重新思考肥胖患者阻塞性睡眠呼吸暂停的诊疗：持续气道正压通气、基于肠促胰素的治疗，还是两者兼用？

文献信息

中文摘要

背景： 肥胖是阻塞性睡眠呼吸暂停的主要驱动因素，并显著促使其相关的心血管发病率和死亡率。尽管持续气道正压通气仍是标准治疗，但其疗效常因患者依从性欠佳而受限，且其对心血管结局的影响尚未在重大临床试验中得到一致确立。因此，需要针对根本问题——即脂肪过多——的治疗。通过生活方式干预或减重手术实现的减重，众所周知可改善阻塞性睡眠呼吸暂停。近期引入的高效减重药物，尤其是基于肠促胰素的药物，如今提供了一种实现相同结果的药理学方法。方法：近期在肥胖患者中开展的随机对照试验表明，这些药物可显著降低呼吸暂停低通气指数并提高血氧饱和度，且相当比例的患者达到疾病缓解。结果：鉴于这些发现，我们提出一种根据症状和体重指数进行分层的治疗算法。结论：对于无症状的肥胖合并阻塞性睡眠呼吸暂停患者，我们建议将基于肠促胰素的治疗作为一线选择，以同时解决体重过重和阻塞性睡眠呼吸暂停。相反，对于睡眠相关生活质量受损的个体，联合持续气道正压通气与肠促胰素治疗可能更为合适，将即时症状控制与长期减重相结合。这种整合策略优先考虑体重管理与症状缓解并重，可能为治疗肥胖相关阻塞性睡眠呼吸暂停及降低其相关心血管风险提供一种全面的方法。

英文摘要

Obesity is a primary driver of obstructive sleep apnea and contributes substantially to its associated cardiovascular morbidity and mortality. Although continuous positive airway pressure remains the standard treatment, its efficacy is often limited by suboptimal patient adherence and its impact on cardiovascular outcomes has yet to be consistently established in major clinical trials. Treatments aimed at the underlying problem, excess adiposity, are therefore needed. Weight loss, whether achieved through lifestyle interventions or bariatric surgery is well-known to improve obstructive sleep apnea. The recent introduction of highly effective weight loss medications, most notably incretin-based agents, now offers a pharmacological approach to accomplish the same result. Recent randomized controlled trials in patients with obesity demonstrated that these medications significantly decrease the apnea-hypopnea index and enhance oxygen saturation, with a significant proportion of disease remission. In light of these findings, we propose a therapeutic algorithm stratifying treatment according to symptoms and body mass index. For asymptomatic patients with obesity and obstructive sleep apnea, we suggest incretin-based therapy as a first-line option to concurrently address excessive weight and obstructive sleep apnea. Conversely, in individuals with impaired sleep-related quality of life combining continuous positive airway pressure and incretin therapy may be more appropriate, pairing immediate symptom control with longer-term weight loss. This integrated strategy, prioritizing weight management alongside symptom relief, may offer a comprehensive approach to treat obesity-related obstructive sleep apnea and decrease its associated cardiovascular risks.