Developments in Pharmacotherapy for Obstructive Sleep Apnoea: Unlocking the Potential for Targeted Treatment

Obstructive sleep apnoea (OSA) is a common, chronic respiratory disorder associated with major co-morbidity and adverse safety consequences. New research has highlighted the heterogeneity of OSA pathogenesis and the importance of non-anatomical contributors beyond the primary cause-impaired pharyngeal anatomy. For > 40 years, continuous positive airway pressure (CPAP), which works downstream from the causes of OSA, has been the mainstay therapeutic approach. While efficacious when used, CPAP is associated with poor tolerance and acceptance which limits real-world clinical effectiveness. Non-CPAP therapies that target the primary anatomical cause such as oral appliances and upper airway surgery, reduce OSA severity by ~ 50%. Given that obesity increases the anatomical predisposition for OSA, new weight loss drugs can reduce OSA severity in the ~ 50% of patients who are obese. Thus, although these therapies can resolve OSA for certain patients, overall efficiency varies and is challenging to predict with currently available clinical tools. Recent translation of OSA pathogenesis research has unlocked new pharmacotherapy targets beyond impaired pharyngeal anatomy. These include drugs to activate the pharyngeal dilator muscles, reduce unstable respiratory control and promote deeper, more stable sleep and breathing. Accordingly, the sleep medicine field is undergoing a paradigm shift as OSA pharmacotherapy becomes a reality. This article outlines the latest OSA pathophysiology knowledge and accompanying recent major developments in OSA pharmacotherapy. Practical, readily available, clinical tools for OSA endotyping to help move beyond the current problematic one-size-fits-all, trial-and-error treatment model towards a targeted paradigm tailored to underlying mechanisms that include emerging pharmacotherapy are also included.