Current treatment approaches for obstructive sleep apnea focus on reducing airway obstruction, improving sleep quality, and mitigating long‑term health risks. This article, from RGA's ReFlections newsletter, explores how ongoing research continues to clarify which therapies meaningfully improve mortality and how evolving evidence should inform underwriting practices.
Obstructive sleep apnea, or OSA, is the most common sleep-related breathing disorder, with an estimated prevalence of 15% in males and 5% in females in the US. Globally, an estimated 425 million people aged 30 to 69 have moderate to severe OSA.
Prevalence increased over recent decades, rising from 11% of males and 4% of females in 1990 to 14% and 5% in 2010.1 A more recent review suggests that upward of 32.4% of US adults aged 20 or older have OSA.2
The American Academy of Sleep Medicine defines OSA as either of the following:
RDI, as measured on a polysomnogram, reflects the hourly number of obstructive apneas, obstructive hypopneas, and respiratory effort-related arousals (RERA). The Apnea-Hypopnea Index (AHI), commonly used in research articles, measures obstructive apneas and obstructive hypopneas per hour.3
Obstructive sleep apnea is divided into categories based on the number of AHI events:
OSA commonly coexists with conditions such as congestive heart failure, atrial fibrillation, pulmonary hypertension, hypertension, end-stage renal disease, chronic lung disease, asthma, chronic obstructive pulmonary disease, stroke, pregnancy, and hypothyroidism.
Obstructive sleep apnea is associated with increased all-cause and cardiovascular mortality, particularly with severe OSA. In a meta-analysis from Fu et al., hazard ratios (HR) for all-cause mortality was 1.19 for mild OSA, 1.28 for moderate OSA, and a statistically significant 2.13 for severe OSA. Cardiovascular mortality HRs were 1.24, 2.05, and 2.73, respectively.4 These findings align with earlier research.
Given the increasing prevalence of OSA, and the known mortality of OSA, particularly severe OSA, understanding treatment modalities and their effect on OSA is increasingly important.
Randomized controlled trials (RCT) and clinical guidelines on OSA management recommend weight loss. A 5%-10% reduction in body weight is associated with significant decreases in AHI, symptom improvement, and, in some cases, remission of OSA, particularly with weight loss >10%. For example, in the INTERAPNEA trial, substantial weight loss led to a 51% reduction in AHI at eight weeks and 57% at six months, with nearly 30% of participants achieving complete remission of OSA at 6 months.5
A meta-analysis published in Sleep Medicine showed that a BMI reduction of 10% was associated with a greater than 20% reduction in AHI; and a 20% reduction in BMI resulted in a 57% reduction in AHI.6
Direct evidence of weight loss impact on the mortality of OSA is limited, but improvements in OSA severity and overall cardiometabolic health suggest a likely reduction in mortality risk.
Positive airway pressure therapy, or PAP, is considered the gold-standard therapy for adults with OSA. PAP prevents obstructive events due to upper airway collapse by maintaining a positive pharyngeal airway pressure that keeps the airway open.
Most experts recommend starting PAP therapy when:
These recommendations are supported by RCTs in this population showing that PAP reduces obstructive events and daytime sleepiness, lowers motor vehicle crash risk, and improves systolic blood pressure (BP) and Quality of Life scores (QoL). Those with severe OSA are most likely to benefit.
In the 2019 Sleep Heart Health Study, continuous PAP (CPAP) significantly improved OSA severity (-23 events per hour), Epworth Sleepiness Scale score, and multiple blood pressure parameters, compared to no PAP.7
Long-term adherence is critical. Studies report 65%-80% adherence at four years, with some smaller studies showing adherence rates as low as 45%. Discomfort is the most common reason for decreased adherence.8
Observational studies have shown that reducing AHI in OSA is associated with reduced mortality, particularly in those with severe OSA.6 However, RCTs have not definitively proven that AHI reduction lowers mortality. A 2025 meta-analysis of 10 RCTs and 20 observational studies found significantly lower all-cause mortality in observational PAP users (HR 0.63), while RCTs did not reach statistical significance. Authors of this study and others have suggested that duration of follow-up, under-powered sample sizes, and restrictive inclusion/exclusion criteria in the RCTs may contribute to the neutral RCT findings.
Several types of oral devices are available, the most common being the mandibular advancement device (MAD). MADs are alternatives to PAP for mild-moderate OSA, or for patients with PAP intolerance. Studies show adherence may be higher with MADs, particularly in younger adults with lower BMI. They are not indicated for severe OSA, due to lack of efficacy.
In studies, PAP is generally superior to MADs in AHI reduction and oxygen desaturation indices. However, MADs appear to be noninferior to PAP in reducing cardiovascular risk factors such as 24-hour ambulatory blood pressure measurements and QoL. Custom-made devices are associated with improved cardiovascular outcomes compared to commercially available off-the-shelf devices. Adverse aspects of the oral appliances include cost (generally $1,000-$2,000 USD) and myofascial discomfort.8
Surgery is used as primary therapy for OSA when a fixed, surgically correctible airway obstruction is responsible for the apnea (e.g., severe tonsillar hypertrophy). However, surgery is usually reserved as second-line therapy for OSA, for patients with PAP intolerance, or as adjunctive therapy in conjunction with PAP or an oral appliance.
The most common upper airway surgery is uvulopalatopharyngoplasty (UPPP), as upper pharyngeal obstruction is the most common anatomic airway abnormality. Modern UPPP techniques typically involve repositioning and restructuring the soft palate and related structures to reduce obstruction.
Reported success rates for UPPP range from 30% to 80%, with success defined as >50% reduction in AHI and a post-surgery AHI of <20 events per hour.
The SAMS study, which used modified UPPP with tongue volume reduction techniques, demonstrated a significant reduction in AHI of nearly 28 events per hour (from 47.9 to 20.8), compared with a reduction of approximately 10 events per in the medical control group (45.3 to 34.5). Complete resolution of OSA (<10) occurred in 26% of surgical patients.
Unfortunately, failure rates are estimated at about 50%, often due to persistent anatomic obstruction. Long-term effects of modern surgical techniques include swallowing difficulties and vocal changes or globus sensation, although most patients report satisfaction.9
Approved in the US in 2014, the hypoglossal nerve stimulator (HGNS) is a second-line therapy for moderate to severe OSA in adults who are unable to tolerate or have failed PAP therapy, in those with AHIs in the 15-65 events per hour range and BMI <32-35 kg/m2. The implanted neurostimulator stimulates the hypoglossal nerve at initiation of inspiration, causing tongue anterior protrusion and stiffening to reduce upper airway collapse during sleep.
Multiple studies show a significant reduction in AHI and oxygen desaturations, as well as improved QoL. For example, the Inspire device, the most widely studied and FDA-approved system, reduces AHI by approximately 20 AHI events per hour in the short-term follow-up (<1 year) and approximately 16 AHI events per hour in long-term follow-up.10 These benefits are durable, with sustained efficacy reported five years after implantation.11
Research continues on alternative approaches to expand eligibility (e.g., higher BMI, alternative pathways of airway collapse). Adverse effects are uncommon and may include tongue discomfort, insomnia, frequent awakenings, and local pain triggered by the stimulation impulse. Despite these issues, adherence and patient satisfaction remain high.
Tirzepatide is the first FDA-approved treatment for moderate to severe OSA in adults with obesity, based on evidence showing substantial reductions in AHI and improvements in patient-reported outcomes and cardiometabolic risk factors. Its efficacy is attributed primarily to weight loss. Studies showed a statistically significant reduction in AHI at 29.3 events per hour compared to a reduction of 5.5 events per hour in the placebo group.12 There were reductions in oxygen desaturation, body weight, systolic blood pressure, and patient-reported sleep symptoms. More than 50% of patients reached AHI thresholds where PAP therapy may no longer be indicated.
In addition to the above results, a study in Chest assessed obese patients with OSA, with the primary outcome of all-cause mortality and secondary outcomes including major adverse cardiovascular events (MACE) and major adverse kidney events (MAKE). Among the 42,300 studied over a nearly three-year period (January 2022 to November 2024), those treated with tirzepatide had a lower risk of all-cause mortality (HR 0.443) compared to placebo, with reduced risks of MACE (HR 0.731) and MAKE (HR 0.427) across all subgroups (age, sex, BMI, PAP use) except for age 18-39. Authors concluded that “tirzepatide may be a potential therapeutic option for improving clinical outcomes [in obese patients with OSA]”.13
While potentially exciting, critics of the study noted that it included significantly obese subjects (BMI >39) and had extensive exclusion criteria, which may limit generalizability. Long-term studies are needed to confirm durability and safety.14
Obstructive sleep apnea (OSA) is a common sleep-related breathing disorder characterized by repeated episodes of partial or complete upper airway obstruction during sleep. Severe, untreated OSA is strongly associated with increased all-cause and cardiovascular mortality.
Although observational studies suggest that treatment may reduce these risks, randomized controlled trials have not yet confirmed a definitive mortality benefit. Current therapies focus on maintaining airway patency, improving sleep quality, and mitigating long-term health risks. Emerging treatments, such as tirzepatide, show promise for reducing mortality, but further research is needed.
For life and disability insurance underwriting, OSA severity, treatment adherence, and comorbidities should be carefully evaluated. As new therapies and stronger outcome data become available, underwriting guidelines are likely to evolve to reflect the complex relationship between OSA management and long-term risk.
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