Sleep Apnea and Obesity: Risks, Policy, and Tirzepatide (Zepbound®)

Key Takeaways

• About 69% of individuals with obesity in the U.S. have some form of obstructive sleep apnea (OSA)

• Sleep apnea and obesity can create a vicious cycle, with each condition contributing to the other

• Both OSA and obesity can increase risk for type 2 diabetes, hypertension, cardiovascular conditions, and osteoarthritis

• Patient preferences often favor medication over CPAP, while providers tend to prefer CPAP therapy

• Tirzepatide (Zepbound®) received FDA approval for treating sleep apnea in patients with obesity in December 2024

• Clinical trials show tirzepatide can reduce sleep apnea severity by approximately 50%

• Medicare Part D plans are beginning to cover tirzepatide specifically for sleep apnea treatment

Photo Courtesy of Eli Lilly and Company

If you or someone you love struggles with obstructive sleep apnea (OSA), you know how challenging this condition can be. One major factor often tied to sleep apnea—obesity—can make the picture even more complicated. Alliance of Sleep Apnea Partners President and CEO Dr. Monica Mallampalli, PhD, caught up with two leading experts to explore the OSA-obesity connection.

Dr. Chris Schmickl is a sleep medicine researcher at UC San Diego and a member of ASAP’s medical advisory team. Dr. Tracy Zvenyach is a registered nurse, policy expert, and director at the Obesity Action Coalition (OAC). They shared valuable insights about the OSA-obesity connection and new treatment approaches, including the Food and Drug Administration’s game-changing approval of the medication Zepbound for sleep apnea.

Their conversation is part of ASAP’s YouTube video series Breathing Room, which spotlights science, clinical practice, and policy issues surrounding sleep apnea. This episode is supported by Eli Lilly and Company.

Watch the complete episode of Breathing Room here.

Learn more about obesity and OSA in our downloadable Fast Facts.

The Connection Between Sleep Apnea and Obesity:

What Patients Need to Know

How Common is Obesity Among Sleep Apnea Patients?

Dr. Schmickl estimates that approximately “70-80% of patients probably have some overweight or obesity” in his sleep apnea practice. But he emphasizes an important point: many patients don't realize that not all sleep apnea is connected to weight.

“Obesity is certainly very important for sleep apnea, but not for everyone,” he said. “There are still plenty of patients with sleep apnea ... regardless of weight or in the absence of obesity.”

So while weight management is often recommended, it's not the only factor in every case of obstructive sleep apnea.

Understanding Obesity as a Chronic Disease: Beyond Personal Responsibility

Dr. Tracy Zvenyach pointed out that our understanding of obesity has evolved, medically and socially.

“Obesity was officially recognized as a chronic disease in 2013 by the American Medical Association,” she noted. That has helped shift the conversation from personal blame to medical management.

“Over the last 12 years, there's been increasing awareness and understanding of the science behind obesity,” Dr. Zvenyach said. “Especially the physiologic, the biologic, pathways of obesity, trying to really connect the science with modern understanding of what it actually is and what it isn't.”

Obesity still carries unique challenges compared to other chronic conditions. “Obesity has an additional layer of complexity when it comes to the bias that society has around body shapes and sizes and what the ideal is,” she noted. But interest in the condition is growing, “because it is kind of a hot topic in medicine right now,” Dr. Zvenyach said, partly driven by the emergence of GLP-1 medications like tirzepatide.

“From a policy landscape, we have seen an increase in coverage for these kinds of medications, and that is a good sign,” she said. “However, we do have a number of policy barriers we’re still trying to address. … We still have a long way to go from a policy and coverage perspective.”

Treatment Options for Sleep Apnea Patients with Obesity

Traditional Management Approaches for OSA with Obesity

Before discussing newer treatments, Dr. Schmickl described the traditional approach to addressing weight in OSA patients.

“In the sleep apnea field, as providers, we always had overweight and obesity certainly on our mind,” he said. “And all the guidelines recommend weight optimization. I also like the term 'optimization' rather than 'weight loss,' to keep it more neutral.”

His patient-centered approach involves “asking them how their weight has been changing, if they've tried losing weight, and having a very careful conversation to see where they are in their journey.”

Historically, treatment options were limited to lifestyle interventions and, in severe cases, bariatric surgery. But Dr. Schmickl acknowledged that those treatments can have limitations. “We do have a weight management program we can refer patients to, but oftentimes it’s booked out or coverage of the services for some patients, depending on insurance, may not be available,” he explained.

Bariatric surgery “can be very helpful for a lot of patients, but it is a big intervention and can come with a lot of potential side effects or complications and risks,” he said.

The FDA's December 2024 approval of tirzepatide specifically for treating OSA in patients with obesity now offers another option for sleep apnea patients with obesity. Dr. Schmickl welcomed the arrival of weight-loss medications like Zepbound, which he noted can help patients “achieve weight loss that is almost in the range of what we’ve seen with bariatric surgery and are pretty well tolerated.”

Tirzepatide (Zepbound): FDA-Approved Medication for Sleep Apnea

Clinical Benefits of Tirzepatide for Sleep Apnea Patients

“With tirzepatide, we had this large trial, Surmount-OSA, led by my mentor, Dr. [Atul] Malhotra, which demonstrated that not only do people lose 15% of body weight if they have comorbid obesity and sleep apnea, but also their sleep apnea over a year improves by about 50%,” Dr. Schmickl said. “That led to huge improvements in blood pressure, markers of cardiovascular risk, and even symptoms related to sleep apnea.”

These results have been compelling enough that Dr. Schmickl believes “personally, my feeling is that sleep providers eventually have to get comfortable with prescribing these new, powerful, effective, safe medications to help our patients with their sleep apnea.”

When to Consider Medication vs. CPAP Therapy

When should sleep specialists recommend tirzepatide?

“For patients with comorbid obesity and sleep apnea who are not at immediate risk of a car accident or losing their job because of sleepiness, I personally believe it would be reasonable to offer them tirzepatide if they're interested, and see where things are going for a year,” Dr. Schmickl said. “There's a chance their sleep apnea is going to go away, and they'll reap many other health benefits, too.”

For patients with more severe symptoms requiring immediate intervention, “it would be reasonable to treat with both tirzepatide and CPAP in combination,” he said. “But a lot of this is going to depend on patient preference.”

For patients who have been using CPAP and are now interested in tirzepatide, Dr. Schmickl noted that “it’s still a very complex landscape.”

“Clearly, there's a need for more education when it comes to physician and, of course, the patients,” he said. “One of the concerns is, are people quickly going to say, ‘I don't want to use my CPAP. There’s this new medication, I would rather take this.’ But again, what is that indicated for? … It is for the obese patients. You have to fit the certain category, and then, if you've been on CPAP for a long time, would you just stop your CPAP? So I think there are a lot of unanswered questions.”

Insurance Coverage and Medicare Updates for Sleep Apnea Treatments

One of the most significant barriers to accessing Zepbound has been cost and insurance coverage. But Dr. Zvenyach pointed to promising policy developments for patients covered by Medicare Part D.

“When the most recent indication for obesity and cardiovascular disease risk reduction came out in March 2024,” she said. “CMS issued Medicare Part D coverage guidance stating that in instances when an obesity medication receives approval for an additional medically accepted indication during the contract year, Part D sponsors may include such drugs on their current Part D formularies.”

That means Medicare Part D plans can begin covering tirzepatide for OSA without waiting for the next plan year. Dr. Zvenyach predicted that some Medicare Part D plans will start covering tirzepatide for OSA in 2025.

“If they are not, one of the roles that OAC does in our in our advocacy, is we will reach out to CMS and say we're hearing from our community and people are having a hard time getting their coverage,” Dr. Zvenyach explained. “So we would love to hear from members of your community, and we will be listening to members of our community who are Medicare beneficiaries.”

Steps to Take if Your Insurance Denies Coverage

For patients with private insurance facing coverage denials, Dr. Zvenyach recommended that they initiate the appeals process. “Provide that documentation of the FDA approval and work with your provider, your clinician, to go through those steps,” she said. “It's a pain, it takes time, but that is how we are supporting members of our community.”

Read more about how one sleep apnea patient navigated this process here.

Patient Perspectives: Choosing Between CPAP and Weight Management

Dr. Schmickl’s team is conducting a survey to explore how patients and providers view different OSA treatment options.

“Interestingly, most patients found that both CPAP and tirzepatide would be acceptable—highly acceptable—to them,” he said. Asked the same question, providers also found both treatment options acceptable but leaned toward CPAP instead of tirzepatide.

When asked which treatment they would prefer if both were equally effective, “about two-thirds of patients lean towards the tirzepatide, versus providers, [for whom] it was exactly the opposite way,” Dr. Schmickl said.

This disconnect between patient and provider preferences highlights the importance of shared decision-making and understanding patient values when developing treatment plans.

Will Weight Loss Cure My Sleep Apnea?

Many patients wonder whether weight loss through medications like tirzepatide will make their sleep apnea disappear.

“Even in Surmount-OSA [clinical trials], on average, sleep apnea improved by about 50-55%, and in about 40% of patients, sleep apnea went away, depending on how you define it, which also means about half the people still had some sleep apnea left,” Dr. Schmickl said.

For those who have OSA after weight loss, he suggested various approaches might be needed. “For some patients at this point, maybe healthy lifestyle measures might be enough ... avoiding sleeping on your back, avoiding alcohol close to bedtime, avoid drowsy driving, make sure you get enough sleep,” he said. “But for a lot of other patients, there may still be a need to use other therapies, like an oral appliance or surgery.”

“There’s a lot of innovation happening in this space,” acknowledged ASAP’s Dr. Mallampalli. “We certainly need to see more treatment options, more tools in the toolbox for physicians. And I think definitely it's going to be a different year with this medication and hopefully others in the pipeline."

Frequently Asked Questions About Sleep Apnea and Obesity

Is sleep apnea always caused by obesity?

No. While 70-80% of his practice’s sleep apnea patients have overweight or obesity, Dr. Schmickl emphasizes that many people develop sleep apnea regardless of their weight. Factors like facial structure, neck circumference, and genetics also play important roles.

How much weight loss is needed to improve sleep apnea?

In the Surmount-OSA clinical trial, patients lost an average of 15% of their body weight using tirzepatide, which led to approximately 50% improvement in sleep apnea severity. Individual results may vary based on initial severity and other factors.

Does Medicare cover tirzepatide (Zepbound) for sleep apnea?

Some Medicare Part D plans are beginning to cover tirzepatide specifically for sleep apnea following recent CMS guidance. Coverage is expected to expand in 2025. Check your specific plan for details.

Can I stop using my CPAP if I lose weight?

According to Dr. Schmickl, “many OSA patients will still require some form of treatment after weight loss.” Any changes to CPAP use should be made under medical supervision, and it is important for patients to talk to their sleep doctors or health care providers.

How effective is tirzepatide compared to CPAP therapy?

While CPAP remains highly effective when used consistently, many patients struggle with adherence. Tirzepatide offers an alternative approach that might be preferred by some patients, and the two treatments can also be used together. Talk to your healthcare provider about the treatment or combination of therapies that might be right for you.

Want more? Watch the Breathing Room video discussion “Examining the Sleep Apnea Relationship From Clinical Practice to Policy Development” now.

This episode of Breathing Room is supported Eli Lilly and Company. Share your stories and experiences with obesity and sleep apnea by emailing info@apneapartners.org. You can also sign up for our newsletter and follow us on Facebook, LinkedIn, Twitter/X, Instagram, and YouTube to stay connected.