Podcast Summary

Podcast: AACE Podcasts
Episode: 67: Obstructive Sleep Apnea – Screening and Treatment Updates
Air Date: September 29, 2025
Host: Dr. Sarah Nadeem
Guests: Dr. Faria Abbasi Feinberg (Sleep Medicine Specialist), Dr. Indrapreet Madhahar (Endocrinologist)

Overview of the Episode

This episode focuses on the intersection between obstructive sleep apnea (OSA) and metabolic diseases, providing updated insights into screening, diagnosis, and treatment. The panel of endocrinology and sleep medicine experts delves into current guidelines, the pathophysiological connections, emerging therapies, and practical advice for healthcare providers.

Key Discussion Points & Insights

1. Pathophysiology and Risk Factors of OSA

• What is OSA?
  OSA is characterized by the actual closure or obstruction of the airway during sleep, leading to repeated cessation of breathing (apneas) lasting at least 10 seconds with drops in oxygen saturation ([02:37]).
• Who is at risk?
  • Anatomical factors: Small/crowded airway, enlarged tonsils, macroglossia, retrognathia ([02:43]).
  • Physiological: Obesity (especially central), men have higher risk but perimenopausal/menopausal women are also at risk ([03:35]).
• Women and OSA Underdiagnosis
  OSA in women is often overlooked due to atypical presentation (less daytime sleepiness, more insomnia) ([04:17]).

Quote:
“Women with sleep apnea usually present a little bit differently... more sleep disturbance, they can come in with insomnia, they say, more than fatigue... especially as we get to the perimenopausal and menopausal ages, that has to be something that's really evaluated consistently.”
— Dr. Faria Abbasi Feinberg [04:17]

2. Bi-directional Relationship between OSA and Metabolic Disorders

• Interplay Explained:
  Poor sleep and intermittent hypoxia from OSA can drive cravings, worsen obesity/diabetes, and propagate a vicious cycle ([05:09]).
• Mechanisms:
  • Intermittent hypoxia and sleep fragmentation provoke insulin resistance and beta-cell dysfunction.
  • HPA axis activation and inflammation further worsen glycemic control.
• Association with Both T1D and T2D:
  OSA is highly prevalent in both, possibly linked to chronic hyperglycemia and associated physiological changes ([07:19]).

Quote:
“When your body doesn’t get enough rest... it kind of feels like it’s going through a stressful phase and starts signaling for higher caloric intake... That results in increased cravings and makes it harder for them to lose weight and results in uncontrolled diabetes and... obesity. It further worsens obstructive sleep apnea that further creates a vicious cycle.”
— Dr. Indrapreet Madhahar [05:13]

3. Screening – Who, When, and How

• Who to Screen:
  • All patients with BMI > 30, especially with central adiposity ([11:06]).
  • Neck circumference >17 inches in men, >16 inches in women.
  • Unexplained fatigue, resistant hypertension, metabolic syndrome, acromegaly, hypothyroidism, PCOS, Cushing’s, pheochromocytoma.
• Screening Tools:
  • STOP-BANG questionnaire is most common, but even asking “How do you sleep?” can be a high-yield starting point ([12:01]).
• Ethnicity and BMI Considerations:
  • Asian (particularly South/Southeast Asian) patients may have higher OSA risk at lower BMIs due to craniofacial anatomy.
  • Central adiposity is a better predictor than BMI alone ([14:37]).

Quote:
“If the patient says I don’t sleep well, then you can ask the next follow up question, do you snore? Are you tired? And then go down that route and figure out if that person needs a referral or sleep study...”
— Dr. Faria Abbasi Feinberg [13:19]

4. Diagnostic Workflow

• Referral Pathways:
  High-suspicion cases should be referred for a sleep study. Due to limited specialty access, many clinics now use home-based sleep studies with increasing accuracy ([16:57]).
• Collaboration Models:
  Some practices allow primary care to directly order sleep studies, speeding up diagnosis ([35:53]).

5. Treatment Modalities and Recent Updates

• First-line Treatment:
  Not always CPAP; depends on severity, cause, and patient circumstances ([17:53]):
  • Weight loss for mild OSA; can be sole intervention in select cases.
  • Positional therapy (side-sleeping aids).
  • Mandibular advancement devices (dental appliances).
  • Hypoglossal nerve stimulation (recently expanded FDA approval).
  • CPAP/BiPAP remains gold standard for moderate-severe OSA.
• Emerging Pharma:
  • Tirzepatide (Zepbound) recently FDA-approved for moderate–severe OSA in obese patients ([22:05]). It’s welcomed by patients and increases willingness for evaluation.
• Treatment Hesitancy:
  Many patients are wary of CPAP but advances in device comfort and technology are improving adherence ([20:49]).
• Multimodal Therapy:
  Combined interventions, gradual desensitization, and involving bed partners optimize outcomes ([20:49], [44:07]).

Quote:
“CPAP has a bad rap, but I cannot tell you the number of people who think that their PAP device is their most valued treasure... At least 70% of our patients do really well with CPAP therapy... If you throw in some modern technology... compliance goes up to about 80%.”
— Dr. Faria Abbasi Feinberg [17:53]

Quote:
“With the latest SURMOUNT-OSA trial... that led to FDA approval of Tirzepatide... now I proactively screen obese patients for moderate to severe OSA...”
— Dr. Indrapreet Madhahar [22:05]

6. Chronic Disease Framing and Patient Education

• Long-term Management:
  Both CPAP and medications like tirzepatide require ongoing use akin to other chronic disease therapies ([27:24]).
• Lifestyle Foundation:
  Diet and exercise remain essential; medications complement, not replace, lifestyle changes ([28:15]).
• Uncertainties:
  Questions remain about insurance coverage if OSA resolves, long-term safety, and what happens if sleep apnea ‘goes away’ after therapy ([27:24]).

Quote:
“I do tell them that this is going to be a chronic medication and they cannot be expecting such an on and off kind of treatment that, okay, you take this medication for a few months and then it's treated and then you’re off it.”
— Dr. Indrapreet Madhahar [28:15]

7. Complications of Untreated OSA

• Risks:
  • Higher rates of hypertension, CVD, diabetes complications, cognitive dysfunction, accidents, and reduced quality of life ([31:49]).
• Treatment Impact:
  CPAP improves symptoms, blood pressure, and (likely) major CV risks in moderate/severe cases. Data on tirzepatide’s long-term effects still emerging ([31:49]).

8. The Future: Pipeline Therapies & Models of Care

• Medications in Development:
  • Atomoxetine + oxybutynin combination—targets tongue/airway muscles ([42:03]).
  • Acetazolamide + dronabinol—stimulates airway patency and ventilatory drive.
  • Expansion in GLP-1/GIP and triple agonist research ([46:07]).
• Multidisciplinary Models:
  Increased need for “team” clinics: Endocrinology, Sleep Medicine, Dietician, Primary Care all working in sync for OSA/obesity/metabolic syndrome ([35:07]).
• Primary Care Empowerment:
  Education and protocol-driven screening are empowering PCPs and NPs to identify OSA sooner ([36:59]).

9. Special Populations: OSA and Testosterone Therapy

• Cautionary Note:
  Testosterone may worsen OSA due to its effects on neck tissue and pharyngeal muscles ([39:20]).
  • OSA should be excluded before starting testosterone; untreated OSA plus testosterone could be risky ([40:05]).
  • Many patients are prescribed testosterone without OSA evaluation; more education is needed ([40:14]).

Quote:
“Testosterone causes the pharyngeal muscle hypertrophy that will cause more congestion in your neck. So if you have untreated obstructive sleep apnea, then it’s going to just make it worse.”
— Dr. Indrapreet Madhahar [39:20]

10. Take-Home Messages and Resources

• Raising Awareness:
  • OSA is common (possibly 15% of the U.S. population); most remain undiagnosed ([14:37]).
  • Not all patients will need or tolerate the same therapy—personalize!
• Resources Mentioned:
  • sleepeducation.org
  • Sleep is Good Medicine public awareness campaign ([48:38])
• Advocacy:
  Address stigma and fear—OSA evaluation and management now comes with more options than ever ([48:38]).

Notable Quotes & Memorable Moments

• “There's so many people who don't even know there's a specialty called sleep medicine!”
  — Dr. Faria Abbasi Feinberg [48:38]

• “If you leave one side unaddressed, the treatment results are not going to be as good as you would expect.”
  — Dr. Indrapreet Madhahar [48:06]

• “I think the future is very bright for treatment of sleep apnea. We have all the things available that we already talked about, but there are some new options that are coming down the line.”
  — Dr. Faria Abbasi Feinberg [48:38]

Timestamps for Key Segments

• Introductions & Pathophysiology: [00:27] – [04:08]
• Screening and Diagnosis: [10:52] – [13:40]
• Ethnicity/BMI Considerations: [14:37] – [16:19]
• Treatment Modalities: [17:53] – [22:05]
• Emerging Medications (Tirzepatide): [22:05] – [28:15]
• Long-Term Management & Complications: [27:24] – [31:49]
• Future Therapies & Care Models: [42:03] – [44:07]
• Testosterone & OSA: [39:20] – [41:42]
• Final Thoughts & Resources: [48:06] – [49:53]

Episode Tone & Language

The discussion is collegial, highly practical, and encouraging, frequently acknowledging patient hesitancy, the rapid evolution of sleep medicine, interdisciplinary collaboration, and the real-world barriers clinicians face. The experts are warm and optimistic about the future, emphasizing patient-centric and evidence-based care.

In Summary

This episode provides a robust, case-based, and forward-looking discussion on obstructive sleep apnea in the context of metabolic disease. Highlights include updated screening recommendations, the practical use of new therapies like tirzepatide, integration of multidisciplinary care, and ongoing challenges such as underdiagnosis, patient hesitancy, and complexities with insurance and chronic management. The future promises exciting new medications and a more patient-friendly approach to this widespread, impactful disorder.