusted periodically over time, and patients are advised to be vigilant about hydration, a nutritious diet and exercise. “I sometimes tell patients to consider taking it on the weekend, just in case they have any gastrointestinal side effects, so they don’t have to deal with them at work,” Tadros said. Less than 10% of patients stop GLP-1 use because of GI side effects, Tadros noted, but it’s still important to pay attention to them and report concerns to a clinician.
Next steps
Khan picked up Alex’s case at about four weeks into his GLP-1 regimen. “He’s lost about 3% of his body weight, and he’s complaining of some early satiety and occasional nausea,” Khan said. “He’s eating and drinking normally, with no vomiting or abdominal pain. Now, the question is whether you go up on the dose or not.” Satiety indicates that the medication is working, but it’s important to ensure patients understand the difference between feeling full and experiencing nausea.
Khan said the clinician should assess how well Alex is tolerating the medication and how much weight has been lost before deciding to step up the dose. Potential concerns include losing too little or too much weight. “We also should monitor waist circumference, blood pressure and glycemia,” she noted. “Look for side effects … including nausea, vomiting, diarrhea and constipation. Also ask about hair loss, check for nutrient deficiencies, and ask about any mood or vision changes.” It’s important to consider the patient’s mobility and physical condition as well.
After several weeks and increasing doses, Alex may find that his side effects are more pronounced. He may be having more severe nausea, worse constipation, less fluid intake and more lightheadedness. These can be significant, Khan said, so it’s important to take a step back and evaluate whether his doses should continue to rise.
“This is done on a case-by-case basis,” Khan said. “It is OK to stay on a dose for longer than 4 to 6 weeks. The dose that the patient is tolerating is the best one for them, especially if they’re experiencing some weight loss.” Serious red flags include symptoms of pancreatitis, cholecystitis, cholelithiasis, ileus, gastroparesis and small bowel obstruction. Khan also pointed out that certain medications should not be taken with GLP-1s, including ondansetron and DPP-4 inhibitors (gliptins).
The sleep management plan
Tu said that once Alex’s other issues have been resolved, he finds that he is losing weight consistently on the medication, and his sleep apnea symptoms have improved. He asks, “Since I’ve lost all this weight, do I still need a CPAP machine?”
“The key point is that the weight loss does not automatically mean the resolution of sleep apnea,” Tu said. “I would first look at the whole clinical picture and symptoms. Sometimes the PAP settings can be adjusted. I think it’s reasonable to move from a fixed CPAP to an APAP. And sometimes we could reconsider other treatment options when appropriate. PAP should not be simply stopped just because the patient has lost weight.”
Long-term considerations
Vieira wrapped up the discussion with ideas on long-term support for the GLP-1 patient with sleep issues. “Alex may wonder what else he needs to do to maintain the weight loss,” he said. “Nutrition is one of the main pillars when we are trying to maintain or decrease his weight. Tell the patient that, if you are eating less [while on a GLP-1 drug], you surely need to eat better.”
Food aversion and nausea may cause the patient to lose nutrients, Vieira said. Macro- and micronutrients are of major importance, so referral to a registered dietitian can be beneficial. “Usually, the best diet is the one that the patient can maintain the longest,” he said. “It’s also very useful if they use health tracking apps or at least a diary. Protein, fiber and water are nutritional priorities.”
Weight loss and better sleep patterns are not the only potential benefits of these drugs, Tadros noted. Women’s fertility issues may improve, blood pressure may get better, and patients may be able to discontinue hypertension medications under a clinician’s supervision.
In any case, multidisciplinary care can help the patient achieve success. “Support and refer when needed, because obesity treatment is much broader than just a prescription,” Tu said.
Want to know more?
AASM’s Obesity Management Task Force provides guidance, clinical resources and strategies for incorporating obesity care into sleep medicine.