CE / CME
Physician Assistants/Physician Associates: 0.50 AAPA Category 1 CME credit
Nurse Practitioners/Nurses: 0.50 Nursing contact hour
Physicians: maximum of 0.50 AMA PRA Category 1 Credit™
ABIM MOC: maximum of 0.50 Medical Knowledge MOC point
Released: June 24, 2025
Expiration: June 23, 2026
Institutional Resources Are Needed and Costly
Babak Mokhlesi, MD, MSc:
I have been trying to introduce this to my colleagues in sleep medicine for 2 reasons. One is because we want to join a research study that is looking at the true feasibility of implementing weight management in current sleep medicine practices to align better with patient-centric outcomes. I want to get my colleagues on board with prescribing antiobesity agents, but there has been some pushback. When I ask them about their concerns they shared some important feedback.
As it stands, my institution is struggling to get patients in for their usual follow-up appointments. Then upon using antiobesity agents and seeing an influx of patients, how do we accommodate them so that we can follow up appropriately to minimize adverse effects and titrate them to the appropriate dose? How do we ensure that we have the appointments available for all patients and ensure that they return for follow-up?
Another concern of course is having the dedicated staff to submit prior authorizations and address denials. This is an incredibly time-consuming process. Furthermore, where is the money going to come from for this needed staffing?
The third concern that my colleagues brought up was training patients on how to administer these agents. Because my wife is an endocrinologist, I asked her for a sample of one and gave it to myself to see how it feels. This way I can better explain how to administer the therapy to patients during their appointments.
Multidisciplinary Care and Education is Critical
Jaime Almandoz, MD, MBA, MRCPI, FTOS:
As a nonsleep endocrinologist, I want to share some insights in speaking with my sleep medicine colleagues. Everyone is engaged to treat, and patients are beating down the door. They want to get tested for OSA now.
My colleagues shared that with the time constraints during their visits that are already congested, the perception is that there is a lack of multidisciplinary support. I think we are in a space now where people are conflating access to treatment with quality care, which is alarming. In hearing Dr Mokhlesi, the list of concerns from your colleagues about access and how to administer the injections, obesity care is not simply providing a prescription, nor will that solve it.
I think there is an inadequate conceptualization of obesity as a chronic and complex disease. My colleagues acknowledge that obesity plays a huge role in OSA and cardiometabolic risk, yet there is a lack of understanding on the complex physiology of a dysregulated appetite, adipose tissue dysfunction, associated metabolic consequences, and what this means when we start antiobesity treatment.1
I also asked a colleague to tell me what the plan is when treating a patient with moderate to severe OSA who is on 3 antihypertensives and a basal insulin. Do you roll out the tirzepatide right away? How are you adjusting their blood pressure medicines? Who is owning the diabetes care? Who is going to stop the patient from experiencing hypotension (ie, falling and hitting their head) because they are on anticoagulation because of atrial fibrillation and OSA?
I noticed in speaking with them that there was a lack of understanding on the implications of treating obesity. Therefore we need to turn this positive engagement into high quality care. We need to ensure that what we communicate to patients is not just about infrastructure and access. Those things are great, but what about everything else?
Radhika S. Breaden, MD, MPH, DABMS, DABOM:
I agree with everything. The barrier that I would focus on is the lack of understanding for many sleep medicine specialists that obesity is a chronic disease. Without that fundamental understanding, HCPs cannot approach patients the same way. And that becomes problematic from day 1 when HCPs may start prescribing antiobesity agents.
I join the Facebook groups for patients who are taking these agents. I talk to them because I want to understand patients better. I feel that their expectations of what is going to happen and the things that I want to talk about in their visit are parallel. But patients also have a significantly limited understanding of obesity as a chronic disease. Some think that they are going to be on these agents for a distinct time; they do not understand that these are life-long treatments. Others are absolutely sure that they are going to be the exception: that after they lose the weight, they are going to stop their antiobesity agent and manage their weight with diet and exercise and resolve their OSA.
Patients also want to know whether it is going to be cheaper for them to get this treatment from their insurance or via a compounding pharmacy. That is all they want to talk about, which is completely different than the agenda that I have for their visit. I then teach them about obesity as a chronic disease, what it means for them to use these therapies, and what realistic expectations look like. Just as with other OSA treatments, the time that we have for education is so limited. Then it begins to feel like we are having that same lengthy discussion with every patient in every visit of theirs. Therefore, HCPs should ensure that they are starting at the same point before moving forward with patients’ care.
In addition, the time constraints are significant. That is where I ask, “How are we going to provide personalized care on a population basis, making sure that we treat patients and educate them well?”
Babak Mokhlesi, MD, MSc:
At my institution, we do not provide extensive patient education that other large institutions might be able to do, such as using nurse educators to save HCPs time and ensure that patients understand the current data regarding their disease. We are doing this for CPAP but not for obesity. But, again, that is because we are not really managing obesity. We simply provide the usual recommendations, telling patients it is good to lose weight without having any real follow-up or plan on that.
Radhika S. Breaden, MD, MPH, DABMS, DABOM:
It is difficult in private practice to get reimbursement for that. I worked at Kaiser Permanente for many years, and I appreciated the group models of education and case management that they had for us. That is where a comprehensive care model can be helpful. But in private practice models, we are unfortunately not able to do that.
Babak Mokhlesi, MD, MSc:
I am a division chief, so I have to come up with a business plan as to why we need to hire more APPs, nurses, and medical assistants. This is an effort to incorporate tirzepatide into our sleep clinic. But we keep getting pushback.
Care Coordination: How Can it Be Done Right?
Amanda J. Piper, PhD:
I do not know how it works in the United States, but HCPs tend to work in silos in Australia and many other places. It is exactly what Dr Almandoz was saying.
My institution’s respiratory HCPs are all pushing tirzepatide and other agents, but they want patients’ endocrinologist involved, too. Although some of these private sleep obesity clinics might provide more holistic treatment, it is not necessarily the right place to be prescribing antiobesity agents. In general, we do not work hand-in-hand with endocrinology either. Therefore how these treatments are affecting patients’ comorbidities is not considered and a team taking responsibility for managing each patient does not naturally happen.
In addition, we do not have overlap with obesity or chronic care where someone is taking responsibility for these patients in the community. I think that is going to be similar across many different countries, regions, and health services. The barrier here is coordination of care. I think that this can be too much. Some people might think that primary care should take responsibility, but I disagree with that. I do not think that is fair because it takes so much time. PCPs likely have less time with patients than those in specialty clinics. Regardless, I think proper care coordination is going to be a difficulty. This idea that everybody wants a pill so that their obesity will melt away—it is far more complex than that.
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