Diabetes Core Update: Special Edition – OSA Part 4 – Bringing it All Together
Date: September 22, 2025
Podcast Host: American Diabetes Association
Episode Theme: Integrating Knowledge of OSA Into Real-World Clinical Decision-Making
Presenters:
- Dr. Neal Skolnick (Host)
- Dr. Sanjay Patel (Guest, Professor of Medicine, UPMC)
- Dr. Susan Kucera (Guest, Program Director, Jefferson Health Abbotton Family Med Residency)
Episode Overview
In the fourth and final installment of the special series on obstructive sleep apnea (OSA), the panel synthesizes prior discussions—covering OSA epidemiology, diagnosis, and treatment—by working through a detailed patient case. The focus is on real-world dilemmas, evidence gaps, and the implications of recent advances (notably, the Surmount OSA trial and the approval of tirzepatide for OSA with obesity). The conversation addresses both practical and conceptual decision points relevant to clinicians handling OSA in patients with diabetes and multiple comorbidities.
Key Discussion Points & Insights
1. Case Introduction & Diagnostic Approach
- Patient Case: 58-year-old man with excessive sleepiness, loud snoring, unrefreshed awakenings; BMI 36; physical exam notable for thick neck ([02:47]-[03:59]).
- Dr. Kucera notes that this presentation is "such a common story" and reinforces high pretest probability; diagnostic barriers exist, including access issues and insurer reluctance for home sleep studies.
- Both Drs. Kucera and Patel agree on home sleep testing as the preferred initial step where available due to convenience, patient preference, and equivalent performance in typical high-pretest-probability cases ([05:11]-[05:50]).
“There are lots of data that show that in patients with high probability... home sleep tests have equivalent performance to in-lab sleep studies. Home testing is quicker, easier, more convenient for patients.”
— Dr. Sanjay Patel [05:19]
2. Interpreting Negative or Discordant Test Results
- Dr. Patel warns about false negative results being more common in home tests, due to sleep misestimation and poorer signal quality. Clinicians should not dismiss high clinical suspicion based on one negative test ([07:02]-[08:04]).
“If your clinical suspicion is high... I wouldn’t believe a negative home sleep test and instead I would follow up with further testing.”
— Dr. Sanjay Patel [07:24]
3. Staging and Definitions
- Dr. Skolnick briefly reviews AHI cutoffs for mild, moderate, and severe OSA ([08:04]-[09:11]).
4. Treatment Landscape in 2025: Integrating New Evidence
- Dr. Kucera highlights how the landscape “looks very different now,” emphasizing the impact of the Surmount OSA trial and recent FDA approval of tirzepatide for OSA with obesity ([09:11]-[13:25]).
- Surmount OSA trial details: ~500 participants with moderate-severe OSA and obesity, but not diabetes; tirzepatide group had major reductions in AHI (20–24 event decrease), with secondary benefits (BP, weight, CRP). Weight loss averaged 18% of total body weight.
- Implications: Tirzepatide offers new therapeutic options, especially for patients not tolerant of CPAP or those disengaged from sleep medicine care.
“This really forces us to consider the use of tirzepatide in our patients with obesity and moderate to severe OSA.”
— Dr. Susan Kucera [11:35]
5. Shared Decision-Making and Aligning Therapy to Patient Goals
- Dr. Patel advises starting treatment conversations by clarifying patient’s goals—whether symptom relief (CPAP/dental appliance for immediate improvement) or risk reduction (tirzepatide for blood pressure, weight, cardiometabolic benefit). ([13:25]-[16:01])
- On symptom benefit: quality of life and sleepiness improvements from tirzepatide in the trial were modest.
“If the patient’s goals are to address symptoms... I’d probably start by talking about traditional treatments like CPAP or dental appliances... but if [they] want to address their cardiometabolic risk, the Surmount OSA trial showed much larger improvements.”
— Dr. Sanjay Patel [13:50]
6. Emergence of Co-Management Between Primary Care and Specialists
- Both guests predict growing co-management for OSA and obesity, as seen in diabetes/cardiology care with GLP-1s, especially given primary care’s comfort with these agents ([16:01]-[17:27]).
“Given that primary care is generally comfortable with it, it seems like the obvious thing to hand off and co-manage with.”
— Dr. Sanjay Patel [17:10]
7. Patient Selection & Indications for Specialist Referral
- Dr. Kucera seeks guidance: which patients must see sleep medicine? Dr. Patel prioritizes patients with severe symptoms, safety risks, or those needing alternative treatments (dental appliances, surgery, advanced CPAP support) ([17:33]-[18:56]).
“People who are having trouble keeping their eyes open, where it’s impacting their work performance... those patients clearly we should see.”
— Dr. Sanjay Patel [18:15]
8. Timing and Insurance Challenges When Initiating Tirzepatide
- If patients start tirzepatide before formal sleep testing, they may lose enough weight to fall below AHI threshold for insurance coverage—patients and clinicians must be aware of this quirk ([19:09]-[20:16]).
“By that time they’ve lost 25 pounds and we do the sleep study and they no longer have moderate to severe sleep apnea... That’s the complicated issue with our health insurance system that we’re dealing with.”
— Dr. Sanjay Patel [19:47]
9. Behavioral and Lifestyle Aspects Remain Foundational
- Both emphasize that behavioral strategies (sleep hygiene, weight loss, exercise, avoiding alcohol/back-sleeping) should accompany medication or device therapy for OSA ([20:16]-[22:10]).
- Surmount OSA trial included active lifestyle intervention in both arms, leading to clinically meaningful symptom improvement even in the placebo group.
“If you look at the Surmount OSA trial results... the symptom improvement in the control arm was quite substantial. And some of that may be a placebo effect, but I think a large effect... was getting all of these patients on a regular exercise regimen really helped improve their symptoms.”
— Dr. Sanjay Patel [21:32]
10. CPAP (PAP) Therapy: Practical Details
- CPAP is highly efficacious at normalizing breathing, but adherence is the main limitation—75% at three months, declining over time ([22:49]-[23:59]).
- Auto-titrating PAP devices have “revolutionized” care, allowing for easy initiation and dynamic pressure adjustment, accommodating patient weight changes ([24:22]-[25:52]).
“If the patient loses weight, the machine will automatically lower the pressure over time... As long as their machine is working well.”
— Dr. Sanjay Patel [25:52]
Notable Quotes & Memorable Moments
On OSA Diagnostic Uncertainty
“When you get a test that is dissonant from what you expect, be careful, don’t just accept the results of the test.”
— Dr. Neal Skolnick [08:04]
On Inter-specialty Collaboration
“We’re doing a lot more co-management along with our cardiology colleagues... I suspect we’re going to be seeing a lot more [in OSA].”
— Dr. Neal Skolnick [16:01]
On Empowering Primary Care
“This is just one more tool in our toolbox and realizing all of our patients are complex... we are really good in primary care at talking through [behavioral changes] with patients.”
— Dr. Susan Kucera [26:23]
On Major Practice Transitions
“It’s really great that the Surmount OSA trial has gotten so much press and gotten so much interest about sleep apnea amongst the primary care community, because this is really something that we could use the help of the primary care doctors in taking care of...”
— Dr. Sanjay Patel [26:56]
Timestamps for Key Segments
| Topic | Speaker(s) | Timestamp | |----------------------------------------------|---------------------|------------------| | Episode series recap and OSA importance | Dr. Skolnick | 00:03 – 02:47 | | Case introduction | Dr. Skolnick | 02:47 – 03:59 | | Diagnostic approach, barriers, home testing | Drs. Kucera, Patel | 03:59 – 05:50 | | Handling ambiguous test results | Dr. Patel | 07:02 – 08:04 | | AHI scoring and severity definitions | Dr. Skolnick | 08:04 – 09:11 | | Treatment advances, Surmount OSA trial | Dr. Kucera | 09:11 – 13:25 | | Aligning treatment to patient goals | Dr. Patel | 13:25 – 16:01 | | Co-management trends, GLP-1 analogy | Drs. Skolnick, Patel| 16:01 – 17:27 | | Who needs sleep medicine referral? | Drs. Kucera, Patel | 17:33 – 18:56 | | Insurance, weight loss, and diagnosis timing | Drs. Skolnick, Patel| 19:09 – 20:16 | | Behavioral aspects of OSA | Dr. Patel | 20:16 – 22:10 | | PAP therapy: efficacy and adherence | Dr. Patel | 22:49 – 23:59 | | Auto-titrating PAP and practical pearls | Dr. Patel | 24:22 – 25:52 | | Final thoughts and takeaways | All Speakers | 26:11 – 27:17 |
Key Takeaways for Clinicians
- OSA is underdiagnosed but highly impactful; high clinical suspicion should override isolated negative test results, especially with classic symptoms and risk factors.
- Home sleep studies are practical, reliable, and preferred for most high-probability cases, but interpret results contextually.
- The Surmount OSA trial and tirzepatide approval have shifted the treatment paradigm, particularly for OSA with obesity—offering new, evidence-based therapeutic options beyond PAP.
- Collaborative care, shared decision-making, and routine primary care involvement in OSA management are increasingly crucial.
- Behavioral changes and lifestyle interventions remain foundational—even with advanced pharmacotherapy and device options.
- Practical barriers, especially around insurance coverage and compliance, require awareness and transparent discussion with patients.
This summary provides clinicians with a structured and practical distillation of the episode’s case-based discussion—and the latest research and treatment guidance for OSA in patients with diabetes and obesity.