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- [00:00]
Dr. Indrapreet Madhahar
Foreign.
- [00:06]
Dr. Faria Abbasi Feinberg
Welcome to ACE Podcasts.
- [00:08]
Dr. Sarah Nadeem
Thanks for tuning in as we elevate clinical endocrinology by taking deep dives into.
- [00:12]
Dr. Faria Abbasi Feinberg
Trends and topics that can help us.
- [00:14]
Dr. Sarah Nadeem
Improve our patient care and global health.
- [00:17]
Dr. Faria Abbasi Feinberg
Find the latest episodes on aace.com podcasts and now let's meet the endocrine experts who will be talking with us today.
- [00:27]
Dr. Sarah Nadeem
Welcome to another episode of the ACE podcast. I'm Dr. Sarah Nadeem, endocrinologist and faculty at Baylor College of Medicine in Houston, Texas. I'm also staff physician at the Michael E. DeBakey VA Medical Center. My area of expertise is diabetes, diabetes, technology and obesity and metabolic disease. I have worked and practiced in Chicago, Houston and Pakistan. Today we will be discussing sleep apnea and metabolic disease, the evaluation and therapeutic management. So before we begin, I would like to thank sponsors for this ACE Podcast. Lilly for supporting this important conversation. Joining me today are Drs. Abbasi Feinberg and Dr. Madheher. Thank you both for being here. Dr. Abbasi Feinberg, let's start with you. Could you please introduce yourself and share a little bit about your background and area of expertise?
- [01:20]
Dr. Faria Abbasi Feinberg
Farah hi, my name is Faria Abbasi Feinberg. I am a board certified sleep medicine specialist. My background is in neurology so we can get into sleep medicine a couple of different ways. I am medical director of Sleep medicine at Millennium Physician Group in Fort Myers, Florida. I also serve as the president elect for the American Academy of Sleep Medicine. I've been practicing clinical sleep medicine for over 20 years, taking care of patients day in and day out. And I love talking about sleep and how it affects your health and your well being. So thank you so much for having me here.
- [01:56]
Dr. Sarah Nadeem
Absolutely. Thank you for joining us. And Dr. Madha Har, could you please also tell us a little bit about your clinical background, introduce yourself and what your clinical focus is.
- [02:06]
Dr. Indrapreet Madhahar
Hi, thank you. First of all, thank you for having me. My name is Indrapreet Madhahar. I'm a board certified endocrinologist. Currently I'm working for Corbell Health in St. Joseph, Michigan. My area of expertise is mainly diabetes, lipids and obesity. Very much interested in treating metabolic syndrome.
- [02:22]
Dr. Sarah Nadeem
Okay, let's dive into our discussion. So the first question, I'll start with Dr. Abbasi. So as a sleep specialist physician, if you can describe the pathophysiology of obstructive sleep apnea and who is at highest risk of developing this disorder?
- [02:37]
Dr. Faria Abbasi Feinberg
Yeah, absolutely. It's such an important question. So an apnea is defined as a cessation of breath.
- [02:43]
Dr. Sarah Nadeem
Right.
- [02:44]
Dr. Faria Abbasi Feinberg
For our Audience here today, we're going to be focusing on obstructive sleep apnea. So as the name implies, there's some type of an obstruction, a closure of the airway. Now, that can be from something anatomical or it could be from a physiologic factor as well. Now, when we look at apneas, we have criteria for it. So the event has to last for at least 10 seconds. There has to be an associated drop in oxygen saturation. And when we look at the sleep studies, we add up all of these events and then divide either by the number of hours of sleep recorded or the number of hours of recording, depending on what type of sleep study we're doing, and we come up with an event index. That event index then helps us classify if somebody has mild, moderate or severe obstructive sleep apnea. You asked about who's at risk. Well, anybody that has a smaller airway or a crowded airway is at risk. And that can be from a lot of different things. So sometimes, you know, enlarged tonsils can do it. Macroglossia can do it. Retrognathia or microagnathia can do it. Obesity is often associated with sleep apnea as well. Definitely a higher risk for men, but I don't want to leave us women out because women do have risk for sleep apnea. And especially as we get to the perimenopausal and menopausal ages, that has to be something that's really evaluated consistently.
- [04:09]
Dr. Sarah Nadeem
Thank you, that's very helpful. So do you feel like sometimes, as you mentioned, in women it's overlooked and not screened as often?
- [04:17]
Dr. Faria Abbasi Feinberg
Yeah, I think that is a huge problem that we see in the sleep world all the time. I think women are often discounted when they come in because they present a little bit differently. So just like in heart disease, women may not have that clutching chest pain like men do. Women, women with sleep apnea usually present a little bit differently. So they can have more sleep disturbance, they can come in with insomnia, they say, more than fatigued, whereas, you know, men tend to doze off a little bit more. And of course, these are big generalities, but I think when a woman comes in, especially she has other risk factors. And if she's of that perimenopausal, menopausal age, it's something that we have to look at.
- [04:57]
Dr. Sarah Nadeem
That's very helpful. So, Dr. Matahar, can you help talk a little bit about how metabolic disorders and sleep apnea apnea are related and what's the bi directional role or relationship.
- [05:09]
Dr. Indrapreet Madhahar
Between the two, oh yes, obstructive sleep apnea and several metabolic disorders like insulin resistance, obesity, diabetes, they share a bi directional relationship, meaning one enhances the development of the other. So how I usually explain it to my patients is when your body doesn't get enough rest, when you're sleeping because of lower levels of oxygen, brain doesn't feel rested enough. It kind of feels like as it's going through a stressful phase and starts signaling for a higher caloric intake. So that results in increased cravings and makes it harder for them to lose weight and results in uncontrolled diabetes and in turn obesity. It further worsens obstructive sleep apnea that further creates a vicious cycle. So this is basically a layman's kind of explanation. I would explain more scientifically would be through two main mechanisms by which osa, the obstructive sleep apnea could version diabetes and obesity. That would be intermittent hypoxia and sleep fragmentation. So these two mechanisms, they can provoke beta cell dysfunction, pancreatic beta cell dysfunction and hence insulin resistance. The alternative hypothesis is they are possibly creating a stressful Alternative hypothesis is activation of the HPA axis, the hypothalamus pituitary adrenal axis, as a stress response that results in increased glucose production or gluconeogenesis and reduced uptake of glucose in the adipose tissue that further results in hyperglycemia. Also, patients with obstructive sleep apnea, they're noted to have higher levels of inflammation because of elevated levels of cytokines in comparison to someone who does not have sleep apnea. That can further worsen the insulin resistance and recurrent arousals. They may result in circadian misalignment that can cause metabolic alterations like lower melatonin levels that further increases the risk of type 2 diabetes. Now, we have seen that OSA is highly prevalent in type 2 diabetes, but it has also been reported highly in type 1 diabetic patients. So that further raises the possibility that this disorder could possibly be just not associated with just adiposity, but also hyperglycemia. So chronic exposure to hyperglycemia that could attenuate the carotid body discharge rate that could result in degeneration of the catal body parenchyma, resulting in dampening of the hypoxic reactivity and hence high risk of obstructive sleep apnea. So those are a few mechanisms by which OSA and diabetes, they're affecting each other. So sleep fragmentation that results in lower reduction of slow wave sleep, that is basically the deep sleep that is important for glucose regulation that can increase the cortisol and growth hormone rise in cortisol and growth hormone levels at inappropriate time, resulting in higher glucose levels and higher ghrelin, that is basically the hunger hormone. And lower leptin that promotes weight gain when you're lowering leptin or in obesity, when leptin resistance arises. Leptin is basically responsible for stimulating the breathing control in the brain stem. In obesity and insulin resistance, leptin resistance can also impair the ventilatory drive that makes the apneas more likely. This is basically how obesity and OSA are interacting with each other. So most common, how we explain it to the patients is basically when your kind of neck mass increases, that under the neck mass, the airway could collapse and that could make your obstructive sleep apnea even more worse. So that is basically the bidirectional relationship that's very helpful.
- [08:40]
Dr. Sarah Nadeem
And as you mentioned, you know, there are multiple pathways that are postulated. And I know we had talked about whether we're going to focus just on OSA or central sleep apnea, but if Fariha, you could talk a little bit. As Inderpreet mentioned that, you know, there's. The central aspect is also there. So is it always very pure, just OSA or in metabolic syndrome or people with obesity and diabetes? Could it be a combination of the two?
- [09:05]
Dr. Faria Abbasi Feinberg
Yeah, I mean, the obstructive sleep apnea is just so much more common. Right. There's a lot of different reasons that people can have central sleep apnea. And sometimes we see it when there's like some arousals going on. Believe it or not, there's something that we call post arousals central events. And they're, you know, we don't really classify them as being pathologic. So they can be there, but they may not be a problem. But they occur because the sleep is very disrupted and the sleep is probably disrupted from the obstructive events in that particular situation. Now, there are times that somebody has neurologic disease associated with it, or if they're on certain medications, such as opioid medications, those obviously increase the risk of central events as well. And then if you have congestive heart failure, that's another big risk factor. So I think in the usual population that most of your audience is going to see, I think it's really the obstructive events that are the bigger factor.
- [10:03]
Dr. Sarah Nadeem
As you were mentioning, the wider neck. So coming back to type 1 population or in women, would that criteria still hold or because that may not be the same risk factor as we say, you know, a wider neck diameter would prompt you to assess for sleep obstructive sleep apnea.
- [10:21]
Dr. Indrapreet Madhahar
So it's more about the neck mass, not about the wider neck, I would particularly say. So it's basically obesity. And women, as we know that they are kind of more prone to obesity. So that's, that's why I would like to. Yes, so that criteria would still hold true for women especially, like Dr. Feinberg said, around perimenopausal age, that's when we see. See most of the obesity in women and women struggling to lose weight. So, yes, so around that age, I would still hold that criteria. True.
- [10:53]
Dr. Sarah Nadeem
And I think that brings us to, you know, then who should we be screening for sleep apnea? As endocrinologists, as primary care physicians, and what screening tools would be utilizing? And I'll begin with in the preet and then Priya, you can chime in as well.
- [11:06]
Dr. Indrapreet Madhahar
Sure. From endocrinology standpoint, I would like to screen anyone who is, whose BMI is more than 30, you know, especially with central adiposity. Any male more than 17 inches neck circumference, or any female more than 16 inches neck circumference, rapid unexplained weight gain. If you're seeing in some patients type 2 diabetes, pre diabetes, metabolic syndrome, resistant or difficult to control hypertension, different endocrinology cases like acromegaly, hypothyroidism, which prone patients to high risk of obstructive sleep apnea, pcos, Cushing syndrome, Cushing diseases, or fear chromocytoma. All these patients would qualify for screening of obstructive sleep apnea. Also, I think most of the patients I see in my clinic, they are usually complaining of unexplained fatigue. That's where I kind of suspect mostly obstructive sleep apnea. And that's when I refer them to our sleep medicine clinic.
- [11:59]
Dr. Sarah Nadeem
And Faria, would you add to that list?
- [12:02]
Dr. Faria Abbasi Feinberg
Yeah, I mean, that's an excellent, very thorough list. So. No, I appreciate that. I think there's a couple of different screening tools that are out there. And the one that's used most commonly is called the Stop Bang. It's basically eight questions that are either yes or no. And then you add up your points and then you can decide if somebody is at low risk, intermediate risk, or high risk of obstructive sleep apnea. The questions are very, very simple. So S stands for do you snore? T is are you tired? O is There observed apneas. P is do you have pressure? High blood pressure issues? B is body mass index. A is age over the age of certain time. What's your neck circumference? And as Indu said, you know, 17 inches for men, 16 inches for women. And then the last one is are you a male? Right. So certain things there you cannot change and so you have those risk factors. So if you score five to eight yeses, your risk of having sleep apnea is pretty high. Now asking eight questions in every visit may be too much. So if you can embed something like that in the emr, that of course helps. But as non sleep specialists, I would love it if primary care physicians and endocrinologists would just ask one simple question. And that simple question is how do you sleep? Because so often it is not something that's focused on. And if the patient says I sleep great, then you can whiz right by it and move on to other important issues that they're there for. But 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 and how you want to approach that.
- [13:40]
Dr. Sarah Nadeem
For sure, I think we need to talk about it more often and consider it especially with as indeprit also said, we see a lot of patients who come in with nonspecific fatigue symptoms and just getting a little bit of sleep history will sometimes often say yes, you know, I can't sleep or I wake up or my, you know, their partner has pointed out to them snoring a lot or stopping breathing in the middle of the night. I think that kind of, once you start asking those questions, we get the whole picture. Looking at this information, looking at who we should screen. I guess the question I would have is, is it different between ethnicities? Does the risk factors, is the prevalence different in terms of even the bmi? And coming from South Asian background myself, the obesity and overweight criteria for bmi, which is still not, I mean BMI is not the best criteria, but that's what we have is different. And at lower BMIs there's increased cardiovascular risk. So does that also hold true for OSA?
- [14:38]
Dr. Faria Abbasi Feinberg
Risk prevalence estimates are that it's about 15% of the population has sleep apnea. And that's sort of being conservative I think, you know, if you look at the US population, we're talking about 50 million people that may have sleep apnea and we have data that 80% or more may be undiagnosed. When we're looking at a worldwide population, numbers that I've seen are as high as a billion people may have obstructive sleep apnea. Right. So it's a very common disorder. You're absolutely right that in different populations you have to look at it differently. So I'm also Southeast Asian. And, you know, when we look at our airwaves and our facial structure, there are some anatomical differences. So there is a higher risk in folks from Asia, Southeast Asia versus some European countries as well. So you do have to look at that. And I think, you know, we all struggle with is the BMI the appropriate measure of risk. And I think talking about central adiposity helps. And also just looking at where the adiposity is. Right. So, I mean, if somebody's got the extra weight in the hips, maybe we don't worry quite as much as if they have it all around their face. And, you know, so I think there's those ways to look at it as well.
- [15:49]
Dr. Sarah Nadeem
Great, thank you. Indrapreet, any input? What are your.
- [15:52]
Dr. Indrapreet Madhahar
I think I see more obstructive sleep apnea in African American population. I feel it could be because of, you know, lack of proper healthcare availability to African American population, that is. And mainly I see higher A1Cs, so that's what I'm kind of increasingly seeing. The area where I'm practicing, I don't see a whole lot of South Asian population, but most of them that I see, they have sleep apnea. So it's kind of area of my interest too.
- [16:19]
Dr. Sarah Nadeem
And just picking up on your answer there. In terms of A1C, is there a correlation between uncontrolled diabetes and increased incidence of OSA in that patient?
- [16:28]
Dr. Indrapreet Madhahar
Yes. So higher uncontrolled diabetes is seen in mainly patients with moderate to severe osa, not as much with mild osa. So yes, there is a correlation.
- [16:39]
Dr. Faria Abbasi Feinberg
Yes, that's helpful.
- [16:40]
Dr. Sarah Nadeem
So it's kind of both of them feed off each other and kind of make it worse. Once we make a diagnosis, I believe we do the screening test. And as an endocrinologist, my next step is usually high suspicion or a high score. And I would refer to a sleep specialist for sleep study. Priya, is that the right approach to take?
- [16:58]
Dr. Faria Abbasi Feinberg
Yeah, I know it's difficult to get into a sleep specialist these days.
- [17:01]
Dr. Indrapreet Madhahar
Right.
- [17:01]
Dr. Faria Abbasi Feinberg
It's almost as difficult as getting into an endocrinologist because you guys are very busy people. And so, you know, I think we're looking at different practice models to make this easy, make this accessible for our colleagues, but also our patients. Doing a sleep study is the right next step. There are different types of sleep studies. There's sleep studies where you come into the sleep lab and you spend the night. And most of the time these days we do home sleep apnea tests and they're getting better and better with newer technologies that make it simpler. So we're trying to figure out how we increase access of care for everybody and make life easier. Yes, that would be the next step. And then once we have the diagnosis, you know, we have couple of different options available and we can go from there.
- [17:47]
Dr. Sarah Nadeem
And so what do you recommend as the first line management of therapy once you made that diagnosis of osa?
- [17:53]
Dr. Faria Abbasi Feinberg
You know, I really look at what's going on with the whole patient. You know, it's not that one size fits all. Everybody thinks that, oh, as soon as you're diagnosed, somebody is going to slap a CPAP on you. But that is not the case. You know, you have to evaluate and see, okay, what's going on. For some people, weight loss is the best choice. And, and if they have mild apnea, maybe that could be the sole intervention. But if you have more moderate or severe, you can do it in combination. Right. There are times that I look at somebody's sleep study and I see that all of their events occur when they're flat on their back. So you can do positional therapy. And there are various devices, either electronic or physical devices that help somebody sleep on their side versus their back. So you can help with that. There is a device called the excite osa. It's a neuromuscular electrical activation that you put stimulation that you put on the back of your tongue and it massages and strengthens the muscles in the back of the tongue. There are mandibular advancement devices that we use, and I'm a big fan of those. For the right people, we have surgeries available. In the past, we used to do the UPPs and the medicillomandibular advancement procedures. We don't do as many of those as we used to once, because now we have hypoglossal nerve stimulation that's available and I consider that surgical. And you know, up till last week, we had one device that was FDA approved and hot off the presses, just last week, another one got FDA approved. And then the other new thing is there's a couple of pharmacologic interventions that are going to be available. They're not available yet. Besides, you know, the weight loss option that we're going to probably talk about now, out of all of those, you're right. Pap therapy still tends to be our first option because it's effective. It, you know, people actually can tolerate it. 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. And in case of a emergency evacuation, that's what they're going to grab to leave the house. Right. And so there's lots of people that love cpap. When we look at data that's based on large cloud based data sets, at least 70% of our patients do really well with CPAP therapy. And you know, if we compare that to how many people take their antihypertensives, that's only 50%. So I think 70% is actually pretty darn good. And then if you throw in some modern technology with active patient engagement and some AI boosts the rate of people using it, compliance goes up to about 80%. So I think, you know, Pap therapy is still our gold standard, but you have to look at the whole situation.
- [20:26]
Dr. Sarah Nadeem
Yes. So I think, you know, there's also this historical perspective about this bigger CPAP machine or bigger masks. And I think people who may have abandoned their machines years ago, they probably can be nudged to go back to the sleep physician, which I end up having to do for a bunch of my patients because from my understanding now the devices, the mask, they've changed, they're more comfortable. Is that correct?
- [20:50]
Dr. Faria Abbasi Feinberg
That's absolutely correct. You know, I'm a big cheerleader for patients and so often people will come in and when I go through my usual spiel about the options, you know, when I mentioned cpap, they roll their eyes at me and I always just laugh and I say, don't roll your eyes, let's wait and see. And you know, there's a process of desensitization that you can work through with people. You know, I think you have to engage the person ahead of time and their bed partner. If their bed partner doesn't buy in, then you're out of luck. Right. Because everything that you do is going to bother them. And so it's a team effort. So I always love having their bed partner with them when they're there for their visit so that they can hear what's going on. And we work through the process and I'm there to help them work through the process because there's lots of little tweaks and adjustments that I can make to help them with things. And I think just knowing that Someone's going to be there to hold their hand is something that's very, very helpful to my patients.
- [21:44]
Dr. Sarah Nadeem
Yeah, that would be valuable because like you said, you know, a lot of times when I mention that, you know, and they're like, oh, I know how they treat it, and I'm like, no, just go and discuss the options at least. So I think for sure. Indrapreet, can you talk a little bit about, you know, if you also see initial hesitancy amongst your patients about treatment and then if you can talk a little bit about adjunct treatments that are available.
- [22:06]
Dr. Indrapreet Madhahar
So like Dr. Abbasi said, initial hesitancy with CPAP therapy. When I start screening my patients for obstructive sleep apnea, they always have this question, if you're gonna put that machine on, I'm not gonna go to that sleep medicine doctor again, because all they have to offer is the cpap. But then again, we are kind of talking to them about how the technology is improving, just like diabetes technology. How about insulin pumps? And this is how I kind of get them to discuss more of sleep apnea with me. That more as we kind of advance, more technologies coming our way. So that will be more helpful. So that is one second is I talk to them mainly about weight loss treatments because with the latest surmount OSA trial that came out that led to FDA approval of Tirzepatide or the brand name Zepbound for obstructive sleep apnea treatment. So that kind of opened many avenues for treatment of patients with obstructive sleep apnea. So now I proactively screen obese patients for moderate to severe OSA, even when they're consulting primarily for type 2 diabetes, metabolic syndrome or for obesity. And we have a really good sleep medicine clinic and the collaboration with them that has helped me to ensure that steep studies are done timely for these candidates. So for patients who are kind of meeting the criteria that obesity plus moderate to severe obstructive sleep apnea. So that's when we are kind of helping them to get zip bound prior authorized through insurance in a timely manner. So initially it was only for obesity. So now we are kind of making sure that obstructive sleep apnea is properly documented in their chart so that that insurance also they know that this is what we're using it for, not just for weight loss. So yeah, that is the alternative treatment available from endocrinology standpoint.
- [23:50]
Dr. Sarah Nadeem
Thank you, thank you for sharing the FDA label expansion for Tirzepatide being from moderate to severe OSA as well have you felt that that has changed your practice when you initially see a patient? Is that something that the patients are asking for or are they already on a CPAP and then that's something added on?
- [24:09]
Dr. Faria Abbasi Feinberg
Yeah, I mean, it's been exciting because honestly, the number of people that are willing to get evaluated has gone up. Right. And so it has raised awareness again about sleep disorders and sleep apnea. And, you know, people come in with a slightly different viewpoint as to, okay, you know, there's hope. And so I think just have that feeling of hope is great. I have a lot of my patients that are on CPAP that are doing well, that ask about Tirzepatide and if they are the appropriate candidates. I have no problem with prescribing that for them. You know, I've seen great success over the last year or two. I mean, there were people that were taking medications even prior to it becoming FDA approved. Right. They were taking it for other reasons or they were taking it off label. And they have done extremely well. And so it's been an exciting time to be in sleep medicine because we are seeing something that's really moving the needle for our patients. So I see a lot of patients that are on CPAP doing it. I do have some people that come in and that's what they want. And if they don't meet the criteria, for instance, if they have mild sleep apnea, they're not thrilled about it. But I talk them into other options at that point. And then, you know, some folks just want for Zepatide. They don't understand that we should probably also be treating their sleep apnea along the way, and then eventually we can reevaluate them. So if somebody has hypoxia down to 61% and their apnea hypopnea index is 100, I'm not going to just give them Tirzepatide. I'm going to convince them that we have to do more. But again, I think once people are in the office, you can talk to them appropriately and educate and they can take it from there.
- [25:49]
Dr. Sarah Nadeem
I'm very happy to hear that you're very comfortable prescribing Tirzepatite, but I have seen, at least in my practice, is that a lot of times we identify they're diagnosed with osa, START and cpap. Usually the prescribing falls to the endocrinologist. I don't know if that's your experience as well.
- [26:05]
Dr. Indrapreet Madhahar
Yes, it has been.
- [26:07]
Dr. Faria Abbasi Feinberg
Yeah. I have to admit, I didn't go willingly into the world right when it first was FDA approved, I thought, okay, I'm going to work with my primary care colleagues and my endocrinology colleagues. But everyone's busy, everyone has full schedules and trying to get these patients help in a timely manner fell back on me. And you know, I've talked to a lot of my sleep colleagues and there's some that are prescribing and are comfortable, there's some that are not. And I think it depends where you practice and what kind of support you have. I insist that my patients also talk to a nutritionist, dietitian and I get them involved with that as well because I feel like I want them to have long term success. And you know, everybody wants that quick fix but you don't succeed long term with just that quick fix. You're going to have to make some changes. And we still don't know long term what we're going to do with these people in a year from now, two years from now, if their sleep apnea is gone, you know, will insurance now stop providing them their medication because now they don't have an indication anymore or will these people continue to be able to get the medication that they need? Because obesity as we all know it is a long term management issue. Right. So there's still some unknowns and I'm maneuvering through and hopefully we'll figure it out with your guys help.
- [27:25]
Dr. Sarah Nadeem
Thanks. Yes, I agree with you like in terms of chronic disease, obesity is considered a chronic disease and I will give the example of diabetes. So a lot of the GLP1s, you know, sometimes people end up losing a lot of weight and their diabetes is really well controlled. I have patients asking about, you know, so now it's gone, like the diabetes is gone or the A1C is so much better but kind of reframing it that this is a chronic disease and this is a chronic medication. But I understand the concerns we all also have and have struggled with is that will insurance be covering it once you know the parameters all improve. So do you consider indiprit you can chime in on this one when you would start tirzepatite for OSA and or obesity. Is this a discussion that you have with your patients about the long term management and you know that it's not short term?
- [28:15]
Dr. Indrapreet Madhahar
Yes, always. I always start with the lifestyle advices first that you know, diet, exercise always have to come first and third avenue is the medication. So I tell them that, see if you're not going to follow the diet and exercise pattern, the medication has to be you know, a long term kind of mode of treatment. But if you can lose weight with just diet and exercise, it's going to kind of help you keep that weight off. Not promising that it's going to be off in the next few months. The medication will be discontinued in the next few months. But I do talk to them about the surmount OSA trial that when we are comparing just the use of Tirzepatide as compared to just diet and exercise, the improvement in apnea hypopnea index was much more as compared to just diet and exercise alone. So if they are kind of not losing enough weight despite the use of Zeppelin or Tirzepatide, that's basically bummer down the road. So that kind of weight regain I commonly see in some patients despite the use of Tirzepatide. When we start these medications, I do tell them that the use of is going to be one year or more and it has to be combined with diet and exercise. Not alone, not medication, just alone is not going to do any kind of magic bringing at that point I do usually bring into the discussions around USA trial and talking to them that how Tirzepatide kind of improved the ahi, the apnea hypopnea index in comparison to just diet and exercise. So when we're looking at Tirzepatide we are looking at a lot of weight loss. But if you look at the level of inflammation that was brought down by Tirzepatide or Zeppelin, so that was kind of very impressive. So we also have to look at the molecular mechanism of action of this drug that possibly right now we don't know how it's kind of affecting obstructive sleep apnea treatment so much. We're looking mainly at weight loss, but down the road maybe we could come up with some mechanisms which could possibly be affecting inflammation, you know, treating inflammation, maybe treating diabetes or treating the carotid branchy map. So when we're kind of talking about the use of this drug on a long term basis, I do tell them that most likely it's going to be a long term medication but they have to incorporate some lifestyle changes, diet and exercise. At that point we can discuss more about surmount OSA trial and how tirzepatide it lowered not just the weight but also the inflammatory markers that also help reduction in OSA events or the HI index in comparison to just the placebo or diet and exercise of both arms. Of that study they incorporated diet, exercise, but only one arm was able to show such a Significant reduction in obstructive sleep apnea. So in my opinion right now, 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. So that's not how it works for now. Maybe in future, once they lose weight, they have incorporated diet and exercise properly into their lifestyle, maybe they're able to maintain that weight loss and they can stay off the medication. So that could be a possible mechanism. But for now I think it's a chronic medication.
- [31:30]
Dr. Sarah Nadeem
Thank you. So far as Indipeet mentioned, in terms of treatment is chronic and long term. When you have your initial discussion after the diagnosis of OSA about what complications come from untreated sleep apnea, apnea, what have we seen how CPAP as well as tirzepatide, how do they decrease that complication rate? If you could talk a little bit about that.
- [31:50]
Dr. Faria Abbasi Feinberg
No, of course, you know, in the end we are looking for what are the end results of what we're doing? Right. What are the, what are the treatment options doing? So, yes, I always talk to patients about what we think are the increased risks. So we know that some of them are related to the constant hypoxic burden that patients with obstructive sleep apnea and if it's untreated have, there seems to be a higher risk of cardiovascular disease, hypertension, some cognitive dysfunction, things like that. We know that the frequent awakenings during the night that are associated with it, the sleep fragmentation causes significant daytime sleepiness and that affects quality of life issues. So people have trouble with driving, have trouble at work, have trouble with interpersonal relationships. And so those are sort of the untreated effects that we look at. You know, there's been some debates as to what are the long term outcomes of treating somebody with CPAP therapy. And you know, the data that we have is a little bit mixed and we're still trying to sort through now we know that it definitely helps people feel better. That's a definite. We know that it helps people's blood pressure in terms of cardiovascular risk. We're sort of stratifying the data, trying to see does it make a difference if someone has mild sleep apnea or more moderate to severe. And it seems to be that for moderate to severe sleep apnea, it seems to make a difference. For people that have mild sleep apnea, I think we need to look at it a little bit more carefully. And so those studies are still ongoing. Yeah. In terms of the question you asked about Zepbound, I don't think we have all those answers yet. Right. I mean some of this data is fairly new. There's ongoing studies right now that are looking at longer data points and I'm excited to see, you know, where we end up with all of this.
- [33:34]
Dr. Sarah Nadeem
No, that's helpful. And that's why like from an endocrine perspective we have relatively long term data about GLP1s in diabetes and then now with obesity, I was curious to know more about the OSA information and I guess we still have a lot to learn the longer these are in the market or these are used. Would also want to point out like in the Preeth you mentioned that you have a multidisciplinary group practice where there is endocrinologists and sleep medicine working together. So could you talk a little bit about that?
- [34:02]
Dr. Indrapreet Madhahar
So yes. So as we have kind of started seeing more obesity patients for as the, you know, the GLP1 awareness has been rising in most of the patients. So most of them they're coming. That's when I start screening for obstructive sleep apnea, basically. So when they're complaining about fatigue, that's my first go to question is do you feel tired during the day? So that's when I start screening them with the Stop bank or Berlin questionnaire. Those are two main questionnaires that I use. And then I feel like in patients who have BMI more than 35, that's when I commonly start seeing obstructive sleep apnea. And in those cases you'll start seeing that, you know, even you don't need to even go through full Stop bank questionnaire at all. Most of the patients, they have full fledged signs of obstructive sleep apnea and that's when I just usually refer them to sleep medicine and they undergo polysomnography or the at home sleep study and usually we kind of get the results and that's when I kind of start prescribing tirzepatide. So I hope that's the question you're asking. Is that right Dr. Nadeem?
- [35:08]
Dr. Sarah Nadeem
Yes, that was helpful. And I was trying to understand how like in terms of developing a multidisciplinary way of managing osa. Faria also alluded to like, you know, I think as a sleep physician, as an endocrinologist, getting those referrals in and coordinating that care, how can we make that better? And is there a way we know that, you know, there Exists a perfect way to kind of make this happen so that the patient is not waiting to see the sleep doctor and then the endocrinologist and then starting treatment somehow, like the model where we manage in diabetics, we manage, you know, eye disease. We have clinics sometimes where. Where the person can come in and have their foot exam, eye exam, and see the endocrinologist and the nutritionist at the same time. So do you foresee a multidisciplinary group practice model like this?
- [35:53]
Dr. Faria Abbasi Feinberg
I would love that if that was accessible for everybody. You know, I think every practice is different and every location is different. So in my practice, the practice that I'm in is mostly primary care and then a handful of specialists. And so I've come up with a program and I'm allowing basically the primary care docs to go ahead and order a sleep study. If they're is a high probability and the patient is at high risk for having obstructive sleep apnea, we have a process where they can put the order in. This patient has a device mailed to them. They have the sleep study done. I can look at the results, and then I contact the primary care physician and tell them the results. Then we can discuss what to do. That's really sped up the whole process quite a bit. We have to look at programs like that to make sure that we can increase access for our patients. Because if there's 50 million people that need to be evaluated, there's just not enough of us to be able to do all of this. Coming up with some inventive ways to work through this problem.
- [36:59]
Dr. Indrapreet Madhahar
In my practice, yes, we do have access to sleep medicine, but I feel like as we involve more primary care, as the awareness to obesity treatment is rising, we are kind of getting the nurse practitioners, the PAs involved. What we're doing is we're holding monthly, sometimes, you know, once in two months, lectures for primary care physicians and the NPAs. I think the more we involve primary care, the better screening we can get out of the system. So I don't want the primary care people to just wait for the endocrinology referrals. Usually what I see is they are referred to endocrinology practice for sometimes hypogonadism, sometimes for fatigue. So those are the cases when you start screening for obesity. But then this is the kind of awareness I want the primary care to have. So I think one way we can kind of increase the whole awareness would be possibly through, you know, more webinars, more lectures. So that's what we are doing in our practice. And this is the trend that I'm seeing now that most of the patients have already undergone the screening by the time I see them in comparison to what I used to see in the past, the patients would wait for them to see me and then we'll be referring patients to sleep medicine. So I think that will bypass my clinic or at won't waste a patient's time to see a sleep medicine physician.
- [38:22]
Dr. Sarah Nadeem
I think both of you added really valuable insight about how, you know, education and maybe empowering other members of our team to kind of getting the process started is helpful. And I also wanted to get your thoughts on in the preet on we see a lot of patients and not just us, us as endocrinologists, but primary care and as well as there are many standalone clinics that are kind of quite busy diagnosing people with low testosterone levels. And I kind of always, that's something where I'm always like, if I see a new patient with hypogonadism, low testosterone, you know, doing a full workup. The evaluation of OSA is also very important because untreated sleep apnea and if testosterone treatment is started could actually be harmful. So, yes. Could you both Fariya and Indrapreet, if you can, comment on that population, which there's a huge large group of people on testosterone replacement, some with the right indications, some unfortunately not because it's unregulated for a little bit. So if you can talk a little bit about that.
- [39:20]
Dr. Indrapreet Madhahar
So usually how I explain to my patients would be that 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. So testosterone not likely would help you with your symptoms. It could possibly make you feel more tired and that could worsen the cytosis and all, you know, the complete bed count numbers in these patient populations, I think the awareness for obstructive sleep apnea and not starting testosterone right away, I think that would be a good step. And possibly the education, again, I would say primary care because they're the first kind of go to people for every patient. So I would not recommend starting testosterone in such patients and just wait so that we can screen them properly.
- [40:06]
Dr. Sarah Nadeem
And Faria, what are your thoughts as a sleep physician? Do you see a lot of patients on testosterone before they've been evaluated for osa?
- [40:14]
Dr. Faria Abbasi Feinberg
Absolutely, yes, I do. You know, there's so many times when somebody presents with, oh, I'm so tired and they get treated with something. And typically most of my patients will tell me that. You know, it initially seemed to help a little bit. I thought I felt a little bit better. And now I'm six months into this and I'm not as good as I'd like to be or you know, I'll hear the oh, it didn't really help at all type of situation. And that's when they come to me. You know, I definitely see it. And like you said, it's difficult for me as a non endocrinologist to always know was the indication appropriate or not. And you know, I'm not the person who's going to tell the patient that, of course, but my job is to evaluate them for what else is going on. And so if they have obstructive sleep apnea, I can definitely help them with that.
- [41:02]
Dr. Sarah Nadeem
And so have you seen the dangers? I guess, because from a sleep medicine perspective, we don't see that. But like somebody who may have started testosterone and not been evaluated or not optimally treated for USA with ending up with complications or with worsening hypoxia, it's.
- [41:18]
Dr. Faria Abbasi Feinberg
Hard for me to tell. Right. Because by the time they come to me, they're already on their testosterone. So I'm not really doing comparison studies on them. But you know, some of these gentlemen have really pretty enlarged necks and you can just, you know, you can just see them struggling to breathe when they're sitting there. Whether that's because of the testosterone or because of their anatomy and physiology already ahead of time, it's really difficult for me to say.
- [41:42]
Dr. Sarah Nadeem
Yes, you're right. Yeah, well, that would be a great study, I think. You know, people going to testosterone low T clinics and kind of doing that. I think that's a great idea probably going forward. I know. Fariya, you had mentioned that besides tirzepatide, which is currently the only FDA approved medication for osa, that what are some things in the pipeline that you would like to talk about?
- [42:04]
Dr. Faria Abbasi Feinberg
Yeah, it's an exciting time to be in sleep medicine. It really is. So there are two medications that are combination of medications that we already have in the system that are being evaluated for sleep apnea. The first one is a combination of atomoxetine and aroxybutynin and you would think, well, how in the heck would that do anything? But it turns out that there is some way that it affects the neurotransmitters. So norepinephrine and, and acetylcholine and they all have to do with movement of the tongue and the airway. And so this particular molecule has had the phase two studies and recently phase three study trials results have come out and they're actually rather promising. Depending on what happens over the next six months, I think we're expecting more data. That's going to be an exciting avenue for people. The other medication that's out is going to be a combination of acetazolamide and dronabinol. And again, both of these are medications that have been FDA approved for other indications. And somehow this combination seems to help. We think that the acetazolamide is causing a little bit of a metabolic acidosis and that seems to increase respiratory drive. And dronabinol targets and binds to cannabinoid receptors and it stimulates airway dilatation. And so again, you know, if you would have asked me 10 years ago, are we ever going to have a pill for sleep apnea, I probably would have have said absolutely not. But here we are. And so I love that science evolves and we learn things and we try new things. And I can't wait to see what the results of these studies are going to be. And it's going to change the way we practice sleep medicine, for sure.
- [43:44]
Dr. Sarah Nadeem
Exciting times like with new medications coming in. And so that brings me to ask about. So this appears like a multi pronged approach to management of osa, right? With tirzepatite targeting sleep and maybe having the central effects which affect it, and then the CPAP machine. So do you feel like we would be using all of these in combination going forward?
- [44:07]
Dr. Faria Abbasi Feinberg
I think it's going to be great to have options available for patients. And it's going to take us years to come up with new clinical practice guidelines. Right. I mean, the American Academy of Sleep Medicine is always looking at best practices and trying to help our membership and help our patients as to what the best order is. And I think it's going to take us a while to source through everything. You know, right now what we have available seems to be that if you, if you're doing tirzepatide, you should also treat the underlying apnea along the way. And so I often will retest people after they've had a significant weight loss or if they, you know, get to their goal weight or close to their goal weight. I usually have them skip their Pap device for a couple of nights and see how they feel. And if they feel great, then it's worthwhile to retest them. You know, if at that point they're still Snoring and gasping and their bed partner tells them that they still are not sleeping well, then we usually hold off until more weight happens. And it's very much an incentive for patients to see the improvement in their numbers and to see that things are getting better. Because then they say, okay, I'm going to keep doing this. I'm going to keep working on this long term. And of course, as you guys all know, with the GLP1s, people don't only just see the weight, but they see their metabolic parameters come down so their cholesterol is better. You know, their blood pressure comes down as they lose the weight and they're just overall feeling better, their joints hurt less. And I think all of that seems to help with their sleep as well, you know, so I think the multi pronged approach works great. It's going to be, you know, partially what is the best multi part, multi pronged approach for which patient. And you know, I think we're finally getting to the point where we can really provide precision personalized care for patients with sleep apnea.
- [45:55]
Dr. Sarah Nadeem
Indrapreet, do you have any input about your patients and, you know, their feedback since Tirzepatide is on board? And then looking forward at the newer medications that Fariya just talked about.
- [46:08]
Dr. Indrapreet Madhahar
So I have been offering them Zepound for obstructive sleep apnea. So I have both sets of patients who have been extremely compliant and who have been non compliant. I have patients who have lost £100 and have come off of the CPAP machines completely. And then I have patients who have gained weight on, you know, despite being on tirzepatite. So it's more about patient response, how they're complying to diet, exercise and their medication regimen. When I talk to them about the newer medications, I do see a lot of medications come on the horizon in terms of GLP1 and GIP. And with the triple GS, I do see a lot of hope coming up. I do see a lot of, you know, right. Options in terms of medication management for obstructive sleep apnea and not just the CPAP machine. So I think in future endocrinology would be contributing as much to the treatment of sleep apnea as much as we see the sleep physicians are doing. So I feel very confident about that.
- [47:05]
Dr. Sarah Nadeem
Great. And I'm curious to know, you mentioned people gaining weight while on tirzepatite. So is that a compliance issue of not taking the medicine or just not being able to tolerate higher doses?
- [47:16]
Dr. Indrapreet Madhahar
Very much a compliance issue. More than Compliance. They are taking the medication expecting that it's going to keep the weight off while they're not working on their diet, exercise as much. I asked them to, you know, caloric deficit, all these things are very important that you know, gaining weight while you're on the medication, it could be a kind of a worse sign for their overall management. So I do see compliance more than the dose issue. I think there's appetite if anything gets tolerated better than what we have seen in any of the GLP ones in the past. So dose is not as much as an issue, I would say.
- [47:52]
Dr. Sarah Nadeem
So I'd like to end with asking both of you and Indeprit, you can go first about any comments or any anything else you would like to add to the conversation that we've had today about the management of sleep apnea and the role of different modalities for its treatment.
- [48:06]
Dr. Indrapreet Madhahar
I would like to involve more primary care, more education for them, you know, so that we can have a broader screening base, a lesser burden for specialties. That will be my comment. And then start treatment early. Diet, exercise and of course from endocrinology standpoint I think we have Zeppelin Ultra's appetite as a treatment and yes, involvement, a multi pronged approach, involvement of sleep medicine earlier would be better because if you leave one side unaddressed, the treatment results are not going to be as good as you would expect.
- [48:36]
Dr. Sarah Nadeem
Very helpful, thank you. And Fariha.
- [48:39]
Dr. Faria Abbasi Feinberg
Yeah, I think I'd like to emphasize that people should not be afraid of being evaluated for sleep apnea. Yes, PAP devices work wonderful and yes, they're still a mainstay of therapy but there are so many other options available and we really are talking to people and trying to meet them where they are and go from there to come up with the best solution for that patient in that particular circumstance. 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's some new options that are coming down the line. There's help out there. I think it's surprising to me how many people don't even know that there is a specialty called sleep medicine. Probably not amongst your readership, but amongst the general public. And so I always put a plug in for. We've got a couple of great websites through the ASM. We've got sleepeducation.org and then we have Sleep is Good Medicine and Sleep is Good Medicine is a public awareness campaign that we're doing which is really geared towards both providers as well as patients. And so I would strongly recommend that your, your listeners perhaps go and check those out and use some of that information to help their patients.
- [49:53]
Dr. Sarah Nadeem
That's very helpful to know because I think in terms of educating our patients, those are good resources to go to. Thank you so much. So I'd like to end our conversation and thank you so much to our guests, Dr. Vasi Feinberg and Dr. Madhe, for sharing your valuable expertise. Thank you so much.
- [50:10]
Dr. Faria Abbasi Feinberg
Thank you. It was a pleasure.
- [50:11]
Dr. Indrapreet Madhahar
Thank you.
- [50:17]
Dr. Faria Abbasi Feinberg
Thanks for listening to another great ACE podcast. Join us for another episode@aace.com podcasts and help us in our mission to elevate clinical endocrinology. Together, we are ACE.