By Atul Malhotra, MD

Obstructive sleep apnea (OSA) has major cardiometabolic and neurocognitive consequences and is estimated to affect up to 1 billion people worldwide. The expectation that all of these patients (and many more at risk) will see a board-certified sleep specialist and undergo polysomnography seems quite unlikely. Therefore, scalable models are required to address this global burden of disease. A few predictions are offered for the future of the OSA field:

  1. Although home sleep apnea testing is here to stay, multiple nights of recording will likely become the standard of care. Data are increasingly showing that night-to-night variability can make a single-night estimate of OSA severity unreliable or even misleading. Indeed, some data show the ability to predict hypertension and other important outcomes is improved by multiple-night recordings as compared to a single night. Thus, technologies that allow serial data assessment will likely gain in popularity.
  2. The apnea-hypopnea index (AHI) will likely become one of many metrics of disease severity. Data suggest that the ability to predict important OSA consequences differs by varying AHI criteria. Based on the underlying biology, one might find it surprising that one metric was able to predict heterogeneous outcomes including vascular disease, Alzheimer’s, cancer, patient-reported outcomes and motor vehicle accidents. Thus, the optimal metric of OSA severity will likely depend on the outcome of interest. Panels of biomarkers, perhaps individualized based on individual preferences, may help to improve predictive value compared with a single metric alone.
  3. OSA heterogeneity will likely need to be considered to optimize disease management. The current “one-size-fits-all” approach of diagnosing and treating OSA could likely be improved via principles of personalized medicine. OSA is now recognized to have varying underlying endotypes (or mechanisms), suggesting that OSA may not be one disease but multiple diseases that may culminate in clinical expression. Treatment of OSA based on underlying mechanisms (e.g., hypnotics for low arousal threshold or muscle training for upper airway dilator muscle dysfunction) is the topic of ongoing research but may be fruitful for some patients. Regarding clinical OSA phenotypes, there is also recognized heterogeneity with some patients having sleepiness, others having disrupted sleep, and others being relatively asymptomatic. Some data support the notion that only the subset of patients with OSA who experience sleepiness are at cardiovascular risk, suggesting that the >50% of patients without sleepiness are unlikely to have major cardiovascular benefit from intervention. Clearly, endophenotypic variability in OSA will need to be appreciated and understood better to optimize disease management.
  4. OSA is commonly associated with obesity, which is a risk factor for OSA. Treatment of OSA in some cases can lead to minor weight gain. Randomized trials have suggested that treatment of both OSA and obesity will be required to optimize cardiometabolic outcomes in afflicted patients. Although weight loss can lead to improvements in OSA, resolution of OSA via weight loss is relatively uncommon clinically. The newer GLP1RA medications can lead to important weight loss; however, studies are ongoing regarding how effective these medications will be in longer-term management of OSA. Although these medications are generally well tolerated, in some studies ~70% of patients discontinue GLP1RA treatment within two years due to issues such as expense, availability, side effects, and inconvenience. Considerable data show abrupt regain of weight following discontinuation of these medications, suggesting they may not be a long-term solution for many afflicted patients. Regardless, comprehensive management of OSA will likely involve addressing risk factors as well as the OSA per se.
  5. Sleep health equity is an increasing topic of discussion. More widespread availability of inexpensive diagnostic testing will likely make the OSA diagnosis more accessible. Increasing appreciation for the unique challenges of various marginalized groups will also likely help to improve overall outcomes in OSA management.

In summary, considerable progress has been made in recent years in OSA diagnosis and treatment, yielding a major sense of optimism for the future of OSA care. Coordinated, multidisciplinary efforts will be required to optimize OSA management and associated outcomes. With health care gradually reforming to emphasize quality versus quantity of care (value-based purchasing versus volume-based), the value of treating OSA is likely to be a major source of discussion in the future.

Atul Malhotra, MD, is triple board certified in pulmonary disease, sleep medicine, and critical care medicine. He is chief of pulmonary, critical care, and sleep medicine at the University of California, San Diego School of Medicine.

This article appeared in volume nine, issue one of Montage magazine.