New Drugs for Sleep Apnea in Older Adults — From GLP-1s to Sulthiame

Obstructive sleep apnea is among the most prevalent sleep disorders in older adults, yet it frequently goes unrecognized because its presentation in this population differs from younger patients — snoring and daytime sleepiness may be less prominent. Screening tools lack specificity and polysomnography access remains difficult, compounding diagnostic challenges. When OSA goes untreated, it accelerates cardiovascular disease, cognitive decline, metabolic dysfunction, and poor sleep quality — all major threats to healthspan.

This review from the Medical College of Georgia systematically examines pharmacologic strategies targeting OSA in older adults. CPAP remains the guideline-recommended standard, but its benefits in older cohorts are uncertain and patient refusal is high, creating a real clinical gap that pharmacotherapy could fill. Advances in understanding OSA pathophysiology — including impaired upper airway dilator muscle tone, low arousal threshold, and anatomical narrowing from adipose deposition — have revealed several drug targets.

GLP-1 receptor agonists, particularly tirzepatide, have emerged as a standout option, reducing upper airway adiposity and demonstrating measurable improvements in apnea-hypopnea index (AHI), hypoxic burden, and overall sleep outcomes. Noradrenergic-antimuscarinic combinations (e.g., atomoxetine plus oxybutynin) produce significant AHI reductions by increasing pharyngeal dilator tone, but their anticholinergic component raises serious safety concerns for older patients. Serotonergic and cholinergic agents have shown some mechanistic rationale for improving muscle tone, though trial data remain limited, small, and inconsistent.

Sedative-hypnotics may address the low arousal threshold subtype of OSA but introduce CNS depression risk — particularly dangerous in the elderly. Sulthiame, a carbonic anhydrase inhibitor, stands out for its dose-dependent AHI improvements and tolerability, representing a potentially age-friendly option.

The review concludes that OSA pharmacotherapy is no longer speculative — multiple mechanistically distinct agents show real promise. However, older adults remain underrepresented in trials. Age-specific studies assessing efficacy, safety, and functional outcomes are essential before routine clinical adoption.