Incretin-based therapies now achieve weight reduction of a magnitude previously attainable only through bariatric surgery and have demonstrated substantial reductions in the apnoea-hypopnoea index (AHI) in adults with obesity-related obstructive sleep apnoea (OSA). Sleep services are consequently managing growing numbers of patients who undergo rapid, substantial weight loss while established on positive airway pressure (PAP) therapy, and who ask whether that therapy can be stopped. No guideline addresses this question. This narrative review synthesises three literatures that have developed largely in isolation: the relationship between weight change and OSA severity, the efficacy data for glucagon-like peptide-1 receptor agonists and dual incretin agonists in OSA, and the experimental PAP withdrawal literature. Across randomised trials and meta-analyses, there is consistent agreement that incretin therapy reduces AHI, body weight and blood pressure, with effect magnitude varying by agent, dose and baseline adiposity. There is, however, material disagreement on three questions directly relevant to de-escalation: whether the effect is wholly weight-mediated, whether AHI reduction translates into reduction in cardiovascular risk, and what proportion of patients achieve genuine disease remission as opposed to severity reduction. Approximately half of participants in the largest trial did not reach a severity threshold at which PAP would ordinarily be considered unnecessary, and withdrawal studies demonstrate recurrence of obstructive events and adverse haemodynamic change within days of stopping therapy. This review proposes a structured, reversible and documented framework for reassessment rather than ad hoc discontinuation and identifies the evidence gaps that must be closed before de-escalation can be considered evidence-based practice.
