Multidisciplinary panel highlights considerations for GLP-1 agonist use in OSA

The glucagon-like peptide-1 (GLP-1) agonist tirzepatide is a prominent new treatment option for patients with both moderate to severe OSA and obesity following approval from the US Food and Drug Administration (FDA) late last year.

To help clinicians navigate this new landscape, a multidisciplinary panel discussed the practical aspects of prescribing GLP-1 agonists for OSA during the CHEST 2025 session Your Patient Wants a GLP-1 Agonist for OSA: What Next? on Tuesday, October 21, in Chicago.

Which patients qualify?

Chitra Lal, MD, FCCP, Clinical Professor of Medicine at the University of Utah, discussed the current indications and coverage criteria for use of tirzepatide for treatment of OSA. She also looked at possible roles for other GLP-1 agonists in OSA treatment.

The inclusion and exclusion criteria of the SURMOUNT-OSA phase 3 trials are important to consider, Dr. Lal said, because insurance coverage decisions are based on and try to replicate the patient population enrolled in the trials that led to FDA approval. However, FDA approval doesn’t necessarily guarantee coverage.

“There is a lot of variability in coverage criteria,” she said.

Romy Block, MD, Assistant Clinical Professor of Medicine at the University of Chicago Pritzker School of Medicine, discussed GLP-1 agonist coverage criteria more broadly and said that patients must begin by checking with their insurance provider.

“You are a partner with your patient. You did not pick their insurance and you don’t know their deductible. It has to start with them,” Dr. Block said.

Most patients qualify for weight loss coverage, which requires a body mass index over 30 or over 27 with two medical conditions, Dr. Block said. He advised including ICD codes in the prescription documentation to facilitate coverage. If coverage isn’t approved, two out-of-pocket options are available, he noted.

How to be thoughtful when prescribing?

Allison L. Rhodes, MD, Assistant Professor of Clinical Medicine at the Ohio State University Wexner Medical Center, discussed the clinical decision-making in managing obesity with GLP-1 agonists.

Obesity is a chronic disease of dysfunctional and inflammatory adipose tissue, Dr. Rhodes said, emphasizing that clinicians should select a treatment plan for obesity according to the disease’s severity and the extent of complications, such as OSA. Managing obesity requires a personalized and adaptable approach for each patient, with lifestyle interventions as the essential foundation, she said. 

“If patients are coming in thinking that just giving themselves a weekly injection is going to solve all their problems, they’re not going to necessarily achieve the degree of weight loss that was seen in the trial,” Dr. Rhodes said. “It’s important to make sure you are advising patients on what needs to go along with their weekly injection for optimal results.”

She noted that the participants from the GLP-1 trial were provided regular counseling sessions; were encouraged to consume healthy, balanced meals and keep a deficit of 500 calories per day; and were advised to achieve at least 150 minutes of physical activity per week.

What about side effects and other drug interactions?

Dr. Block explained that the most common side effects associated with tirzepatide are nausea, queasiness, and vomiting. He recommended taking it low and slow in terms of dosing and titrating, starting at 2.5 mg weekly for at least a month if possible and titrating up to 7.5 mg, the approved dose for OSA.

Beyond gastrointestinal side effects, GLP-1s can also increase resting heart rate and decrease blood pressure, said Matthew Biszewski, PharmD, BCACP, BCGP, Clinical Pharmacy Specialist at Endeavor Health Medical Group.

GLP-1s can increase the risk of gallbladder or biliary diseases, but overall, the risk is low, Dr. Biszewski said. Recent studies showed a reduction in pancreatic cancer risk with GLP-1 agonists compared with other medications for diabetes, he said.

In terms of pharmacokinetic drug interactions, GLP-1s are unlikely to have significant drug interactions via transporters. The pharmacodynamic drug interactions are much more important, Dr. Biszewski said.

“The reduction in fat mass, reduced inflammation, and increase in glomerular filtration rate can, in theory, change how drugs are distributed throughout the body. But the most important interaction is probably more related to delayed gastric emptying,” he said.

Importantly, Dr. Biszewski said, a drug interaction has been identified with oral contraceptives, and this appears to occur exclusively with tirzepatide. As for the future, he said, “more medications are likely going to be on the horizon. There’s a nonpeptide GLP-1, an even longer-acting GLP-1, and then dual and triple agents.”