Clinician Reviews

TOPLINE:

Excessive intrapancreatic fat deposition (IPFD) leading to fatty change of the pancreas (FP) was prevalent in almost 18% of participants in a large population-based cohort, and both IPFD and FP were associated with an increased risk for diabetes, acute pancreatitis, and pancreatic cancer.

METHODOLOGY:

• Excessive IPFD is a common pancreatic disorder in the general population; however, there is a paucity of longitudinal studies investigating the relationship between FP and the risk for exocrine and endocrine pancreatic diseases.
• This prospective cohort study conducted from July 2014 to January 2023 investigated the prevalence of FP and the link between IPFD and pancreatic diseases in 42,599 participants (median age, 65 years; 46.6% men) from the UK Biobank who underwent abdominal Dixon MRI.
• IPFD levels were measured using MRI and a deep learning-based framework called nnUNet.
• The outcomes assessed in this study were diseases of the exocrine pancreas and endocrine pancreas, including acute pancreatitis, pancreatic cancer, diabetes, and other pancreatic conditions.

TAKEAWAY:

• The prevalence of FP was 17.86%.
• Elevation in IPFD levels by one quintile increased the risk for the development of acute pancreatitis by 51.3% (P = .001), pancreatic cancer by 36.5% (P = .017), diabetes by 22.1% (P < .001), and all pancreatic diseases by 22.7% (P < .001).
• FP increased the risk for acute pancreatitis by 298.2% (P < .001), pancreatic cancer by 97.6% (P = .034), diabetes by 33.7% (P = .001), and all pancreatic diseases by 44.1% (P < .001).
• An increasing trend in the prevalence of FP with advancing age was observed in both men and women.

IN PRACTICE:

“FP is a common pancreatic disorder. Fat in the pancreas is an independent risk factor for diseases of both the exocrine pancreas and endocrine pancreas,” the authors wrote.

SOURCE:

This study, led by Xiaowu Dong, MD, of the Pancreatic Center, Department of Gastroenterology, Yangzhou Key Laboratory of Pancreatic Disease, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China, was published online in The American Journal of Gastroenterology.

LIMITATIONS:

The authors acknowledged that most of the enrolled participants were White and older than 45 years. A low response rate to recruitment invitations in the UK Biobank database may have introduced self-selection bias. The median follow-up duration of 4.61 years was short and may be insufficient to fully capture the impact of IPFD. Additionally, the use of the average fat fraction for the entire pancreas may have led to spatial variations being ignored.

DISCLOSURES:

This work was supported by the National Natural Science Foundation of China, Cultivation Foundation of Yangzhou Municipal Key Laboratory, The Medical Research Project of Jiangsu Provincial Health Commission, Yangzhou key research and development plan, and Suzhou Innovation Platform Construction Projects-Municipal Key Laboratory Construction. The authors declared no conflicts of interest.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Excessive intrapancreatic fat deposition (IPFD) leading to fatty change of the pancreas (FP) was prevalent in almost 18% of participants in a large population-based cohort, and both IPFD and FP were associated with an increased risk for diabetes, acute pancreatitis, and pancreatic cancer.

METHODOLOGY:

• Excessive IPFD is a common pancreatic disorder in the general population; however, there is a paucity of longitudinal studies investigating the relationship between FP and the risk for exocrine and endocrine pancreatic diseases.
• This prospective cohort study conducted from July 2014 to January 2023 investigated the prevalence of FP and the link between IPFD and pancreatic diseases in 42,599 participants (median age, 65 years; 46.6% men) from the UK Biobank who underwent abdominal Dixon MRI.
• IPFD levels were measured using MRI and a deep learning-based framework called nnUNet.
• The outcomes assessed in this study were diseases of the exocrine pancreas and endocrine pancreas, including acute pancreatitis, pancreatic cancer, diabetes, and other pancreatic conditions.

TAKEAWAY:

• The prevalence of FP was 17.86%.
• Elevation in IPFD levels by one quintile increased the risk for the development of acute pancreatitis by 51.3% (P = .001), pancreatic cancer by 36.5% (P = .017), diabetes by 22.1% (P < .001), and all pancreatic diseases by 22.7% (P < .001).
• FP increased the risk for acute pancreatitis by 298.2% (P < .001), pancreatic cancer by 97.6% (P = .034), diabetes by 33.7% (P = .001), and all pancreatic diseases by 44.1% (P < .001).
• An increasing trend in the prevalence of FP with advancing age was observed in both men and women.

IN PRACTICE:

“FP is a common pancreatic disorder. Fat in the pancreas is an independent risk factor for diseases of both the exocrine pancreas and endocrine pancreas,” the authors wrote.

SOURCE:

This study, led by Xiaowu Dong, MD, of the Pancreatic Center, Department of Gastroenterology, Yangzhou Key Laboratory of Pancreatic Disease, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China, was published online in The American Journal of Gastroenterology.

LIMITATIONS:

The authors acknowledged that most of the enrolled participants were White and older than 45 years. A low response rate to recruitment invitations in the UK Biobank database may have introduced self-selection bias. The median follow-up duration of 4.61 years was short and may be insufficient to fully capture the impact of IPFD. Additionally, the use of the average fat fraction for the entire pancreas may have led to spatial variations being ignored.

DISCLOSURES:

This work was supported by the National Natural Science Foundation of China, Cultivation Foundation of Yangzhou Municipal Key Laboratory, The Medical Research Project of Jiangsu Provincial Health Commission, Yangzhou key research and development plan, and Suzhou Innovation Platform Construction Projects-Municipal Key Laboratory Construction. The authors declared no conflicts of interest.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Excessive intrapancreatic fat deposition (IPFD) leading to fatty change of the pancreas (FP) was prevalent in almost 18% of participants in a large population-based cohort, and both IPFD and FP were associated with an increased risk for diabetes, acute pancreatitis, and pancreatic cancer.

METHODOLOGY:

• Excessive IPFD is a common pancreatic disorder in the general population; however, there is a paucity of longitudinal studies investigating the relationship between FP and the risk for exocrine and endocrine pancreatic diseases.
• This prospective cohort study conducted from July 2014 to January 2023 investigated the prevalence of FP and the link between IPFD and pancreatic diseases in 42,599 participants (median age, 65 years; 46.6% men) from the UK Biobank who underwent abdominal Dixon MRI.
• IPFD levels were measured using MRI and a deep learning-based framework called nnUNet.
• The outcomes assessed in this study were diseases of the exocrine pancreas and endocrine pancreas, including acute pancreatitis, pancreatic cancer, diabetes, and other pancreatic conditions.

TAKEAWAY:

• The prevalence of FP was 17.86%.
• Elevation in IPFD levels by one quintile increased the risk for the development of acute pancreatitis by 51.3% (P = .001), pancreatic cancer by 36.5% (P = .017), diabetes by 22.1% (P < .001), and all pancreatic diseases by 22.7% (P < .001).
• FP increased the risk for acute pancreatitis by 298.2% (P < .001), pancreatic cancer by 97.6% (P = .034), diabetes by 33.7% (P = .001), and all pancreatic diseases by 44.1% (P < .001).
• An increasing trend in the prevalence of FP with advancing age was observed in both men and women.

IN PRACTICE:

“FP is a common pancreatic disorder. Fat in the pancreas is an independent risk factor for diseases of both the exocrine pancreas and endocrine pancreas,” the authors wrote.

SOURCE:

This study, led by Xiaowu Dong, MD, of the Pancreatic Center, Department of Gastroenterology, Yangzhou Key Laboratory of Pancreatic Disease, Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, China, was published online in The American Journal of Gastroenterology.

LIMITATIONS:

The authors acknowledged that most of the enrolled participants were White and older than 45 years. A low response rate to recruitment invitations in the UK Biobank database may have introduced self-selection bias. The median follow-up duration of 4.61 years was short and may be insufficient to fully capture the impact of IPFD. Additionally, the use of the average fat fraction for the entire pancreas may have led to spatial variations being ignored.

DISCLOSURES:

This work was supported by the National Natural Science Foundation of China, Cultivation Foundation of Yangzhou Municipal Key Laboratory, The Medical Research Project of Jiangsu Provincial Health Commission, Yangzhou key research and development plan, and Suzhou Innovation Platform Construction Projects-Municipal Key Laboratory Construction. The authors declared no conflicts of interest.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Metabolic dysfunction-associated steatotic liver disease (MASLD) co-occurring with HIV infection does not appear to increase the risk for cirrhosis or hepatocellular carcinoma (HCC) compared with MASLD alone. However, the incidence of major adverse cardiovascular events (MACE) is significantly increased among patients with MASLD and HIV, a large study suggested.

METHODOLOGY:

• MASLD is highly prevalent in people living with HIV, but the impact of HIV on liver and cardiovascular disease (CVD) outcomes in people with MASLD remains unclear.
• To investigate, researchers created a propensity score-matched cohort of veterans with noncirrhotic MASLD, with and without HIV (920 patients in each group).
• They evaluated the incidence of cirrhosis, HCC, and MACE, as well as overall survival, among the two groups. They also assessed these outcomes in MASLD patients with HIV on the basis of whether they were on antiretroviral therapy (ART).

TAKEAWAY:

• During a median follow-up of 10.4 years in the MASLD with HIV group and 11.8 years in the MASLD-only group, the overall incidence of cirrhosis and HCC was similar in MASLD with vs without HIV (cirrhosis: 0.97 vs 1.06 per 100 person-years, P = .54; HCC: 0.26 vs 0.17 per 100,000 person-years, P = .23), regardless of ART use.

• In contrast, the incidence of MACE was significantly higher in MASLD with vs without HIV (5.18 vs 4.48 per 100 person-years, P = .03). The incidence also was higher in patients with MASLD and HIV who were not on ART compared with those on ART (5.83 vs 4.7 per 100 person-years, P = .07).

• Compared with MASLD without HIV, the overall 5-year survival was significantly lower in MASLD with HIV (91.3% vs 85.7%). In MASLD with HIV, receipt of ART was associated with a significantly higher 5-year survival than no ART (87.4% vs 81.6%).

IN PRACTICE:

“Ensuring timely and appropriate initiation of HIV treatment is critical in patients with MASLD who have concurrent HIV infection, as well as optimizing metabolic comorbidities that may also contribute to increased risks of CVD and increased mortality,” the authors wrote.

SOURCE:

The study, led by Robert J. Wong, MD, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, was published online in the American Journal of Gastroenterology.

LIMITATIONS:

The study cohort consisted predominantly of older men, which may limit generalizability to women and younger populations. Metabolic comorbidities are more common in veterans compared with the general population, potentially affecting the generalizability of the CVD risk findings.

DISCLOSURES:

The study was supported by an investigator-initiated research grant from Theratechnologies. Wong has received funding for his institution from Gilead Sciences, Exact Sciences, and Durect Corporation and has served as a consultant for Gilead Sciences.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Metabolic dysfunction-associated steatotic liver disease (MASLD) co-occurring with HIV infection does not appear to increase the risk for cirrhosis or hepatocellular carcinoma (HCC) compared with MASLD alone. However, the incidence of major adverse cardiovascular events (MACE) is significantly increased among patients with MASLD and HIV, a large study suggested.

METHODOLOGY:

• MASLD is highly prevalent in people living with HIV, but the impact of HIV on liver and cardiovascular disease (CVD) outcomes in people with MASLD remains unclear.
• To investigate, researchers created a propensity score-matched cohort of veterans with noncirrhotic MASLD, with and without HIV (920 patients in each group).
• They evaluated the incidence of cirrhosis, HCC, and MACE, as well as overall survival, among the two groups. They also assessed these outcomes in MASLD patients with HIV on the basis of whether they were on antiretroviral therapy (ART).

TAKEAWAY:

• During a median follow-up of 10.4 years in the MASLD with HIV group and 11.8 years in the MASLD-only group, the overall incidence of cirrhosis and HCC was similar in MASLD with vs without HIV (cirrhosis: 0.97 vs 1.06 per 100 person-years, P = .54; HCC: 0.26 vs 0.17 per 100,000 person-years, P = .23), regardless of ART use.

• In contrast, the incidence of MACE was significantly higher in MASLD with vs without HIV (5.18 vs 4.48 per 100 person-years, P = .03). The incidence also was higher in patients with MASLD and HIV who were not on ART compared with those on ART (5.83 vs 4.7 per 100 person-years, P = .07).

• Compared with MASLD without HIV, the overall 5-year survival was significantly lower in MASLD with HIV (91.3% vs 85.7%). In MASLD with HIV, receipt of ART was associated with a significantly higher 5-year survival than no ART (87.4% vs 81.6%).

IN PRACTICE:

“Ensuring timely and appropriate initiation of HIV treatment is critical in patients with MASLD who have concurrent HIV infection, as well as optimizing metabolic comorbidities that may also contribute to increased risks of CVD and increased mortality,” the authors wrote.

SOURCE:

The study, led by Robert J. Wong, MD, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, was published online in the American Journal of Gastroenterology.

LIMITATIONS:

The study cohort consisted predominantly of older men, which may limit generalizability to women and younger populations. Metabolic comorbidities are more common in veterans compared with the general population, potentially affecting the generalizability of the CVD risk findings.

DISCLOSURES:

The study was supported by an investigator-initiated research grant from Theratechnologies. Wong has received funding for his institution from Gilead Sciences, Exact Sciences, and Durect Corporation and has served as a consultant for Gilead Sciences.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Metabolic dysfunction-associated steatotic liver disease (MASLD) co-occurring with HIV infection does not appear to increase the risk for cirrhosis or hepatocellular carcinoma (HCC) compared with MASLD alone. However, the incidence of major adverse cardiovascular events (MACE) is significantly increased among patients with MASLD and HIV, a large study suggested.

METHODOLOGY:

• MASLD is highly prevalent in people living with HIV, but the impact of HIV on liver and cardiovascular disease (CVD) outcomes in people with MASLD remains unclear.
• To investigate, researchers created a propensity score-matched cohort of veterans with noncirrhotic MASLD, with and without HIV (920 patients in each group).
• They evaluated the incidence of cirrhosis, HCC, and MACE, as well as overall survival, among the two groups. They also assessed these outcomes in MASLD patients with HIV on the basis of whether they were on antiretroviral therapy (ART).

TAKEAWAY:

• During a median follow-up of 10.4 years in the MASLD with HIV group and 11.8 years in the MASLD-only group, the overall incidence of cirrhosis and HCC was similar in MASLD with vs without HIV (cirrhosis: 0.97 vs 1.06 per 100 person-years, P = .54; HCC: 0.26 vs 0.17 per 100,000 person-years, P = .23), regardless of ART use.

• In contrast, the incidence of MACE was significantly higher in MASLD with vs without HIV (5.18 vs 4.48 per 100 person-years, P = .03). The incidence also was higher in patients with MASLD and HIV who were not on ART compared with those on ART (5.83 vs 4.7 per 100 person-years, P = .07).

• Compared with MASLD without HIV, the overall 5-year survival was significantly lower in MASLD with HIV (91.3% vs 85.7%). In MASLD with HIV, receipt of ART was associated with a significantly higher 5-year survival than no ART (87.4% vs 81.6%).

IN PRACTICE:

“Ensuring timely and appropriate initiation of HIV treatment is critical in patients with MASLD who have concurrent HIV infection, as well as optimizing metabolic comorbidities that may also contribute to increased risks of CVD and increased mortality,” the authors wrote.

SOURCE:

The study, led by Robert J. Wong, MD, Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Palo Alto, California, was published online in the American Journal of Gastroenterology.

LIMITATIONS:

The study cohort consisted predominantly of older men, which may limit generalizability to women and younger populations. Metabolic comorbidities are more common in veterans compared with the general population, potentially affecting the generalizability of the CVD risk findings.

DISCLOSURES:

The study was supported by an investigator-initiated research grant from Theratechnologies. Wong has received funding for his institution from Gilead Sciences, Exact Sciences, and Durect Corporation and has served as a consultant for Gilead Sciences.
 

A version of this article appeared on Medscape.com.

LIVERPOOL, ENGLAND — Optimizing how people experiencing a gout flare are managed in hospital and then followed-up afterwards can substantially increase the uptake of guideline-recommended urate-lowering therapy (ULT), researchers reported at the annual meeting of the British Society for Rheumatology (BSR).

In a prospective study, 92% of 97 people admitted to hospital for gout flares were using ULT within 6 months of discharge after a multifaceted intervention was introduced. By comparison, 49% of 94 people admitted for gout flares before the introduction of the intervention were taking ULT within the same postdischarge time frame. 

Moreover, a higher proportion of individuals had urate blood tests done at least once within the 6-month postdischarge period after the intervention’s introduction (58% vs 32%) and fewer (9% vs 15%) needed repeated hospital treatment. 

“Gout is the most common inflammatory arthritis affecting one in 30 adults in the United Kingdom, yet it’s one of the most poorly managed,” study investigator Mark D. Russell, MB, BChir, pointed out during a poster presentation. 

“There are very effective treatments,” added Dr. Russell, a rheumatology registrar and postdoctoral research fellow at King’s College London in London, England. “Urate-lowering therapies such as allopurinol, which when taken at the correct dose, in the long term, effectively cures patients of their symptoms and prevents complications.” 

Dr. Russell said in an interview that there was still work to be done as the rate of people achieving urate levels below the recommended threshold of 360 micromol/L (6 mg/dL) within 6 months was still low, at 27%, even it if was still better than the 11% seen before the intervention was introduced.
 

Improving the In- and Post-Hospital Pathway

“We developed and implemented an in-hospital management pathway which encouraged urate-lowering therapy initiation prior to discharge, followed by a post-discharge nurse-led review,” Dr. Russell explained. 

The in-hospital pathway was based upon BSR, European Alliance of Associations for Rheumatology, and American College of Rheumatology guidelines and involved diagnosing and managing the gout flare appropriately. This may have been via early joint aspiration, medication, or both, as directed by the rheumatology team. Affected individuals also received education and were directed where to obtain further information on the use of ULT. Outpatient follow-up was considered if an individual had severe or tophaceous gout, recurrent episodes, or contraindications or intolerances to ULT. Otherwise, a rheumatology nurse telephoned the individual 2 weeks later to review symptoms and discuss next steps.

The researchers recorded improvements in in-hospital outcomes. The frequency of in-hospital serum urate level measurements rose from 66% in the 12-month preimplementation period to 93% in the 12-month period after the intervention’s introduction. Almost two thirds (62%) of patients were discharged on ULT compared with 18% preimplementation. And gout-specific recommendations were given 86% of the time compared with 59% before the intervention.
 

Related Work on Gout Incidence

Separately, Dr. Russell also presented data from a nationwide, population-level cohort study that used data from OpenSAFELY, the secure data analytics platform used by the National Health Service in England. 

“We did an analysis previously using the CPRD [Clinical Research Practice Datalink], which is another good primary care database, showing that only a third of people with gout in the UK get urate-lowering drugs, when really it should be the vast majority,” he said in the interview.

“And then we wanted to look at, on top of that, what was the impact of the [COVID-19] pandemic,” Russell added. Specifically, the aim was to look at how the pandemic had affected the incidence, management, and prevalence of gout.

Between March 2015 and February 2023, 246,695 new cases of gout were identified among 17.9 million adults, seen in primary and secondary care. 
 

COVID-19 Pandemic Affected Cases

“The number of new cases of gout dropped by about one third in the first year of the pandemic,” Dr. Russell said. Incidence declined from 1.78 to 1.23 per 1000 adults. “Whether that was through people not feeling comfortable going to their GP [general practitioner] or not being able to get an appointment, we don’t know.”

While there was a subsequent increase in new cases of gout since this time, the rates still haven’t reached what they were before the pandemic. This implies that there could be a substantial number of people who may be undiagnosed because of the pandemic, Dr. Russell suggested. 

Moreover, he reported that in 2022-2023, the prevalence of gout was 3.21%, up slightly from the 3.07% recorded 7 years earlier in 2015-2016.
 

ULT Treatment Rates Low

“If you did see a GP, however, so as long as you saw someone, the treatment wasn’t any worse,” Dr. Russell said. Just under 30% of people with incident gout for whom follow-up data were available had initiated ULT within 6 months of their diagnosis. And, of these new starters, around a quarter had a serum urate level below a target of 360 micromol/L. 

“This doesn’t detract from the fact that this is pretty low. Despite guidelines, we’re still not getting the majority of people on these very effective urate-lowering drugs,” Dr. Russell said.

There is perhaps too much reliance on modifying diet and lifestyle, he added, which are important for many reasons but will not do much to lower blood urate levels. 

As a final word, Dr. Russell said, “It’s not just a case of preventing a bit of joint pain. People get lots of complications when they’re undertreated — erosive joint damage, work disability, impaired quality of life — and yet we’ve got very cheap, well-tolerated drugs.”

The work was independently funded. Dr. Russell acknowledged grant or research support from Eli Lilly, Janssen, Pfizer, and UCB and receipt of honoraria from AbbVie, Biogen, Eli Lilly, Galapagos, and Menarini. 

A version of this article appeared on Medscape.com.

LIVERPOOL, ENGLAND — Optimizing how people experiencing a gout flare are managed in hospital and then followed-up afterwards can substantially increase the uptake of guideline-recommended urate-lowering therapy (ULT), researchers reported at the annual meeting of the British Society for Rheumatology (BSR).

In a prospective study, 92% of 97 people admitted to hospital for gout flares were using ULT within 6 months of discharge after a multifaceted intervention was introduced. By comparison, 49% of 94 people admitted for gout flares before the introduction of the intervention were taking ULT within the same postdischarge time frame. 

Moreover, a higher proportion of individuals had urate blood tests done at least once within the 6-month postdischarge period after the intervention’s introduction (58% vs 32%) and fewer (9% vs 15%) needed repeated hospital treatment. 

“Gout is the most common inflammatory arthritis affecting one in 30 adults in the United Kingdom, yet it’s one of the most poorly managed,” study investigator Mark D. Russell, MB, BChir, pointed out during a poster presentation. 

“There are very effective treatments,” added Dr. Russell, a rheumatology registrar and postdoctoral research fellow at King’s College London in London, England. “Urate-lowering therapies such as allopurinol, which when taken at the correct dose, in the long term, effectively cures patients of their symptoms and prevents complications.” 

Dr. Russell said in an interview that there was still work to be done as the rate of people achieving urate levels below the recommended threshold of 360 micromol/L (6 mg/dL) within 6 months was still low, at 27%, even it if was still better than the 11% seen before the intervention was introduced.
 

Improving the In- and Post-Hospital Pathway

“We developed and implemented an in-hospital management pathway which encouraged urate-lowering therapy initiation prior to discharge, followed by a post-discharge nurse-led review,” Dr. Russell explained. 

The in-hospital pathway was based upon BSR, European Alliance of Associations for Rheumatology, and American College of Rheumatology guidelines and involved diagnosing and managing the gout flare appropriately. This may have been via early joint aspiration, medication, or both, as directed by the rheumatology team. Affected individuals also received education and were directed where to obtain further information on the use of ULT. Outpatient follow-up was considered if an individual had severe or tophaceous gout, recurrent episodes, or contraindications or intolerances to ULT. Otherwise, a rheumatology nurse telephoned the individual 2 weeks later to review symptoms and discuss next steps.

The researchers recorded improvements in in-hospital outcomes. The frequency of in-hospital serum urate level measurements rose from 66% in the 12-month preimplementation period to 93% in the 12-month period after the intervention’s introduction. Almost two thirds (62%) of patients were discharged on ULT compared with 18% preimplementation. And gout-specific recommendations were given 86% of the time compared with 59% before the intervention.
 

Related Work on Gout Incidence

Separately, Dr. Russell also presented data from a nationwide, population-level cohort study that used data from OpenSAFELY, the secure data analytics platform used by the National Health Service in England. 

“We did an analysis previously using the CPRD [Clinical Research Practice Datalink], which is another good primary care database, showing that only a third of people with gout in the UK get urate-lowering drugs, when really it should be the vast majority,” he said in the interview.

“And then we wanted to look at, on top of that, what was the impact of the [COVID-19] pandemic,” Russell added. Specifically, the aim was to look at how the pandemic had affected the incidence, management, and prevalence of gout.

Between March 2015 and February 2023, 246,695 new cases of gout were identified among 17.9 million adults, seen in primary and secondary care. 
 

COVID-19 Pandemic Affected Cases

“The number of new cases of gout dropped by about one third in the first year of the pandemic,” Dr. Russell said. Incidence declined from 1.78 to 1.23 per 1000 adults. “Whether that was through people not feeling comfortable going to their GP [general practitioner] or not being able to get an appointment, we don’t know.”

While there was a subsequent increase in new cases of gout since this time, the rates still haven’t reached what they were before the pandemic. This implies that there could be a substantial number of people who may be undiagnosed because of the pandemic, Dr. Russell suggested. 

Moreover, he reported that in 2022-2023, the prevalence of gout was 3.21%, up slightly from the 3.07% recorded 7 years earlier in 2015-2016.
 

ULT Treatment Rates Low

“If you did see a GP, however, so as long as you saw someone, the treatment wasn’t any worse,” Dr. Russell said. Just under 30% of people with incident gout for whom follow-up data were available had initiated ULT within 6 months of their diagnosis. And, of these new starters, around a quarter had a serum urate level below a target of 360 micromol/L. 

“This doesn’t detract from the fact that this is pretty low. Despite guidelines, we’re still not getting the majority of people on these very effective urate-lowering drugs,” Dr. Russell said.

There is perhaps too much reliance on modifying diet and lifestyle, he added, which are important for many reasons but will not do much to lower blood urate levels. 

As a final word, Dr. Russell said, “It’s not just a case of preventing a bit of joint pain. People get lots of complications when they’re undertreated — erosive joint damage, work disability, impaired quality of life — and yet we’ve got very cheap, well-tolerated drugs.”

The work was independently funded. Dr. Russell acknowledged grant or research support from Eli Lilly, Janssen, Pfizer, and UCB and receipt of honoraria from AbbVie, Biogen, Eli Lilly, Galapagos, and Menarini. 

A version of this article appeared on Medscape.com.

LIVERPOOL, ENGLAND — Optimizing how people experiencing a gout flare are managed in hospital and then followed-up afterwards can substantially increase the uptake of guideline-recommended urate-lowering therapy (ULT), researchers reported at the annual meeting of the British Society for Rheumatology (BSR).

In a prospective study, 92% of 97 people admitted to hospital for gout flares were using ULT within 6 months of discharge after a multifaceted intervention was introduced. By comparison, 49% of 94 people admitted for gout flares before the introduction of the intervention were taking ULT within the same postdischarge time frame. 

Moreover, a higher proportion of individuals had urate blood tests done at least once within the 6-month postdischarge period after the intervention’s introduction (58% vs 32%) and fewer (9% vs 15%) needed repeated hospital treatment. 

“Gout is the most common inflammatory arthritis affecting one in 30 adults in the United Kingdom, yet it’s one of the most poorly managed,” study investigator Mark D. Russell, MB, BChir, pointed out during a poster presentation. 

“There are very effective treatments,” added Dr. Russell, a rheumatology registrar and postdoctoral research fellow at King’s College London in London, England. “Urate-lowering therapies such as allopurinol, which when taken at the correct dose, in the long term, effectively cures patients of their symptoms and prevents complications.” 

Dr. Russell said in an interview that there was still work to be done as the rate of people achieving urate levels below the recommended threshold of 360 micromol/L (6 mg/dL) within 6 months was still low, at 27%, even it if was still better than the 11% seen before the intervention was introduced.
 

Improving the In- and Post-Hospital Pathway

“We developed and implemented an in-hospital management pathway which encouraged urate-lowering therapy initiation prior to discharge, followed by a post-discharge nurse-led review,” Dr. Russell explained. 

The in-hospital pathway was based upon BSR, European Alliance of Associations for Rheumatology, and American College of Rheumatology guidelines and involved diagnosing and managing the gout flare appropriately. This may have been via early joint aspiration, medication, or both, as directed by the rheumatology team. Affected individuals also received education and were directed where to obtain further information on the use of ULT. Outpatient follow-up was considered if an individual had severe or tophaceous gout, recurrent episodes, or contraindications or intolerances to ULT. Otherwise, a rheumatology nurse telephoned the individual 2 weeks later to review symptoms and discuss next steps.

The researchers recorded improvements in in-hospital outcomes. The frequency of in-hospital serum urate level measurements rose from 66% in the 12-month preimplementation period to 93% in the 12-month period after the intervention’s introduction. Almost two thirds (62%) of patients were discharged on ULT compared with 18% preimplementation. And gout-specific recommendations were given 86% of the time compared with 59% before the intervention.
 

Related Work on Gout Incidence

Separately, Dr. Russell also presented data from a nationwide, population-level cohort study that used data from OpenSAFELY, the secure data analytics platform used by the National Health Service in England. 

“We did an analysis previously using the CPRD [Clinical Research Practice Datalink], which is another good primary care database, showing that only a third of people with gout in the UK get urate-lowering drugs, when really it should be the vast majority,” he said in the interview.

“And then we wanted to look at, on top of that, what was the impact of the [COVID-19] pandemic,” Russell added. Specifically, the aim was to look at how the pandemic had affected the incidence, management, and prevalence of gout.

Between March 2015 and February 2023, 246,695 new cases of gout were identified among 17.9 million adults, seen in primary and secondary care. 
 

COVID-19 Pandemic Affected Cases

“The number of new cases of gout dropped by about one third in the first year of the pandemic,” Dr. Russell said. Incidence declined from 1.78 to 1.23 per 1000 adults. “Whether that was through people not feeling comfortable going to their GP [general practitioner] or not being able to get an appointment, we don’t know.”

While there was a subsequent increase in new cases of gout since this time, the rates still haven’t reached what they were before the pandemic. This implies that there could be a substantial number of people who may be undiagnosed because of the pandemic, Dr. Russell suggested. 

Moreover, he reported that in 2022-2023, the prevalence of gout was 3.21%, up slightly from the 3.07% recorded 7 years earlier in 2015-2016.
 

ULT Treatment Rates Low

“If you did see a GP, however, so as long as you saw someone, the treatment wasn’t any worse,” Dr. Russell said. Just under 30% of people with incident gout for whom follow-up data were available had initiated ULT within 6 months of their diagnosis. And, of these new starters, around a quarter had a serum urate level below a target of 360 micromol/L. 

“This doesn’t detract from the fact that this is pretty low. Despite guidelines, we’re still not getting the majority of people on these very effective urate-lowering drugs,” Dr. Russell said.

There is perhaps too much reliance on modifying diet and lifestyle, he added, which are important for many reasons but will not do much to lower blood urate levels. 

As a final word, Dr. Russell said, “It’s not just a case of preventing a bit of joint pain. People get lots of complications when they’re undertreated — erosive joint damage, work disability, impaired quality of life — and yet we’ve got very cheap, well-tolerated drugs.”

The work was independently funded. Dr. Russell acknowledged grant or research support from Eli Lilly, Janssen, Pfizer, and UCB and receipt of honoraria from AbbVie, Biogen, Eli Lilly, Galapagos, and Menarini. 

A version of this article appeared on Medscape.com.

As the pendulum has swung against recommending aspirin for the primary prevention of heart attacks and strokes, clinicians should focus on other ways to help patients avoid cardiovascular events.

A landmark study published in 1988 in The New England Journal of Medicine reported an astonishing 44% drop in the number of heart attacks among US male physicians aged 40-84 years who took aspirin.

Aspirin subsequently became a daily habit for millions of Americans. In 2017, nearly a quarter of Americans over age 40 who did not have cardiovascular disease (CVD) took the drug, and over 20% of those were doing so without a physician’s recommendation.

But in 2018, three studies (ASCEND, ARRIVE, and ASPREE) showed a stunning reversal in the purported benefit, according to John Wong, MD, vice-chair of the US Preventive Services Task Force (USPSTF).

The calculus for taking aspirin appeared to have changed dramatically: The drug decreased the risk for myocardial infarction by only 11% among study subjects, while its potential harms were much more pronounced.

According to Dr. Wong, who is also a professor of medicine and a primary care physician at Tufts University School of Medicine in Boston, Massachusetts, patients taking low-dose aspirin had a 58% increase in their risk for gastrointestinal bleeding compared with those not on aspirin, as well as a 31% increased risk for intracranial bleeding.

Did aspirin suddenly lose its magic powers in preventing heart attacks? Dr. Wong attributed the decline in effectiveness of aspirin in preventing heart attacks to other “primary care interventions that help reduce the cardiovascular disease risk in patients who haven’t had a heart attack or stroke.”

Fewer Americans smoke cigarettes, more realize the benefits of a healthy diet and physical activity, and the medical community better recognizes and treats hypertension. New classes of medications such as statins for high cholesterol are also moving the needle.

But a newer class of drugs may provide a safer replacement for aspirin, according to Muhammad Maqsood, MD, a cardiology fellow at DeBakey Heart and Vascular Center at Methodist Hospital in Houston, Texas. P2Y purinoceptor 12 (P2Y12) inhibitors are effective in lowering the risk for heart attack and stroke in patients with acute coronary syndrome or those undergoing elective percutaneous coronary interventions.

“They have shown a better bleeding profile, especially clopidogrel compared to aspirin,” Dr. Maqsood said.

However, the findings come from trials of patients who already had CVD, so results cannot yet be extrapolated to primary prevention. Dr. Maqsood said the gap highlights the need for clinical trials that evaluate P2Y12 inhibitors for primary prevention, but no such study is registered on clinicaltrials.gov.
 

Benefits Persist for Some Patients

The new evidence led the USPSTF to publish new guidelines in 2022, downgrading the recommendation for low-dose aspirin use for primary prevention. Previously, the organization stated that clinicians “should” initiate daily low-dose aspirin in adults aged 50-59 years and “consider” its use in adults aged 60-69 years whose 10-year risk for CVD was higher than 10%.

The updated guidelines stated that the decision to initiate low-dose aspirin in adults aged 40-59 years with a greater than 10% risk for CVD “should be an individual one,” based on professional judgment and individual patient preferences. The USPSTF also recommended against the use of aspirin in anyone over the age of 60.

Meanwhile, the American College of Cardiology and American Heart Association also dialed down previously strong recommendations on low-dose aspirin to a more nuanced recommendation stating, “low-dose aspirin might be considered for primary prevention of ASCVD among select adults 40-70 years of age.”

With a varying age limit for recommending aspirin, clinicians may take into consideration several variables.

“Is there a magic age? I don’t think there is,” said Douglas Lloyd-Jones, the former president of the American Heart Association and current chair of the Department of Preventive Medicine and a practicing cardiologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

For a patient over age 60 who is at a high risk for adverse cardiovascular outcomes, is unable to quit smoking, and is not likely to experience problematic bleeding, a clinician might recommend aspirin, Dr. Lloyd-Jones said. He said he sometimes also assesses coronary artery calcium to guide his clinical decisions: If elevated (an Agatston score above 100), he might recommend low-dose aspirin.

Dr. Lloyd-Jones also reiterated that patients should continue taking low-dose aspirin if they have already experienced a heart attack, stroke, episode of atrial fibrillation, or required a vascular stent.

Unless a patient with established CVD has intractable bleeding, “the aspirin is really for life,” Dr. Lloyd-Jones said. Patients who have a stent or who are at high risk for recurrence of stroke are more likely to experience thrombosis, and aspirin can decrease the risk.

“In our cardiology community, we don’t just strictly use the age of 70; the decision is always individualized,” Dr. Maqsood said.

Dr. Wong said primary care providers should focus on the USPSTF’s other recommendations that address CVD (Table), such as smoking cessation and screening for hypertension.

“I think our challenge is that we have so many of those A and B recommendations,” Dr. Wong said. “And I think part of the challenge for us is working with the patient to find out what’s most important to them.”

Discussing heart attacks and strokes often will strike a chord with patients because someone they know has been affected.

Dr. Maqsood emphasized the importance of behavioral interventions, such as helping patients decrease their body mass index and control their hyperlipidemia.

“The behavioral interventions are those which are the most cost-effective without any side effects,” he said.

His other piece of advice is to inquire with younger patients about a family history of heart attacks. Familial hypercholesteremia is unlikely to be controlled by diet and exercise and will need medical therapy.

Dr. Lloyd-Jones described the discussions he has with patients about preventing heart attacks as “the most important conversations we can have: Remember that cardiovascular disease is still the leading cause of death and disability in the world and in the United States.”

Dr. Wong, Dr. Lloyd-Jones, and Dr. Maqsood reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

As the pendulum has swung against recommending aspirin for the primary prevention of heart attacks and strokes, clinicians should focus on other ways to help patients avoid cardiovascular events.

A landmark study published in 1988 in The New England Journal of Medicine reported an astonishing 44% drop in the number of heart attacks among US male physicians aged 40-84 years who took aspirin.

Aspirin subsequently became a daily habit for millions of Americans. In 2017, nearly a quarter of Americans over age 40 who did not have cardiovascular disease (CVD) took the drug, and over 20% of those were doing so without a physician’s recommendation.

But in 2018, three studies (ASCEND, ARRIVE, and ASPREE) showed a stunning reversal in the purported benefit, according to John Wong, MD, vice-chair of the US Preventive Services Task Force (USPSTF).

The calculus for taking aspirin appeared to have changed dramatically: The drug decreased the risk for myocardial infarction by only 11% among study subjects, while its potential harms were much more pronounced.

According to Dr. Wong, who is also a professor of medicine and a primary care physician at Tufts University School of Medicine in Boston, Massachusetts, patients taking low-dose aspirin had a 58% increase in their risk for gastrointestinal bleeding compared with those not on aspirin, as well as a 31% increased risk for intracranial bleeding.

Did aspirin suddenly lose its magic powers in preventing heart attacks? Dr. Wong attributed the decline in effectiveness of aspirin in preventing heart attacks to other “primary care interventions that help reduce the cardiovascular disease risk in patients who haven’t had a heart attack or stroke.”

Fewer Americans smoke cigarettes, more realize the benefits of a healthy diet and physical activity, and the medical community better recognizes and treats hypertension. New classes of medications such as statins for high cholesterol are also moving the needle.

But a newer class of drugs may provide a safer replacement for aspirin, according to Muhammad Maqsood, MD, a cardiology fellow at DeBakey Heart and Vascular Center at Methodist Hospital in Houston, Texas. P2Y purinoceptor 12 (P2Y12) inhibitors are effective in lowering the risk for heart attack and stroke in patients with acute coronary syndrome or those undergoing elective percutaneous coronary interventions.

“They have shown a better bleeding profile, especially clopidogrel compared to aspirin,” Dr. Maqsood said.

However, the findings come from trials of patients who already had CVD, so results cannot yet be extrapolated to primary prevention. Dr. Maqsood said the gap highlights the need for clinical trials that evaluate P2Y12 inhibitors for primary prevention, but no such study is registered on clinicaltrials.gov.
 

Benefits Persist for Some Patients

The new evidence led the USPSTF to publish new guidelines in 2022, downgrading the recommendation for low-dose aspirin use for primary prevention. Previously, the organization stated that clinicians “should” initiate daily low-dose aspirin in adults aged 50-59 years and “consider” its use in adults aged 60-69 years whose 10-year risk for CVD was higher than 10%.

The updated guidelines stated that the decision to initiate low-dose aspirin in adults aged 40-59 years with a greater than 10% risk for CVD “should be an individual one,” based on professional judgment and individual patient preferences. The USPSTF also recommended against the use of aspirin in anyone over the age of 60.

Meanwhile, the American College of Cardiology and American Heart Association also dialed down previously strong recommendations on low-dose aspirin to a more nuanced recommendation stating, “low-dose aspirin might be considered for primary prevention of ASCVD among select adults 40-70 years of age.”

With a varying age limit for recommending aspirin, clinicians may take into consideration several variables.

“Is there a magic age? I don’t think there is,” said Douglas Lloyd-Jones, the former president of the American Heart Association and current chair of the Department of Preventive Medicine and a practicing cardiologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

For a patient over age 60 who is at a high risk for adverse cardiovascular outcomes, is unable to quit smoking, and is not likely to experience problematic bleeding, a clinician might recommend aspirin, Dr. Lloyd-Jones said. He said he sometimes also assesses coronary artery calcium to guide his clinical decisions: If elevated (an Agatston score above 100), he might recommend low-dose aspirin.

Dr. Lloyd-Jones also reiterated that patients should continue taking low-dose aspirin if they have already experienced a heart attack, stroke, episode of atrial fibrillation, or required a vascular stent.

Unless a patient with established CVD has intractable bleeding, “the aspirin is really for life,” Dr. Lloyd-Jones said. Patients who have a stent or who are at high risk for recurrence of stroke are more likely to experience thrombosis, and aspirin can decrease the risk.

“In our cardiology community, we don’t just strictly use the age of 70; the decision is always individualized,” Dr. Maqsood said.

Dr. Wong said primary care providers should focus on the USPSTF’s other recommendations that address CVD (Table), such as smoking cessation and screening for hypertension.

“I think our challenge is that we have so many of those A and B recommendations,” Dr. Wong said. “And I think part of the challenge for us is working with the patient to find out what’s most important to them.”

Discussing heart attacks and strokes often will strike a chord with patients because someone they know has been affected.

Dr. Maqsood emphasized the importance of behavioral interventions, such as helping patients decrease their body mass index and control their hyperlipidemia.

“The behavioral interventions are those which are the most cost-effective without any side effects,” he said.

His other piece of advice is to inquire with younger patients about a family history of heart attacks. Familial hypercholesteremia is unlikely to be controlled by diet and exercise and will need medical therapy.

Dr. Lloyd-Jones described the discussions he has with patients about preventing heart attacks as “the most important conversations we can have: Remember that cardiovascular disease is still the leading cause of death and disability in the world and in the United States.”

Dr. Wong, Dr. Lloyd-Jones, and Dr. Maqsood reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

As the pendulum has swung against recommending aspirin for the primary prevention of heart attacks and strokes, clinicians should focus on other ways to help patients avoid cardiovascular events.

A landmark study published in 1988 in The New England Journal of Medicine reported an astonishing 44% drop in the number of heart attacks among US male physicians aged 40-84 years who took aspirin.

Aspirin subsequently became a daily habit for millions of Americans. In 2017, nearly a quarter of Americans over age 40 who did not have cardiovascular disease (CVD) took the drug, and over 20% of those were doing so without a physician’s recommendation.

But in 2018, three studies (ASCEND, ARRIVE, and ASPREE) showed a stunning reversal in the purported benefit, according to John Wong, MD, vice-chair of the US Preventive Services Task Force (USPSTF).

The calculus for taking aspirin appeared to have changed dramatically: The drug decreased the risk for myocardial infarction by only 11% among study subjects, while its potential harms were much more pronounced.

According to Dr. Wong, who is also a professor of medicine and a primary care physician at Tufts University School of Medicine in Boston, Massachusetts, patients taking low-dose aspirin had a 58% increase in their risk for gastrointestinal bleeding compared with those not on aspirin, as well as a 31% increased risk for intracranial bleeding.

Did aspirin suddenly lose its magic powers in preventing heart attacks? Dr. Wong attributed the decline in effectiveness of aspirin in preventing heart attacks to other “primary care interventions that help reduce the cardiovascular disease risk in patients who haven’t had a heart attack or stroke.”

Fewer Americans smoke cigarettes, more realize the benefits of a healthy diet and physical activity, and the medical community better recognizes and treats hypertension. New classes of medications such as statins for high cholesterol are also moving the needle.

But a newer class of drugs may provide a safer replacement for aspirin, according to Muhammad Maqsood, MD, a cardiology fellow at DeBakey Heart and Vascular Center at Methodist Hospital in Houston, Texas. P2Y purinoceptor 12 (P2Y12) inhibitors are effective in lowering the risk for heart attack and stroke in patients with acute coronary syndrome or those undergoing elective percutaneous coronary interventions.

“They have shown a better bleeding profile, especially clopidogrel compared to aspirin,” Dr. Maqsood said.

However, the findings come from trials of patients who already had CVD, so results cannot yet be extrapolated to primary prevention. Dr. Maqsood said the gap highlights the need for clinical trials that evaluate P2Y12 inhibitors for primary prevention, but no such study is registered on clinicaltrials.gov.
 

Benefits Persist for Some Patients

The new evidence led the USPSTF to publish new guidelines in 2022, downgrading the recommendation for low-dose aspirin use for primary prevention. Previously, the organization stated that clinicians “should” initiate daily low-dose aspirin in adults aged 50-59 years and “consider” its use in adults aged 60-69 years whose 10-year risk for CVD was higher than 10%.

The updated guidelines stated that the decision to initiate low-dose aspirin in adults aged 40-59 years with a greater than 10% risk for CVD “should be an individual one,” based on professional judgment and individual patient preferences. The USPSTF also recommended against the use of aspirin in anyone over the age of 60.

Meanwhile, the American College of Cardiology and American Heart Association also dialed down previously strong recommendations on low-dose aspirin to a more nuanced recommendation stating, “low-dose aspirin might be considered for primary prevention of ASCVD among select adults 40-70 years of age.”

With a varying age limit for recommending aspirin, clinicians may take into consideration several variables.

“Is there a magic age? I don’t think there is,” said Douglas Lloyd-Jones, the former president of the American Heart Association and current chair of the Department of Preventive Medicine and a practicing cardiologist at Northwestern University Feinberg School of Medicine in Chicago, Illinois.

For a patient over age 60 who is at a high risk for adverse cardiovascular outcomes, is unable to quit smoking, and is not likely to experience problematic bleeding, a clinician might recommend aspirin, Dr. Lloyd-Jones said. He said he sometimes also assesses coronary artery calcium to guide his clinical decisions: If elevated (an Agatston score above 100), he might recommend low-dose aspirin.

Dr. Lloyd-Jones also reiterated that patients should continue taking low-dose aspirin if they have already experienced a heart attack, stroke, episode of atrial fibrillation, or required a vascular stent.

Unless a patient with established CVD has intractable bleeding, “the aspirin is really for life,” Dr. Lloyd-Jones said. Patients who have a stent or who are at high risk for recurrence of stroke are more likely to experience thrombosis, and aspirin can decrease the risk.

“In our cardiology community, we don’t just strictly use the age of 70; the decision is always individualized,” Dr. Maqsood said.

Dr. Wong said primary care providers should focus on the USPSTF’s other recommendations that address CVD (Table), such as smoking cessation and screening for hypertension.

“I think our challenge is that we have so many of those A and B recommendations,” Dr. Wong said. “And I think part of the challenge for us is working with the patient to find out what’s most important to them.”

Discussing heart attacks and strokes often will strike a chord with patients because someone they know has been affected.

Dr. Maqsood emphasized the importance of behavioral interventions, such as helping patients decrease their body mass index and control their hyperlipidemia.

“The behavioral interventions are those which are the most cost-effective without any side effects,” he said.

His other piece of advice is to inquire with younger patients about a family history of heart attacks. Familial hypercholesteremia is unlikely to be controlled by diet and exercise and will need medical therapy.

Dr. Lloyd-Jones described the discussions he has with patients about preventing heart attacks as “the most important conversations we can have: Remember that cardiovascular disease is still the leading cause of death and disability in the world and in the United States.”

Dr. Wong, Dr. Lloyd-Jones, and Dr. Maqsood reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

Moderate to vigorous aerobic physical activity performed in the evening is associated with the lowest risk for mortality, cardiovascular disease (CVD), and microvascular disease (MVD) in adults with obesity, including those with type 2 diabetes (T2D).

METHODOLOGY:

• Bouts of moderate to vigorous aerobic physical activity are widely recognized to improve cardiometabolic risk factors, but whether morning, afternoon, or evening timing may lead to greater improvements is unclear.
• Researchers analyzed UK Biobank data of 29,836 participants with obesity (body mass index, › 30; mean age, 62.2 years; 53.2% women), including 2995 also diagnosed with T2D, all enrolled in 2006-2010.
• Aerobic activity was defined as bouts lasting ≥ 3 minutes, and the intensity of activity was classified as light, moderate, or vigorous using accelerometer data collected from participants.
• Participants were stratified into the morning (6 a.m. to < 12 p.m.), afternoon (12 p.m. to < 6 p.m.), and evening (6 p.m. to < 12 a.m.) groups based on when > 50% of their total moderate to vigorous activity occurred, and those with no aerobic bouts were considered the reference group.
• The association between the timing of aerobic physical activity and risk for all-cause mortality, CVD (defined as circulatory, such as hypertension), and MVD (neuropathy, nephropathy, or retinopathy) was evaluated over a median follow-up of 7.9 years.

TAKEAWAY:

• Mortality risk was lowest in the evening moderate to vigorous physical activity group (hazard ratio [HR], 0.39; 95% CI, 0.27-0.55) and even lower in the T2D subgroup (HR, 0.24; 95% CI, 0.08-0.76) than in the reference group.
• Mortality risk was lower in the afternoon (HR, 0.60; 95% CI, 0.51-0.71) and morning (HR, 0.67; 95% CI, 0.56-0.79) activity groups than in the reference group, but this association was weaker than that observed in the evening activity group.
• The evening moderate to vigorous activity group had a lower risk for CVD (HR, 0.64; 95% CI, 0.54-0.75) and MVD (HR, 0.76; 95% CI, 0.63-0.92) than the reference group.
• Among participants with obesity and T2D, moderate to vigorous physical activity in the evening was associated with a lower risk for mortality, CVD, and MVD.

IN PRACTICE:

The authors wrote, “The results of this study emphasize that beyond the total volume of MVPA [moderate to vigorous physical activity], its timing, particularly in the evening, was consistently associated with the lowest risk of mortality relative to other timing windows.”

SOURCE:

The study, led by Angelo Sabag, PhD, Charles Perkins Centre, University of Sydney, Australia, was published online in Diabetes Care.

LIMITATIONS:

Because this was an observational study, the possibility of reverse causation from prodromal disease and unaccounted confounding factors could not have been ruled out. There was a lag of a median of 5.5 years between the UK Biobank baseline, when covariate measurements were taken, and the accelerometry study. Moreover, the response rate of the UK Biobank was low.

DISCLOSURES:

The study was funded by an Australian National Health and Medical Research Council Investigator Grant and the National Heart Foundation of Australia Postdoctoral Fellowship. The authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Moderate to vigorous aerobic physical activity performed in the evening is associated with the lowest risk for mortality, cardiovascular disease (CVD), and microvascular disease (MVD) in adults with obesity, including those with type 2 diabetes (T2D).

METHODOLOGY:

• Bouts of moderate to vigorous aerobic physical activity are widely recognized to improve cardiometabolic risk factors, but whether morning, afternoon, or evening timing may lead to greater improvements is unclear.
• Researchers analyzed UK Biobank data of 29,836 participants with obesity (body mass index, › 30; mean age, 62.2 years; 53.2% women), including 2995 also diagnosed with T2D, all enrolled in 2006-2010.
• Aerobic activity was defined as bouts lasting ≥ 3 minutes, and the intensity of activity was classified as light, moderate, or vigorous using accelerometer data collected from participants.
• Participants were stratified into the morning (6 a.m. to < 12 p.m.), afternoon (12 p.m. to < 6 p.m.), and evening (6 p.m. to < 12 a.m.) groups based on when > 50% of their total moderate to vigorous activity occurred, and those with no aerobic bouts were considered the reference group.
• The association between the timing of aerobic physical activity and risk for all-cause mortality, CVD (defined as circulatory, such as hypertension), and MVD (neuropathy, nephropathy, or retinopathy) was evaluated over a median follow-up of 7.9 years.

TAKEAWAY:

• Mortality risk was lowest in the evening moderate to vigorous physical activity group (hazard ratio [HR], 0.39; 95% CI, 0.27-0.55) and even lower in the T2D subgroup (HR, 0.24; 95% CI, 0.08-0.76) than in the reference group.
• Mortality risk was lower in the afternoon (HR, 0.60; 95% CI, 0.51-0.71) and morning (HR, 0.67; 95% CI, 0.56-0.79) activity groups than in the reference group, but this association was weaker than that observed in the evening activity group.
• The evening moderate to vigorous activity group had a lower risk for CVD (HR, 0.64; 95% CI, 0.54-0.75) and MVD (HR, 0.76; 95% CI, 0.63-0.92) than the reference group.
• Among participants with obesity and T2D, moderate to vigorous physical activity in the evening was associated with a lower risk for mortality, CVD, and MVD.

IN PRACTICE:

The authors wrote, “The results of this study emphasize that beyond the total volume of MVPA [moderate to vigorous physical activity], its timing, particularly in the evening, was consistently associated with the lowest risk of mortality relative to other timing windows.”

SOURCE:

The study, led by Angelo Sabag, PhD, Charles Perkins Centre, University of Sydney, Australia, was published online in Diabetes Care.

LIMITATIONS:

Because this was an observational study, the possibility of reverse causation from prodromal disease and unaccounted confounding factors could not have been ruled out. There was a lag of a median of 5.5 years between the UK Biobank baseline, when covariate measurements were taken, and the accelerometry study. Moreover, the response rate of the UK Biobank was low.

DISCLOSURES:

The study was funded by an Australian National Health and Medical Research Council Investigator Grant and the National Heart Foundation of Australia Postdoctoral Fellowship. The authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

TOPLINE:

Moderate to vigorous aerobic physical activity performed in the evening is associated with the lowest risk for mortality, cardiovascular disease (CVD), and microvascular disease (MVD) in adults with obesity, including those with type 2 diabetes (T2D).

METHODOLOGY:

• Bouts of moderate to vigorous aerobic physical activity are widely recognized to improve cardiometabolic risk factors, but whether morning, afternoon, or evening timing may lead to greater improvements is unclear.
• Researchers analyzed UK Biobank data of 29,836 participants with obesity (body mass index, › 30; mean age, 62.2 years; 53.2% women), including 2995 also diagnosed with T2D, all enrolled in 2006-2010.
• Aerobic activity was defined as bouts lasting ≥ 3 minutes, and the intensity of activity was classified as light, moderate, or vigorous using accelerometer data collected from participants.
• Participants were stratified into the morning (6 a.m. to < 12 p.m.), afternoon (12 p.m. to < 6 p.m.), and evening (6 p.m. to < 12 a.m.) groups based on when > 50% of their total moderate to vigorous activity occurred, and those with no aerobic bouts were considered the reference group.
• The association between the timing of aerobic physical activity and risk for all-cause mortality, CVD (defined as circulatory, such as hypertension), and MVD (neuropathy, nephropathy, or retinopathy) was evaluated over a median follow-up of 7.9 years.

TAKEAWAY:

• Mortality risk was lowest in the evening moderate to vigorous physical activity group (hazard ratio [HR], 0.39; 95% CI, 0.27-0.55) and even lower in the T2D subgroup (HR, 0.24; 95% CI, 0.08-0.76) than in the reference group.
• Mortality risk was lower in the afternoon (HR, 0.60; 95% CI, 0.51-0.71) and morning (HR, 0.67; 95% CI, 0.56-0.79) activity groups than in the reference group, but this association was weaker than that observed in the evening activity group.
• The evening moderate to vigorous activity group had a lower risk for CVD (HR, 0.64; 95% CI, 0.54-0.75) and MVD (HR, 0.76; 95% CI, 0.63-0.92) than the reference group.
• Among participants with obesity and T2D, moderate to vigorous physical activity in the evening was associated with a lower risk for mortality, CVD, and MVD.

IN PRACTICE:

The authors wrote, “The results of this study emphasize that beyond the total volume of MVPA [moderate to vigorous physical activity], its timing, particularly in the evening, was consistently associated with the lowest risk of mortality relative to other timing windows.”

SOURCE:

The study, led by Angelo Sabag, PhD, Charles Perkins Centre, University of Sydney, Australia, was published online in Diabetes Care.

LIMITATIONS:

Because this was an observational study, the possibility of reverse causation from prodromal disease and unaccounted confounding factors could not have been ruled out. There was a lag of a median of 5.5 years between the UK Biobank baseline, when covariate measurements were taken, and the accelerometry study. Moreover, the response rate of the UK Biobank was low.

DISCLOSURES:

The study was funded by an Australian National Health and Medical Research Council Investigator Grant and the National Heart Foundation of Australia Postdoctoral Fellowship. The authors reported no conflicts of interest.

A version of this article appeared on Medscape.com.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

In a small, nonrandomized controlled trial, the injectable calcitonin gene-related peptide (CGRP) inhibitor erenumab significantly reduced treatment-resistant flushing and erythema associated with rosacea. Skin-related quality-of-life (QOL) measures also improved, albeit modestly.

The study was published in JAMA Dermatology.

National Rosacea Society

“The transient erythema of rosacea is one of the most challenging rosacea symptoms to treat,” Emmy Graber, MD, MBA, who was not involved with the study, said in an interview. “As flushing can adversely impact quality of life in our rosacea patients, it is important to find therapeutic options for our patients. This study is exciting, not only because the treatment was successful for a notable number of patients, but also because it involved a drug with a novel mode of action in rosacea.” Dr. Graber practices in Boston and is an affiliate clinical instructor at Northeastern University, Boston.

Spotlight on CGRP

Rosacea’s pathophysiology remains incompletely understood, wrote Nita K.F. Wienholtz, MD, PhD, Department of Dermatology, Bispebjerg and Frederiksberg Hospital, University of Copenhagen, Denmark, and coinvestigators. However, they added, mounting evidence suggests a possible role for CGRP. For example, a study published in JAMA Dermatology in 2015 revealed elevated CGRP levels in facial skin biopsies from patients with rosacea.

For the present study, the investigators enrolled 30 adults (including 23 women) with rosacea who experienced at least 15 days of moderate to severe erythema or extreme flushing during a 4-week, treatment-free run-in period. Most participants (87%) had previously failed one or more rosacea treatments because of a lack of efficacy or adverse reactions, and 43% had failed three or more treatments.

Participants received 3-monthly 140-mg doses of erenumab, which is approved by the Food and Drug Administration for migraine prevention. Patients recorded scores on the Patient Self-Assessment (PSA) and item 2 of the Flushing Assessment Tool online daily and made a final follow-up visit 12 weeks after the third dose.

Among the 27 patients who completed the study, the mean number of days with moderate to severe flushing from week 9 to week 12 fell by 6.9 from 23.6 days over 4 weeks at baseline (P < .001). Patients most severely affected by flushing at baseline experienced an 81% decline in days with severe to extreme flushing. Overall, 26% of patients experienced at least 50% reductions in moderate to extreme flushing days. The number of days with moderate to severe erythema as measured by PSA fell by 8.1 (mean) from baseline, and 56% of patients experienced at least 50% reductions in PSA scores. No unexpected safety signals emerged.
 

Questions Over QOL Data

“Although there were significant decreases in flushing and erythema,” wrote John S. Barbieri, MD, MBA, in an accompanying Editor’s Note, “the present study had relatively modest improvements in quality of life.” He is director of the Advanced Acne Therapeutics Clinic, Brigham and Women’s Hospital, Boston, and associate editor and evidence-based practice editor of JAMA Dermatology.

Brigham and Women&#039;s Hospital

Compared with baseline (6.22), mean Dermatology Life Quality Index scores fell 2.08 points and 2.73 points at weeks 8 and 20, respectively (P = .004 and .003). At the same intervals, the mean baseline Rosacea Quality of Life score (48.22) decreased by 2.58 points and 4.14 points, respectively (P = .04 and .02).

No significant changes appeared in gauges of anxiety and depression. These findings, authors wrote, could stem from their decision to omit a follow-up visit at week 12 — where they may have seen mental-health effects which disappeared by week 20 — in response to patients’ logistical concerns.

However, Dr. Webster questioned the value of QOL measurements in rosacea. “Quality-of-life measures are blunt instruments,” he explained, and reducing severe itching or chronic pain improves the lives of affected patients. “But what question are you going to ask to tease out whether being less red-cheeked has made someone’s life easier? It’s not a problem that lends itself to quality-of-life assessments.” Moreover, he said, regulators who increasingly require such measures in clinical trials ignore this point, creating challenges for drug developers and researchers.

Because the study was neither blinded nor controlled, Dr. Webster suggested considering it a tantalizing proof of concept. “If I were putting money into a CGRP inhibitor, I’d want at least a small, placebo-controlled, double-blinded study.”

Study authors and Dr. Barbieri recommended larger randomized studies involving different populations and erenumab doses. For now, Dr. Barbieri wrote, CGRP inhibition represents a promising potential strategy for patients who have rosacea with comorbid migraine or recalcitrant flushing and erythema.

Dr. Wienholtz reported no relevant financial interests. Dr. Barbieri had no related disclosures. Dr. Webster reported no relevant financial interests. Dr. Graber reported no conflicts related to erenumab but consults for other companies with rosacea-related products including Galderma. The study was supported by and conducted in collaboration with Novartis Pharma AG. Additional funding came from the Novo Nordisk Foundation and the Lundbeck Foundation.

A version of this article appeared on Medscape.com.

Children with growth hormone deficiency (GHD) have differences in gut microbiota and microbial metabolites from both individuals with idiopathic short stature (ISS) and healthy controls, suggesting an interaction with growth hormone levels, said Chinese researchers.

The research, published recently in Pediatric Research, involved more than 80 children and showed that those with GHD had alterations in microbial populations that have been linked to longevity, as well as a microbial and metabolite signature that allowed accurate discrimination from ISS.

“These findings provide novel insights into potential early diagnosis and innovative treatment alternatives, such as fecal microbiota transplantation, for short stature with varying growth hormone levels,” the authors wrote.

Andrew Dauber, MD, MMSc, chief of endocrinology, Children’s National Hospital, Washington, who was not involved in the study, said that while this is “a really interesting area of research,” he expressed “hesitancy about getting too excited about this data yet.”

“One of the problems is how you define growth hormone deficiency,” as it is “not a black and white diagnosis,” and the etiology and child’s growth trajectory also need to be considered, Dr. Dauber told said.

He explained: “The problem is that, when you rely on the growth hormone stimulation test alone, there’s so many false positives and so much overlap between patients with true growth hormone deficiency and those without. And I think that this article fell prey to that.”

He added: “It would be really, really interesting and helpful to have a microbiome signature that allows you to distinguish between true growth hormone deficiency and patients with idiopathic short stature.”

“But you have to make sure that your groups are very well defined for this study to be really valid. And that’s one of my concerns here.”

Dr. Dauber continued: “Now, that being said, they did find some associations that correlated with growth hormone peak levels,” some which replicate previous findings, “so I do think that there are kernels of important findings here.”
 

‘Tease Out Influences’ to Isolate the Interaction

He pointed out that there are “many factors that influence the microbiome,” such as the use of antibiotics, diet, age, and geographic location. Therefore, a study that could truly tease out all these influences and isolate the interaction with growth hormone levels would need to be “very thoughtfully designed.”

A number of factors contribute to short stature, lead author Lan Li, MD, Department of Radiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China, and colleagues.

These include genetic factors, environmental factors, and conditions such as being small for gestational age at birth, familial short stature, and chronic systemic diseases, as well as GHD and ISS.

Recent animal studies have suggested that there may be a bidirectional relationship between the gut microbiota and the growth hormone/insulin-like growth factor 1 axis, and it has been shown that individuals with GHD have significant alterations in their gut microbiota compared with healthy controls.

To investigate, they studied 36 children diagnosed with GHD, 32 with ISS, and 16 age- and sex-matched healthy controls, all of whom were recruited between February 2019 and June 2021 from the Pediatric Endocrinology Department of The Second Affiliated Hospital of Wenzhou Medical University.

Fecal samples obtained from the children underwent microbiome analysis using 16S ribosomal RNA gene sequencing, alongside nuclear MRI analysis of the metabolome, or the entire complement of small molecules in the samples.

Patients with GHD had a significantly higher body mass index than those with ISS (P < .05), and their peak growth hormone level was significantly lower (P < .001). Patients with GHD also had significantly higher total cholesterol and low-density lipoprotein cholesterol levels than patients with ISS (P < .05).

The team reports that the alpha diversity of the fecal microbiome, which measures the microbial diversity within a fecal sample, was similar between the three groups.

However, there was significant variation between the groups in the beta diversity, which quantifies the similarity or dissimilarity between two samples, and allows the overall taxonomic or functional diversity pattern to be linked to environmental features.

Compared with the healthy control group, the abundance of Pelomonas, Rodentibacter, and Rothia was significantly decreased in GHD and patients with ISS, while the abundance of Prevotellaceae_NK3B31_group was increased in the two patient groups, particularly in those with GHD.

In addition, the researchers found a decreased Firmicutes/Bacteroidota (F/B) ratio in participants with short stature, particularly in the GHD group. They noted that “emerging evidence suggests the F/B ratio may play a role in longevity.”

Nocardioides was substantially more common in the ISS group vs both patients with GHD and healthy controls, while Fusobacterium mortiferum was characteristic of GHD. The team suggests this “may serve as a critical intestinal factor contributing to the short stature observed in GHD.”

The metabolome analysis revealed that glucose, pyruvate, and pyrimidine metabolism may also play a significant role in distinguishing between patients with GHD and ISS and healthy control groups.

Finally, the team demonstrated that a panel combining 13 microbiome and metabolome markers was able to discriminate between GHD and ISS at an area under the receiver operating characteristic curve of 0.945, with a sensitivity of 87% and a specificity of 91%.

The study was supported by grants from the National Natural Science Foundation of China and Wenzhou Science and Technology Bureau in China. No relevant financial relationships were declared.
 

A version of this article appeared on Medscape.com.

Children with growth hormone deficiency (GHD) have differences in gut microbiota and microbial metabolites from both individuals with idiopathic short stature (ISS) and healthy controls, suggesting an interaction with growth hormone levels, said Chinese researchers.

The research, published recently in Pediatric Research, involved more than 80 children and showed that those with GHD had alterations in microbial populations that have been linked to longevity, as well as a microbial and metabolite signature that allowed accurate discrimination from ISS.

“These findings provide novel insights into potential early diagnosis and innovative treatment alternatives, such as fecal microbiota transplantation, for short stature with varying growth hormone levels,” the authors wrote.

Andrew Dauber, MD, MMSc, chief of endocrinology, Children’s National Hospital, Washington, who was not involved in the study, said that while this is “a really interesting area of research,” he expressed “hesitancy about getting too excited about this data yet.”

“One of the problems is how you define growth hormone deficiency,” as it is “not a black and white diagnosis,” and the etiology and child’s growth trajectory also need to be considered, Dr. Dauber told said.

He explained: “The problem is that, when you rely on the growth hormone stimulation test alone, there’s so many false positives and so much overlap between patients with true growth hormone deficiency and those without. And I think that this article fell prey to that.”

He added: “It would be really, really interesting and helpful to have a microbiome signature that allows you to distinguish between true growth hormone deficiency and patients with idiopathic short stature.”

“But you have to make sure that your groups are very well defined for this study to be really valid. And that’s one of my concerns here.”

Dr. Dauber continued: “Now, that being said, they did find some associations that correlated with growth hormone peak levels,” some which replicate previous findings, “so I do think that there are kernels of important findings here.”
 

‘Tease Out Influences’ to Isolate the Interaction

He pointed out that there are “many factors that influence the microbiome,” such as the use of antibiotics, diet, age, and geographic location. Therefore, a study that could truly tease out all these influences and isolate the interaction with growth hormone levels would need to be “very thoughtfully designed.”

A number of factors contribute to short stature, lead author Lan Li, MD, Department of Radiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China, and colleagues.

These include genetic factors, environmental factors, and conditions such as being small for gestational age at birth, familial short stature, and chronic systemic diseases, as well as GHD and ISS.

Recent animal studies have suggested that there may be a bidirectional relationship between the gut microbiota and the growth hormone/insulin-like growth factor 1 axis, and it has been shown that individuals with GHD have significant alterations in their gut microbiota compared with healthy controls.

To investigate, they studied 36 children diagnosed with GHD, 32 with ISS, and 16 age- and sex-matched healthy controls, all of whom were recruited between February 2019 and June 2021 from the Pediatric Endocrinology Department of The Second Affiliated Hospital of Wenzhou Medical University.

Fecal samples obtained from the children underwent microbiome analysis using 16S ribosomal RNA gene sequencing, alongside nuclear MRI analysis of the metabolome, or the entire complement of small molecules in the samples.

Patients with GHD had a significantly higher body mass index than those with ISS (P < .05), and their peak growth hormone level was significantly lower (P < .001). Patients with GHD also had significantly higher total cholesterol and low-density lipoprotein cholesterol levels than patients with ISS (P < .05).

The team reports that the alpha diversity of the fecal microbiome, which measures the microbial diversity within a fecal sample, was similar between the three groups.

However, there was significant variation between the groups in the beta diversity, which quantifies the similarity or dissimilarity between two samples, and allows the overall taxonomic or functional diversity pattern to be linked to environmental features.

Compared with the healthy control group, the abundance of Pelomonas, Rodentibacter, and Rothia was significantly decreased in GHD and patients with ISS, while the abundance of Prevotellaceae_NK3B31_group was increased in the two patient groups, particularly in those with GHD.

In addition, the researchers found a decreased Firmicutes/Bacteroidota (F/B) ratio in participants with short stature, particularly in the GHD group. They noted that “emerging evidence suggests the F/B ratio may play a role in longevity.”

Nocardioides was substantially more common in the ISS group vs both patients with GHD and healthy controls, while Fusobacterium mortiferum was characteristic of GHD. The team suggests this “may serve as a critical intestinal factor contributing to the short stature observed in GHD.”

The metabolome analysis revealed that glucose, pyruvate, and pyrimidine metabolism may also play a significant role in distinguishing between patients with GHD and ISS and healthy control groups.

Finally, the team demonstrated that a panel combining 13 microbiome and metabolome markers was able to discriminate between GHD and ISS at an area under the receiver operating characteristic curve of 0.945, with a sensitivity of 87% and a specificity of 91%.

The study was supported by grants from the National Natural Science Foundation of China and Wenzhou Science and Technology Bureau in China. No relevant financial relationships were declared.
 

A version of this article appeared on Medscape.com.

Children with growth hormone deficiency (GHD) have differences in gut microbiota and microbial metabolites from both individuals with idiopathic short stature (ISS) and healthy controls, suggesting an interaction with growth hormone levels, said Chinese researchers.

The research, published recently in Pediatric Research, involved more than 80 children and showed that those with GHD had alterations in microbial populations that have been linked to longevity, as well as a microbial and metabolite signature that allowed accurate discrimination from ISS.

“These findings provide novel insights into potential early diagnosis and innovative treatment alternatives, such as fecal microbiota transplantation, for short stature with varying growth hormone levels,” the authors wrote.

Andrew Dauber, MD, MMSc, chief of endocrinology, Children’s National Hospital, Washington, who was not involved in the study, said that while this is “a really interesting area of research,” he expressed “hesitancy about getting too excited about this data yet.”

“One of the problems is how you define growth hormone deficiency,” as it is “not a black and white diagnosis,” and the etiology and child’s growth trajectory also need to be considered, Dr. Dauber told said.

He explained: “The problem is that, when you rely on the growth hormone stimulation test alone, there’s so many false positives and so much overlap between patients with true growth hormone deficiency and those without. And I think that this article fell prey to that.”

He added: “It would be really, really interesting and helpful to have a microbiome signature that allows you to distinguish between true growth hormone deficiency and patients with idiopathic short stature.”

“But you have to make sure that your groups are very well defined for this study to be really valid. And that’s one of my concerns here.”

Dr. Dauber continued: “Now, that being said, they did find some associations that correlated with growth hormone peak levels,” some which replicate previous findings, “so I do think that there are kernels of important findings here.”
 

‘Tease Out Influences’ to Isolate the Interaction

He pointed out that there are “many factors that influence the microbiome,” such as the use of antibiotics, diet, age, and geographic location. Therefore, a study that could truly tease out all these influences and isolate the interaction with growth hormone levels would need to be “very thoughtfully designed.”

A number of factors contribute to short stature, lead author Lan Li, MD, Department of Radiology, The Second Affiliated Hospital and Yuying Children’s Hospital of Wenzhou Medical University, Wenzhou, China, and colleagues.

These include genetic factors, environmental factors, and conditions such as being small for gestational age at birth, familial short stature, and chronic systemic diseases, as well as GHD and ISS.

Recent animal studies have suggested that there may be a bidirectional relationship between the gut microbiota and the growth hormone/insulin-like growth factor 1 axis, and it has been shown that individuals with GHD have significant alterations in their gut microbiota compared with healthy controls.

To investigate, they studied 36 children diagnosed with GHD, 32 with ISS, and 16 age- and sex-matched healthy controls, all of whom were recruited between February 2019 and June 2021 from the Pediatric Endocrinology Department of The Second Affiliated Hospital of Wenzhou Medical University.

Fecal samples obtained from the children underwent microbiome analysis using 16S ribosomal RNA gene sequencing, alongside nuclear MRI analysis of the metabolome, or the entire complement of small molecules in the samples.

Patients with GHD had a significantly higher body mass index than those with ISS (P < .05), and their peak growth hormone level was significantly lower (P < .001). Patients with GHD also had significantly higher total cholesterol and low-density lipoprotein cholesterol levels than patients with ISS (P < .05).

The team reports that the alpha diversity of the fecal microbiome, which measures the microbial diversity within a fecal sample, was similar between the three groups.

However, there was significant variation between the groups in the beta diversity, which quantifies the similarity or dissimilarity between two samples, and allows the overall taxonomic or functional diversity pattern to be linked to environmental features.

Compared with the healthy control group, the abundance of Pelomonas, Rodentibacter, and Rothia was significantly decreased in GHD and patients with ISS, while the abundance of Prevotellaceae_NK3B31_group was increased in the two patient groups, particularly in those with GHD.

In addition, the researchers found a decreased Firmicutes/Bacteroidota (F/B) ratio in participants with short stature, particularly in the GHD group. They noted that “emerging evidence suggests the F/B ratio may play a role in longevity.”

Nocardioides was substantially more common in the ISS group vs both patients with GHD and healthy controls, while Fusobacterium mortiferum was characteristic of GHD. The team suggests this “may serve as a critical intestinal factor contributing to the short stature observed in GHD.”

The metabolome analysis revealed that glucose, pyruvate, and pyrimidine metabolism may also play a significant role in distinguishing between patients with GHD and ISS and healthy control groups.

Finally, the team demonstrated that a panel combining 13 microbiome and metabolome markers was able to discriminate between GHD and ISS at an area under the receiver operating characteristic curve of 0.945, with a sensitivity of 87% and a specificity of 91%.

The study was supported by grants from the National Natural Science Foundation of China and Wenzhou Science and Technology Bureau in China. No relevant financial relationships were declared.
 

A version of this article appeared on Medscape.com.

WIESBADEN, GERMANY — Crowded waiting rooms, long wait times, irritable patients, and aggression toward nursing staff and doctors are increasingly the reality in German emergency rooms. Clearly, emergencies belong in the emergency room. However, “In about half of all patients in the emergency room, there is no urgent medical emergency,” Norbert Schütz, MD, director of geriatrics and rheumatology at Helios Dr. Horst Schmidt Hospital in Wiesbaden, Germany, said at a press conference for the 130th Annual Meeting of the German Society of Internal Medicine (DGIM).

“In our daily medical practice, we repeatedly experience people either accessing our emergency departments and ambulances too quickly or lingering at home for too long when they have severe symptoms,” said Dr. Schütz, who organized the Patient Day during the Internist Congress.
 

DGIM Educates Patients

What is an emergency? “I think the public is quite well informed about conditions associated with loss of consciousness, severe pain, chest pain, or paralysis: Think stroke or heart attack. This is undoubtedly a success of recent years. The difficulty arises with everything in between. For instance, should I go to the hospital with severe headaches?” asked Dr. Schütz.

When is a patient a case for the emergency room, the physician on-call service, or the general practitioner? At the Patient Day in Wiesbaden, DGIM aims to educate and train interested parties with a dedicated lecture. The focus is on recognizing an emergency, specifically emergencies in children and mental illnesses.

“Our Patient Day aims to contribute to making the right decisions. We want to inform, answer questions, and alleviate fears,” said Dr. Schütz. Interested parties can refresh their emergency knowledge, tour ambulances, and have the equipment explained. The public also has the opportunity to learn about resuscitation techniques theoretically and practically.

“In general, the general practitioner should always be the first point of contact. They know their patients best and have the most background information,” explained Dr. Schütz. A trusting relationship is crucial for correctly assessing an unclear medical situation. “Should, for whatever reason, the general practitioner not be reachable, the physician on-call service can be reached,” said Dr. Schütz. It may happen, however, that neither the general practitioner nor the on-call physician is immediately available.
 

What Are Emergencies?

In cases of severe health impairment, urgency is required, and a severe emergency should be assumed in the following cases:

• Chest pain
• Circulatory disorder
• Disorders of consciousness
• Breathing difficulties
• Sudden weakness or numbness/paralysis
• Severe bleeding
• Allergic shock

“In such cases, the emergency departments of the hospitals are available around the clock, and if necessary, an emergency doctor should be present during transportation to the hospital,” said Dr. Schütz.

Classifying emergencies is challenging, especially with children. “Children often find it difficult to clearly categorize or describe symptoms,” said Dr. Schütz. A situation is critical if, for example, the child’s breathing or consciousness is impaired.

Mental emergencies pose a particular challenge for patients and relatives because the patient and relatives are often overwhelmed by the situation. If there are suicidal thoughts, the patient should present him- or herself immediately to an emergency room.

“Patients who come to the emergency room because they cannot get appointments with their general practitioner or specialist, for whatever reason, are no emergency. We also see this in the emergency room from time to time,” said Dr. Schütz. Emergency rooms are not intended for this purpose. “And generally, these are not emergencies.”
 

Four of 10 Cases

The number of patients in emergency rooms has steadily increased in recent years. Statistically, only 4 out of 10 cases are genuine emergencies, as detailed surveys of patients in the emergency rooms of northern German hospitals have shown.

In the PiNo Nord cross-sectional study, Martin Scherer, MD, of University Hospital Hamburg-Eppendorf in Hamburg, Germany, and his team examined the reasons why patients visit the emergency room. They interviewed 1175 patients in five hospitals and documented the medical diagnoses. Patients classified as “immediately” or “very urgently” in need of treatment were excluded.

The surveyed patients were on average 41.8 years old, 52.9% were men, and 54.7% of the patients indicated a low urgency of treatment. About 41% of the patients visited the emergency room on their own initiative, 17% stated they were referred or entrusted by their general practitioner, and 8% were referred by a specialist in the emergency room.

The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR], 2.18), skin afflictions (OR, 2.15), and the unavailability of an open general practitioner’s office (OR, 1.70).

According to Dr. Scherer and his colleagues, the reasons for visiting an emergency room are diverse and can be based on the perceived structural conditions and individual patient preferences in addition to the urgency of the health problem.
 

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

WIESBADEN, GERMANY — Crowded waiting rooms, long wait times, irritable patients, and aggression toward nursing staff and doctors are increasingly the reality in German emergency rooms. Clearly, emergencies belong in the emergency room. However, “In about half of all patients in the emergency room, there is no urgent medical emergency,” Norbert Schütz, MD, director of geriatrics and rheumatology at Helios Dr. Horst Schmidt Hospital in Wiesbaden, Germany, said at a press conference for the 130th Annual Meeting of the German Society of Internal Medicine (DGIM).

“In our daily medical practice, we repeatedly experience people either accessing our emergency departments and ambulances too quickly or lingering at home for too long when they have severe symptoms,” said Dr. Schütz, who organized the Patient Day during the Internist Congress.
 

DGIM Educates Patients

What is an emergency? “I think the public is quite well informed about conditions associated with loss of consciousness, severe pain, chest pain, or paralysis: Think stroke or heart attack. This is undoubtedly a success of recent years. The difficulty arises with everything in between. For instance, should I go to the hospital with severe headaches?” asked Dr. Schütz.

When is a patient a case for the emergency room, the physician on-call service, or the general practitioner? At the Patient Day in Wiesbaden, DGIM aims to educate and train interested parties with a dedicated lecture. The focus is on recognizing an emergency, specifically emergencies in children and mental illnesses.

“Our Patient Day aims to contribute to making the right decisions. We want to inform, answer questions, and alleviate fears,” said Dr. Schütz. Interested parties can refresh their emergency knowledge, tour ambulances, and have the equipment explained. The public also has the opportunity to learn about resuscitation techniques theoretically and practically.

“In general, the general practitioner should always be the first point of contact. They know their patients best and have the most background information,” explained Dr. Schütz. A trusting relationship is crucial for correctly assessing an unclear medical situation. “Should, for whatever reason, the general practitioner not be reachable, the physician on-call service can be reached,” said Dr. Schütz. It may happen, however, that neither the general practitioner nor the on-call physician is immediately available.
 

What Are Emergencies?

In cases of severe health impairment, urgency is required, and a severe emergency should be assumed in the following cases:

• Chest pain
• Circulatory disorder
• Disorders of consciousness
• Breathing difficulties
• Sudden weakness or numbness/paralysis
• Severe bleeding
• Allergic shock

“In such cases, the emergency departments of the hospitals are available around the clock, and if necessary, an emergency doctor should be present during transportation to the hospital,” said Dr. Schütz.

Classifying emergencies is challenging, especially with children. “Children often find it difficult to clearly categorize or describe symptoms,” said Dr. Schütz. A situation is critical if, for example, the child’s breathing or consciousness is impaired.

Mental emergencies pose a particular challenge for patients and relatives because the patient and relatives are often overwhelmed by the situation. If there are suicidal thoughts, the patient should present him- or herself immediately to an emergency room.

“Patients who come to the emergency room because they cannot get appointments with their general practitioner or specialist, for whatever reason, are no emergency. We also see this in the emergency room from time to time,” said Dr. Schütz. Emergency rooms are not intended for this purpose. “And generally, these are not emergencies.”
 

Four of 10 Cases

The number of patients in emergency rooms has steadily increased in recent years. Statistically, only 4 out of 10 cases are genuine emergencies, as detailed surveys of patients in the emergency rooms of northern German hospitals have shown.

In the PiNo Nord cross-sectional study, Martin Scherer, MD, of University Hospital Hamburg-Eppendorf in Hamburg, Germany, and his team examined the reasons why patients visit the emergency room. They interviewed 1175 patients in five hospitals and documented the medical diagnoses. Patients classified as “immediately” or “very urgently” in need of treatment were excluded.

The surveyed patients were on average 41.8 years old, 52.9% were men, and 54.7% of the patients indicated a low urgency of treatment. About 41% of the patients visited the emergency room on their own initiative, 17% stated they were referred or entrusted by their general practitioner, and 8% were referred by a specialist in the emergency room.

The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR], 2.18), skin afflictions (OR, 2.15), and the unavailability of an open general practitioner’s office (OR, 1.70).

According to Dr. Scherer and his colleagues, the reasons for visiting an emergency room are diverse and can be based on the perceived structural conditions and individual patient preferences in addition to the urgency of the health problem.
 

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

WIESBADEN, GERMANY — Crowded waiting rooms, long wait times, irritable patients, and aggression toward nursing staff and doctors are increasingly the reality in German emergency rooms. Clearly, emergencies belong in the emergency room. However, “In about half of all patients in the emergency room, there is no urgent medical emergency,” Norbert Schütz, MD, director of geriatrics and rheumatology at Helios Dr. Horst Schmidt Hospital in Wiesbaden, Germany, said at a press conference for the 130th Annual Meeting of the German Society of Internal Medicine (DGIM).

“In our daily medical practice, we repeatedly experience people either accessing our emergency departments and ambulances too quickly or lingering at home for too long when they have severe symptoms,” said Dr. Schütz, who organized the Patient Day during the Internist Congress.
 

DGIM Educates Patients

What is an emergency? “I think the public is quite well informed about conditions associated with loss of consciousness, severe pain, chest pain, or paralysis: Think stroke or heart attack. This is undoubtedly a success of recent years. The difficulty arises with everything in between. For instance, should I go to the hospital with severe headaches?” asked Dr. Schütz.

When is a patient a case for the emergency room, the physician on-call service, or the general practitioner? At the Patient Day in Wiesbaden, DGIM aims to educate and train interested parties with a dedicated lecture. The focus is on recognizing an emergency, specifically emergencies in children and mental illnesses.

“Our Patient Day aims to contribute to making the right decisions. We want to inform, answer questions, and alleviate fears,” said Dr. Schütz. Interested parties can refresh their emergency knowledge, tour ambulances, and have the equipment explained. The public also has the opportunity to learn about resuscitation techniques theoretically and practically.

“In general, the general practitioner should always be the first point of contact. They know their patients best and have the most background information,” explained Dr. Schütz. A trusting relationship is crucial for correctly assessing an unclear medical situation. “Should, for whatever reason, the general practitioner not be reachable, the physician on-call service can be reached,” said Dr. Schütz. It may happen, however, that neither the general practitioner nor the on-call physician is immediately available.
 

What Are Emergencies?

In cases of severe health impairment, urgency is required, and a severe emergency should be assumed in the following cases:

• Chest pain
• Circulatory disorder
• Disorders of consciousness
• Breathing difficulties
• Sudden weakness or numbness/paralysis
• Severe bleeding
• Allergic shock

“In such cases, the emergency departments of the hospitals are available around the clock, and if necessary, an emergency doctor should be present during transportation to the hospital,” said Dr. Schütz.

Classifying emergencies is challenging, especially with children. “Children often find it difficult to clearly categorize or describe symptoms,” said Dr. Schütz. A situation is critical if, for example, the child’s breathing or consciousness is impaired.

Mental emergencies pose a particular challenge for patients and relatives because the patient and relatives are often overwhelmed by the situation. If there are suicidal thoughts, the patient should present him- or herself immediately to an emergency room.

“Patients who come to the emergency room because they cannot get appointments with their general practitioner or specialist, for whatever reason, are no emergency. We also see this in the emergency room from time to time,” said Dr. Schütz. Emergency rooms are not intended for this purpose. “And generally, these are not emergencies.”
 

Four of 10 Cases

The number of patients in emergency rooms has steadily increased in recent years. Statistically, only 4 out of 10 cases are genuine emergencies, as detailed surveys of patients in the emergency rooms of northern German hospitals have shown.

In the PiNo Nord cross-sectional study, Martin Scherer, MD, of University Hospital Hamburg-Eppendorf in Hamburg, Germany, and his team examined the reasons why patients visit the emergency room. They interviewed 1175 patients in five hospitals and documented the medical diagnoses. Patients classified as “immediately” or “very urgently” in need of treatment were excluded.

The surveyed patients were on average 41.8 years old, 52.9% were men, and 54.7% of the patients indicated a low urgency of treatment. About 41% of the patients visited the emergency room on their own initiative, 17% stated they were referred or entrusted by their general practitioner, and 8% were referred by a specialist in the emergency room.

The strongest predictors for low subjective treatment urgency were musculoskeletal trauma (odds ratio [OR], 2.18), skin afflictions (OR, 2.15), and the unavailability of an open general practitioner’s office (OR, 1.70).

According to Dr. Scherer and his colleagues, the reasons for visiting an emergency room are diverse and can be based on the perceived structural conditions and individual patient preferences in addition to the urgency of the health problem.
 

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

With all the excitement about GLP-1 agonists, I get many questions from providers about which antiobesity drug they should prescribe. I’ll tell you the methods that I use to determine which drug is best for which patient.

Of course, we want to make sure that we’re treating the right condition. If the patient has type 2 diabetes, we tend to give them medication that is indicated for type 2 diabetes. Many GLP-1 agonists are available in a diabetes version and a chronic weight management or obesity version. If a patient has diabetes and obesity, they can receive either one. If a patient has only diabetes but not obesity, they should be prescribed the diabetes version. For obesity without diabetes, we tend to stick with the drugs that are indicated for chronic weight management.

Let’s go through them.

Exenatide. In chronological order of approval, the first GLP-1 drug that was used for diabetes dates back to exenatide (Bydureon). Bydureon had a partner called Byetta (also exenatide), both of which are still on the market but infrequently used. Some patients reported that these medications were inconvenient because they required twice-daily injections and caused painful injection-site nodules.

Diabetes drugs in more common use include liraglutide (Victoza) for type 2 diabetes. It is a daily injection and has various doses. We always start low and increase with tolerance and desired effect for A1c.

Liraglutide. Victoza has an antiobesity counterpart called Saxenda. The Saxenda pen looks very similar to the Victoza pen. It is a daily GLP-1 agonist for chronic weight management. The SCALE trial demonstrated 8%-12% weight loss with Saxenda.

Those are the daily injections: Victoza for diabetes and Saxenda for weight loss.

Our patients are very excited about the advent of weekly injections for diabetes and weight management. Ozempic is very popular. It is a weekly GLP-1 agonist for type 2 diabetes. Many patients come in asking for Ozempic, and we must make sure that we’re moving them in the right direction depending on their condition.

Semaglutide. Ozempic has a few different doses. It is a weekly injection and has been found to be quite efficacious for treating diabetes. The drug’s weight loss counterpart is called Wegovy, which comes in a different pen. Both forms contain the compound semaglutide. While all of these GLP-1 agonists are indicated to treat type 2 diabetes or for weight management, Wegovy has a special indication that none of the others have. In March 2024, Wegovy acquired an indication to decrease cardiac risk in those with a BMI ≥ 27 and a previous cardiac history. This will really change the accessibility of this medication because patients with heart conditions who are on Medicare are expected to have access to Wegovy.

Tirzepatide. Another weekly injection for treatment of type 2 diabetes is called Mounjaro. Its counterpart for weight management is called Zepbound, which was found to have about 20.9% weight loss over 72 weeks. These medications have similar side effects in differing degrees, but the most-often reported are nausea, stool changes, abdominal pain, and reflux. There are some other potential side effects; I recommend that you read the individual prescribing information available for each drug to have more clarity about that.

It is important that we stay on label for using the GLP-1 receptor agonists, for many reasons. One, it increases our patients’ accessibility to the right medication for them, and we can also make sure that we’re treating the patient with the right drug according to the clinical trials. When the clinical trials are done, the study populations demonstrate safety and efficacy for that population. But if we’re prescribing a GLP-1 for a different population, it is considered off-label use.
 

Dr. Lofton, an obesity medicine specialist, is clinical associate professor of surgery and medicine at NYU Grossman School of Medicine, and director of the medical weight management program at NYU Langone Weight Management Center, New York. She disclosed ties to Novo Nordisk and Eli Lilly. This transcript has been edited for clarity.

A version of this article appeared on Medscape.com.

With all the excitement about GLP-1 agonists, I get many questions from providers about which antiobesity drug they should prescribe. I’ll tell you the methods that I use to determine which drug is best for which patient.

Of course, we want to make sure that we’re treating the right condition. If the patient has type 2 diabetes, we tend to give them medication that is indicated for type 2 diabetes. Many GLP-1 agonists are available in a diabetes version and a chronic weight management or obesity version. If a patient has diabetes and obesity, they can receive either one. If a patient has only diabetes but not obesity, they should be prescribed the diabetes version. For obesity without diabetes, we tend to stick with the drugs that are indicated for chronic weight management.

Let’s go through them.

Exenatide. In chronological order of approval, the first GLP-1 drug that was used for diabetes dates back to exenatide (Bydureon). Bydureon had a partner called Byetta (also exenatide), both of which are still on the market but infrequently used. Some patients reported that these medications were inconvenient because they required twice-daily injections and caused painful injection-site nodules.

Diabetes drugs in more common use include liraglutide (Victoza) for type 2 diabetes. It is a daily injection and has various doses. We always start low and increase with tolerance and desired effect for A1c.

Liraglutide. Victoza has an antiobesity counterpart called Saxenda. The Saxenda pen looks very similar to the Victoza pen. It is a daily GLP-1 agonist for chronic weight management. The SCALE trial demonstrated 8%-12% weight loss with Saxenda.

Those are the daily injections: Victoza for diabetes and Saxenda for weight loss.

Our patients are very excited about the advent of weekly injections for diabetes and weight management. Ozempic is very popular. It is a weekly GLP-1 agonist for type 2 diabetes. Many patients come in asking for Ozempic, and we must make sure that we’re moving them in the right direction depending on their condition.

Semaglutide. Ozempic has a few different doses. It is a weekly injection and has been found to be quite efficacious for treating diabetes. The drug’s weight loss counterpart is called Wegovy, which comes in a different pen. Both forms contain the compound semaglutide. While all of these GLP-1 agonists are indicated to treat type 2 diabetes or for weight management, Wegovy has a special indication that none of the others have. In March 2024, Wegovy acquired an indication to decrease cardiac risk in those with a BMI ≥ 27 and a previous cardiac history. This will really change the accessibility of this medication because patients with heart conditions who are on Medicare are expected to have access to Wegovy.

Tirzepatide. Another weekly injection for treatment of type 2 diabetes is called Mounjaro. Its counterpart for weight management is called Zepbound, which was found to have about 20.9% weight loss over 72 weeks. These medications have similar side effects in differing degrees, but the most-often reported are nausea, stool changes, abdominal pain, and reflux. There are some other potential side effects; I recommend that you read the individual prescribing information available for each drug to have more clarity about that.

It is important that we stay on label for using the GLP-1 receptor agonists, for many reasons. One, it increases our patients’ accessibility to the right medication for them, and we can also make sure that we’re treating the patient with the right drug according to the clinical trials. When the clinical trials are done, the study populations demonstrate safety and efficacy for that population. But if we’re prescribing a GLP-1 for a different population, it is considered off-label use.
 

Dr. Lofton, an obesity medicine specialist, is clinical associate professor of surgery and medicine at NYU Grossman School of Medicine, and director of the medical weight management program at NYU Langone Weight Management Center, New York. She disclosed ties to Novo Nordisk and Eli Lilly. This transcript has been edited for clarity.

A version of this article appeared on Medscape.com.

With all the excitement about GLP-1 agonists, I get many questions from providers about which antiobesity drug they should prescribe. I’ll tell you the methods that I use to determine which drug is best for which patient.

Of course, we want to make sure that we’re treating the right condition. If the patient has type 2 diabetes, we tend to give them medication that is indicated for type 2 diabetes. Many GLP-1 agonists are available in a diabetes version and a chronic weight management or obesity version. If a patient has diabetes and obesity, they can receive either one. If a patient has only diabetes but not obesity, they should be prescribed the diabetes version. For obesity without diabetes, we tend to stick with the drugs that are indicated for chronic weight management.

Let’s go through them.

Exenatide. In chronological order of approval, the first GLP-1 drug that was used for diabetes dates back to exenatide (Bydureon). Bydureon had a partner called Byetta (also exenatide), both of which are still on the market but infrequently used. Some patients reported that these medications were inconvenient because they required twice-daily injections and caused painful injection-site nodules.

Diabetes drugs in more common use include liraglutide (Victoza) for type 2 diabetes. It is a daily injection and has various doses. We always start low and increase with tolerance and desired effect for A1c.

Liraglutide. Victoza has an antiobesity counterpart called Saxenda. The Saxenda pen looks very similar to the Victoza pen. It is a daily GLP-1 agonist for chronic weight management. The SCALE trial demonstrated 8%-12% weight loss with Saxenda.

Those are the daily injections: Victoza for diabetes and Saxenda for weight loss.

Our patients are very excited about the advent of weekly injections for diabetes and weight management. Ozempic is very popular. It is a weekly GLP-1 agonist for type 2 diabetes. Many patients come in asking for Ozempic, and we must make sure that we’re moving them in the right direction depending on their condition.

Semaglutide. Ozempic has a few different doses. It is a weekly injection and has been found to be quite efficacious for treating diabetes. The drug’s weight loss counterpart is called Wegovy, which comes in a different pen. Both forms contain the compound semaglutide. While all of these GLP-1 agonists are indicated to treat type 2 diabetes or for weight management, Wegovy has a special indication that none of the others have. In March 2024, Wegovy acquired an indication to decrease cardiac risk in those with a BMI ≥ 27 and a previous cardiac history. This will really change the accessibility of this medication because patients with heart conditions who are on Medicare are expected to have access to Wegovy.

Tirzepatide. Another weekly injection for treatment of type 2 diabetes is called Mounjaro. Its counterpart for weight management is called Zepbound, which was found to have about 20.9% weight loss over 72 weeks. These medications have similar side effects in differing degrees, but the most-often reported are nausea, stool changes, abdominal pain, and reflux. There are some other potential side effects; I recommend that you read the individual prescribing information available for each drug to have more clarity about that.

It is important that we stay on label for using the GLP-1 receptor agonists, for many reasons. One, it increases our patients’ accessibility to the right medication for them, and we can also make sure that we’re treating the patient with the right drug according to the clinical trials. When the clinical trials are done, the study populations demonstrate safety and efficacy for that population. But if we’re prescribing a GLP-1 for a different population, it is considered off-label use.
 

Dr. Lofton, an obesity medicine specialist, is clinical associate professor of surgery and medicine at NYU Grossman School of Medicine, and director of the medical weight management program at NYU Langone Weight Management Center, New York. She disclosed ties to Novo Nordisk and Eli Lilly. This transcript has been edited for clarity.

A version of this article appeared on Medscape.com.

Thirty years ago I had an experience in the office that influenced my approach to obesity for the rest of my career. The patient was a 4-year-old whom I had been seeing since her birth. At her annual well-child visit her weight had jumped up significantly from the previous year’s visit. She appeared well, but the change in her growth trajectory prompted a bit more in-depth history taking.

It turned out that finances had forced the family to employ one of the child’s grandmothers as the day care provider. Unfortunately, this grandmother’s passion was cooking and she was particularly adept at baking. She had no other hobbies and a sore hip limited her mobility, so she seldom went outside. When I eventually met her she was a cheerful, overweight, and delightful woman.

Deconstructing this obesogenic environment without disrupting this otherwise healthy family was an exercise that required tact, patience, and creativity. Fortunately, the young girl’s mother had already harbored some concerns about her child’s weight and was more than willing to participate in this environmental re-engineering project. It’s a long story, but she and I achieved our goals and the child eventually coasted back toward her previous growth curve.

I have always suspected that this scenario is being replayed hundreds of thousands of time across this country. But, sadly most don’t share this one’s happy ending. Parents don’t alway perceive the seriousness of the problem. The economic hurdles are often too steep to overcome, even when the most creative minds are involved.

How prevalent are obesogenic day care environments? We certainly know childhood obesity is a problem and the statistics in the preschool age group are particularly concerning. More than 14 million children are in non-parental early care and education programs; these environments would seem to be a logical place to target our prevention strategies. Understandably, there seems to be a hesitancy to point fingers, but how many day care providers are similar to the well-intentioned grandmother in the scenario I described? We must at least suspect that the example set by the adults in the preschool and day care environment might be having some influence on the children under their care.

There has been some research that sheds some light on this question. A paper from the University of Oklahoma has looked at the predictors of overweight and obesity in early care and education (ECE) teachers in hopes of “finding modifiable opportunities to enhance the health of this critical workforce.” In their paper, the investigators refer to other research that has found the prevalence of overweight and obesity among ECE teachers is higher than our national average and their waist circumference is significantly greater than the standard recommendation for women.

A study from Norway has looked at the association between preschool staff’s activity level and that of the children under their care using accelerometers. This particular investigation couldn’t determine whether it was the staff’s activity level that influenced the children or vice versa because it wasn’t an observational study. Common sense would lead one to believe it was the staff’s relative inactivity that was being reflected in the children’s.

It is interesting that in this Norwegian study when the teachers were asked about their attitudes toward activity and their self-perception of their own activity, there was no relationship between the staff’s and the children’s level of activity. In other words, the educators and caregivers bought into the importance of activity but had difficulty translating this philosophy into own behavior.

So where does this leave us? It turns out my experience decades ago was not a one-off event, but instead represents the tip of very large iceberg. Should we immediately create a system of day care provider boot camps? Let’s remember that each educator and caregiver is one of us. They may be slight outliers but not a group of individuals deserving of forced marches and half-rations to get them in shape.

ECEs have listened to the same message we have all heard about diet and activity and their importance for a child’s health. Our challenge is to create effective, yet sensitive, strategies to help the educators and caregivers modify their dietary habits behaviors in a way that helps them be a more positive influence on their students. It’s for their own health and that of their charges. This could be as simple as providing accelerometers or step-counting smartwatches. Or, by having physical educators perform on-site audits that could then be used to create site-specific plans for increasing both teacher and student activity.

Modifying the educators’ diet is a more complex procedure and can quickly become entangled in the socio-economic background of each individual teacher. A healthy diet is not always equally available to everyone. The solution may involve providing the teachers with food to be eaten at work and to be prepared at home. But, creative answers can be found if we look for them.

Before we get too far down the obesity-is-a-disease pathway, we must take a closer look at the role the early care and early school milieu are playing in the obesity problem. A little common sense behavior modification when children are in the controlled environment of school/day care may allow us to be less reliant on the those new wonder drugs in the long run.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Thirty years ago I had an experience in the office that influenced my approach to obesity for the rest of my career. The patient was a 4-year-old whom I had been seeing since her birth. At her annual well-child visit her weight had jumped up significantly from the previous year’s visit. She appeared well, but the change in her growth trajectory prompted a bit more in-depth history taking.

It turned out that finances had forced the family to employ one of the child’s grandmothers as the day care provider. Unfortunately, this grandmother’s passion was cooking and she was particularly adept at baking. She had no other hobbies and a sore hip limited her mobility, so she seldom went outside. When I eventually met her she was a cheerful, overweight, and delightful woman.

Deconstructing this obesogenic environment without disrupting this otherwise healthy family was an exercise that required tact, patience, and creativity. Fortunately, the young girl’s mother had already harbored some concerns about her child’s weight and was more than willing to participate in this environmental re-engineering project. It’s a long story, but she and I achieved our goals and the child eventually coasted back toward her previous growth curve.

I have always suspected that this scenario is being replayed hundreds of thousands of time across this country. But, sadly most don’t share this one’s happy ending. Parents don’t alway perceive the seriousness of the problem. The economic hurdles are often too steep to overcome, even when the most creative minds are involved.

How prevalent are obesogenic day care environments? We certainly know childhood obesity is a problem and the statistics in the preschool age group are particularly concerning. More than 14 million children are in non-parental early care and education programs; these environments would seem to be a logical place to target our prevention strategies. Understandably, there seems to be a hesitancy to point fingers, but how many day care providers are similar to the well-intentioned grandmother in the scenario I described? We must at least suspect that the example set by the adults in the preschool and day care environment might be having some influence on the children under their care.

There has been some research that sheds some light on this question. A paper from the University of Oklahoma has looked at the predictors of overweight and obesity in early care and education (ECE) teachers in hopes of “finding modifiable opportunities to enhance the health of this critical workforce.” In their paper, the investigators refer to other research that has found the prevalence of overweight and obesity among ECE teachers is higher than our national average and their waist circumference is significantly greater than the standard recommendation for women.

A study from Norway has looked at the association between preschool staff’s activity level and that of the children under their care using accelerometers. This particular investigation couldn’t determine whether it was the staff’s activity level that influenced the children or vice versa because it wasn’t an observational study. Common sense would lead one to believe it was the staff’s relative inactivity that was being reflected in the children’s.

It is interesting that in this Norwegian study when the teachers were asked about their attitudes toward activity and their self-perception of their own activity, there was no relationship between the staff’s and the children’s level of activity. In other words, the educators and caregivers bought into the importance of activity but had difficulty translating this philosophy into own behavior.

So where does this leave us? It turns out my experience decades ago was not a one-off event, but instead represents the tip of very large iceberg. Should we immediately create a system of day care provider boot camps? Let’s remember that each educator and caregiver is one of us. They may be slight outliers but not a group of individuals deserving of forced marches and half-rations to get them in shape.

ECEs have listened to the same message we have all heard about diet and activity and their importance for a child’s health. Our challenge is to create effective, yet sensitive, strategies to help the educators and caregivers modify their dietary habits behaviors in a way that helps them be a more positive influence on their students. It’s for their own health and that of their charges. This could be as simple as providing accelerometers or step-counting smartwatches. Or, by having physical educators perform on-site audits that could then be used to create site-specific plans for increasing both teacher and student activity.

Modifying the educators’ diet is a more complex procedure and can quickly become entangled in the socio-economic background of each individual teacher. A healthy diet is not always equally available to everyone. The solution may involve providing the teachers with food to be eaten at work and to be prepared at home. But, creative answers can be found if we look for them.

Before we get too far down the obesity-is-a-disease pathway, we must take a closer look at the role the early care and early school milieu are playing in the obesity problem. A little common sense behavior modification when children are in the controlled environment of school/day care may allow us to be less reliant on the those new wonder drugs in the long run.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.

Thirty years ago I had an experience in the office that influenced my approach to obesity for the rest of my career. The patient was a 4-year-old whom I had been seeing since her birth. At her annual well-child visit her weight had jumped up significantly from the previous year’s visit. She appeared well, but the change in her growth trajectory prompted a bit more in-depth history taking.

It turned out that finances had forced the family to employ one of the child’s grandmothers as the day care provider. Unfortunately, this grandmother’s passion was cooking and she was particularly adept at baking. She had no other hobbies and a sore hip limited her mobility, so she seldom went outside. When I eventually met her she was a cheerful, overweight, and delightful woman.

Deconstructing this obesogenic environment without disrupting this otherwise healthy family was an exercise that required tact, patience, and creativity. Fortunately, the young girl’s mother had already harbored some concerns about her child’s weight and was more than willing to participate in this environmental re-engineering project. It’s a long story, but she and I achieved our goals and the child eventually coasted back toward her previous growth curve.

I have always suspected that this scenario is being replayed hundreds of thousands of time across this country. But, sadly most don’t share this one’s happy ending. Parents don’t alway perceive the seriousness of the problem. The economic hurdles are often too steep to overcome, even when the most creative minds are involved.

How prevalent are obesogenic day care environments? We certainly know childhood obesity is a problem and the statistics in the preschool age group are particularly concerning. More than 14 million children are in non-parental early care and education programs; these environments would seem to be a logical place to target our prevention strategies. Understandably, there seems to be a hesitancy to point fingers, but how many day care providers are similar to the well-intentioned grandmother in the scenario I described? We must at least suspect that the example set by the adults in the preschool and day care environment might be having some influence on the children under their care.

There has been some research that sheds some light on this question. A paper from the University of Oklahoma has looked at the predictors of overweight and obesity in early care and education (ECE) teachers in hopes of “finding modifiable opportunities to enhance the health of this critical workforce.” In their paper, the investigators refer to other research that has found the prevalence of overweight and obesity among ECE teachers is higher than our national average and their waist circumference is significantly greater than the standard recommendation for women.

A study from Norway has looked at the association between preschool staff’s activity level and that of the children under their care using accelerometers. This particular investigation couldn’t determine whether it was the staff’s activity level that influenced the children or vice versa because it wasn’t an observational study. Common sense would lead one to believe it was the staff’s relative inactivity that was being reflected in the children’s.

It is interesting that in this Norwegian study when the teachers were asked about their attitudes toward activity and their self-perception of their own activity, there was no relationship between the staff’s and the children’s level of activity. In other words, the educators and caregivers bought into the importance of activity but had difficulty translating this philosophy into own behavior.

So where does this leave us? It turns out my experience decades ago was not a one-off event, but instead represents the tip of very large iceberg. Should we immediately create a system of day care provider boot camps? Let’s remember that each educator and caregiver is one of us. They may be slight outliers but not a group of individuals deserving of forced marches and half-rations to get them in shape.

ECEs have listened to the same message we have all heard about diet and activity and their importance for a child’s health. Our challenge is to create effective, yet sensitive, strategies to help the educators and caregivers modify their dietary habits behaviors in a way that helps them be a more positive influence on their students. It’s for their own health and that of their charges. This could be as simple as providing accelerometers or step-counting smartwatches. Or, by having physical educators perform on-site audits that could then be used to create site-specific plans for increasing both teacher and student activity.

Modifying the educators’ diet is a more complex procedure and can quickly become entangled in the socio-economic background of each individual teacher. A healthy diet is not always equally available to everyone. The solution may involve providing the teachers with food to be eaten at work and to be prepared at home. But, creative answers can be found if we look for them.

Before we get too far down the obesity-is-a-disease pathway, we must take a closer look at the role the early care and early school milieu are playing in the obesity problem. A little common sense behavior modification when children are in the controlled environment of school/day care may allow us to be less reliant on the those new wonder drugs in the long run.

Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at pdnews@mdedge.com.