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AACE 2019: Top takeaways from Yehuda Handelsman and Paul Jellinger
in a video interview at the meeting.
Dr. Handelsman, medical director of the Metabolic Institute of America, in Tarzana, Calif., summarized the top take-home messages from a premeeting symposium he chaired on diabetes, cardiovascular disease (CVD), and lipid management in high-risk patients. Dr. Jellinger, professor of clinical medicine on the voluntary faculty at the University of Miami Miller School of Medicine, looked at management aspects and therapy goals based on a comparison of the lipid guideline from the American College of Cardiology and the American Heart Association with that from the AACE. Other highlights from the symposium included expert analysis of the CREDENCE trial results on canagliflozin for improving renal outcomes in patients with type 2 diabetes, advice on the management of heart failure in diabetes, and recommendations on managing hyperglycemia.
Dr. Jellinger and Dr. Handelsman, who are members of the editorial advisory board of Clinical Endocrinology News, highlighted the emergence of anabolic treatments for osteoporosis, in particular the sclerostin-neutralizing monoclonal antibody, romosozumab. The therapy was recently approved for the treatment of postmenopausal osteoporosis and is unique in that it both promotes bone formation and reduces resorption. They also noted the switch away from previous practice to now using an anabolic drug first, then going to an antiresorptive therapy, rather than the other way around.
They discussed the keynote address by social media guru, Kevin Pho, MD; a debate that centered on the merits of the American Diabetes Association’s guideline for treating diabetes versus that from the AACE; a presentation on sustained remission of type 2 diabetes with a very low calorie diet; and a report on encouraging findings with an experimental drug for Graves eye disease.
in a video interview at the meeting.
Dr. Handelsman, medical director of the Metabolic Institute of America, in Tarzana, Calif., summarized the top take-home messages from a premeeting symposium he chaired on diabetes, cardiovascular disease (CVD), and lipid management in high-risk patients. Dr. Jellinger, professor of clinical medicine on the voluntary faculty at the University of Miami Miller School of Medicine, looked at management aspects and therapy goals based on a comparison of the lipid guideline from the American College of Cardiology and the American Heart Association with that from the AACE. Other highlights from the symposium included expert analysis of the CREDENCE trial results on canagliflozin for improving renal outcomes in patients with type 2 diabetes, advice on the management of heart failure in diabetes, and recommendations on managing hyperglycemia.
Dr. Jellinger and Dr. Handelsman, who are members of the editorial advisory board of Clinical Endocrinology News, highlighted the emergence of anabolic treatments for osteoporosis, in particular the sclerostin-neutralizing monoclonal antibody, romosozumab. The therapy was recently approved for the treatment of postmenopausal osteoporosis and is unique in that it both promotes bone formation and reduces resorption. They also noted the switch away from previous practice to now using an anabolic drug first, then going to an antiresorptive therapy, rather than the other way around.
They discussed the keynote address by social media guru, Kevin Pho, MD; a debate that centered on the merits of the American Diabetes Association’s guideline for treating diabetes versus that from the AACE; a presentation on sustained remission of type 2 diabetes with a very low calorie diet; and a report on encouraging findings with an experimental drug for Graves eye disease.
in a video interview at the meeting.
Dr. Handelsman, medical director of the Metabolic Institute of America, in Tarzana, Calif., summarized the top take-home messages from a premeeting symposium he chaired on diabetes, cardiovascular disease (CVD), and lipid management in high-risk patients. Dr. Jellinger, professor of clinical medicine on the voluntary faculty at the University of Miami Miller School of Medicine, looked at management aspects and therapy goals based on a comparison of the lipid guideline from the American College of Cardiology and the American Heart Association with that from the AACE. Other highlights from the symposium included expert analysis of the CREDENCE trial results on canagliflozin for improving renal outcomes in patients with type 2 diabetes, advice on the management of heart failure in diabetes, and recommendations on managing hyperglycemia.
Dr. Jellinger and Dr. Handelsman, who are members of the editorial advisory board of Clinical Endocrinology News, highlighted the emergence of anabolic treatments for osteoporosis, in particular the sclerostin-neutralizing monoclonal antibody, romosozumab. The therapy was recently approved for the treatment of postmenopausal osteoporosis and is unique in that it both promotes bone formation and reduces resorption. They also noted the switch away from previous practice to now using an anabolic drug first, then going to an antiresorptive therapy, rather than the other way around.
They discussed the keynote address by social media guru, Kevin Pho, MD; a debate that centered on the merits of the American Diabetes Association’s guideline for treating diabetes versus that from the AACE; a presentation on sustained remission of type 2 diabetes with a very low calorie diet; and a report on encouraging findings with an experimental drug for Graves eye disease.
REPORTING FROM AACE 2019
Simple initiative boosted proportion of residents who screen for obesity
LOS ANGELES – After a simple educational initiative was implemented, the proportion of internal medicine residents who discussed the topic of overweight and obesity with patients improved from 17% to 69%, results from a single center have demonstrated.
“Everybody knows about the obesity epidemic, but nobody’s talking about it,” Hassan Mehmood, MD, said in an interview at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “They’re not doing enough to treat obesity. The United States Preventive Services Task Force [USPSTF] recommends screening all adults over the age of 18 years for obesity.”
In an effort to determine how often internal medicine residents are discussing obesity with patients, Dr. Mehmood and colleagues retrospectively reviewed the medical charts of 301 adults with a body mass index of 30 kg/m2 or greater who were seen at Temple University/Conemaugh Memorial Medical Center in Johnstown, Pa., between May and June of 2018. They recorded the total number of problems addressed, type of visit, whether obesity was discussed, and the resources used by the residents and attendings for management.
Between July and December of 2018, residents received education through lectures and conferences on obesity screening and management tools. The educational initiative included placement of posters in the clinic about obesity, and all physicians were encouraged to schedule separate visits to discuss the topic with patients. To evaluate the effects of the initiative, the researchers collected data on 255 adults with a BMI of 30 or greater who were seen in the clinic between May and June of 2018.
The mean age of patients in the study sample was between 40 and 50 years, 61% were women, and 91% of the office visits were for follow-up. The patients’ average BMI was 38, they had an average of two comorbidities, and residents most often addressed five diagnoses. From preintervention to postintervention, the researchers observed a statistically significant improvement in the frequency with which residents addressed general health maintenance with patients (from 62% to 83%; P less than .0005) and obesity (from 17% to 69%; P less than .0005). The discussions around obesity included talking about lifestyle modification, medication management, or bariatric surgical intervention.
Before the intervention, many residents reported not being aware of the USPSTF recommendations to screen all patients aged 18 years or older for obesity. They also felt pinched for time during office visits.
“They have only 30 minutes for treatment of chronic problems, so they didn’t find time to talk about obesity,” said Dr. Mehmood, who is a third-year resident at the medical center. “If residents don’t find time for talking about obesity, they can ask patients to return for a separate visit to talk about obesity and give management options to patients. Patients should know what their BMI is so that they can discuss it with their physician.”
He acknowledged that few patients are comfortable talking about their weight, and he suggested starting the conversation by asking “How do you feel about your weight?” during office visits. “That is the best question you can ask,” he said. “[It] helps open the conversation.”
Dr Mehmood reported having no financial disclosures.
LOS ANGELES – After a simple educational initiative was implemented, the proportion of internal medicine residents who discussed the topic of overweight and obesity with patients improved from 17% to 69%, results from a single center have demonstrated.
“Everybody knows about the obesity epidemic, but nobody’s talking about it,” Hassan Mehmood, MD, said in an interview at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “They’re not doing enough to treat obesity. The United States Preventive Services Task Force [USPSTF] recommends screening all adults over the age of 18 years for obesity.”
In an effort to determine how often internal medicine residents are discussing obesity with patients, Dr. Mehmood and colleagues retrospectively reviewed the medical charts of 301 adults with a body mass index of 30 kg/m2 or greater who were seen at Temple University/Conemaugh Memorial Medical Center in Johnstown, Pa., between May and June of 2018. They recorded the total number of problems addressed, type of visit, whether obesity was discussed, and the resources used by the residents and attendings for management.
Between July and December of 2018, residents received education through lectures and conferences on obesity screening and management tools. The educational initiative included placement of posters in the clinic about obesity, and all physicians were encouraged to schedule separate visits to discuss the topic with patients. To evaluate the effects of the initiative, the researchers collected data on 255 adults with a BMI of 30 or greater who were seen in the clinic between May and June of 2018.
The mean age of patients in the study sample was between 40 and 50 years, 61% were women, and 91% of the office visits were for follow-up. The patients’ average BMI was 38, they had an average of two comorbidities, and residents most often addressed five diagnoses. From preintervention to postintervention, the researchers observed a statistically significant improvement in the frequency with which residents addressed general health maintenance with patients (from 62% to 83%; P less than .0005) and obesity (from 17% to 69%; P less than .0005). The discussions around obesity included talking about lifestyle modification, medication management, or bariatric surgical intervention.
Before the intervention, many residents reported not being aware of the USPSTF recommendations to screen all patients aged 18 years or older for obesity. They also felt pinched for time during office visits.
“They have only 30 minutes for treatment of chronic problems, so they didn’t find time to talk about obesity,” said Dr. Mehmood, who is a third-year resident at the medical center. “If residents don’t find time for talking about obesity, they can ask patients to return for a separate visit to talk about obesity and give management options to patients. Patients should know what their BMI is so that they can discuss it with their physician.”
He acknowledged that few patients are comfortable talking about their weight, and he suggested starting the conversation by asking “How do you feel about your weight?” during office visits. “That is the best question you can ask,” he said. “[It] helps open the conversation.”
Dr Mehmood reported having no financial disclosures.
LOS ANGELES – After a simple educational initiative was implemented, the proportion of internal medicine residents who discussed the topic of overweight and obesity with patients improved from 17% to 69%, results from a single center have demonstrated.
“Everybody knows about the obesity epidemic, but nobody’s talking about it,” Hassan Mehmood, MD, said in an interview at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “They’re not doing enough to treat obesity. The United States Preventive Services Task Force [USPSTF] recommends screening all adults over the age of 18 years for obesity.”
In an effort to determine how often internal medicine residents are discussing obesity with patients, Dr. Mehmood and colleagues retrospectively reviewed the medical charts of 301 adults with a body mass index of 30 kg/m2 or greater who were seen at Temple University/Conemaugh Memorial Medical Center in Johnstown, Pa., between May and June of 2018. They recorded the total number of problems addressed, type of visit, whether obesity was discussed, and the resources used by the residents and attendings for management.
Between July and December of 2018, residents received education through lectures and conferences on obesity screening and management tools. The educational initiative included placement of posters in the clinic about obesity, and all physicians were encouraged to schedule separate visits to discuss the topic with patients. To evaluate the effects of the initiative, the researchers collected data on 255 adults with a BMI of 30 or greater who were seen in the clinic between May and June of 2018.
The mean age of patients in the study sample was between 40 and 50 years, 61% were women, and 91% of the office visits were for follow-up. The patients’ average BMI was 38, they had an average of two comorbidities, and residents most often addressed five diagnoses. From preintervention to postintervention, the researchers observed a statistically significant improvement in the frequency with which residents addressed general health maintenance with patients (from 62% to 83%; P less than .0005) and obesity (from 17% to 69%; P less than .0005). The discussions around obesity included talking about lifestyle modification, medication management, or bariatric surgical intervention.
Before the intervention, many residents reported not being aware of the USPSTF recommendations to screen all patients aged 18 years or older for obesity. They also felt pinched for time during office visits.
“They have only 30 minutes for treatment of chronic problems, so they didn’t find time to talk about obesity,” said Dr. Mehmood, who is a third-year resident at the medical center. “If residents don’t find time for talking about obesity, they can ask patients to return for a separate visit to talk about obesity and give management options to patients. Patients should know what their BMI is so that they can discuss it with their physician.”
He acknowledged that few patients are comfortable talking about their weight, and he suggested starting the conversation by asking “How do you feel about your weight?” during office visits. “That is the best question you can ask,” he said. “[It] helps open the conversation.”
Dr Mehmood reported having no financial disclosures.
REPORTING FROM AACE 2019
Key clinical point:
Major finding: From preintervention to postintervention, the researchers observed a statistically significant improvement in the frequency with which residents addressed obesity with patients (from 17% to 69%; P less than .0005).
Study details: A retrospective analysis of 301 patient visits before and 255 after implementation of an educational initiative.
Disclosures: Dr. Mehmood reported having no financial disclosures.
Weight-loss drug options expand, but beware cardiac risk
LOS ANGELES – Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.
Diabetes drugs help, but may need a boost
Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).
There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.
“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”
To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).
In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”
Consider insurance coverage and other factors
Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.
Newer weight-loss drugs ...
Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.
- Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
- Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
- Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
- Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).
... but watch out for safety in patients with heart disease
Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.
Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.
Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
LOS ANGELES – Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.
Diabetes drugs help, but may need a boost
Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).
There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.
“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”
To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).
In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”
Consider insurance coverage and other factors
Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.
Newer weight-loss drugs ...
Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.
- Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
- Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
- Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
- Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).
... but watch out for safety in patients with heart disease
Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.
Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.
Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
LOS ANGELES – Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.
Diabetes drugs help, but may need a boost
Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).
There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.
“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”
To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).
In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”
Consider insurance coverage and other factors
Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.
Newer weight-loss drugs ...
Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.
- Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
- Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
- Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
- Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).
... but watch out for safety in patients with heart disease
Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.
Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.
Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
EXPERT ANALYSIS FROM AACE 2019
Endo fellows report lack of confidence in managing some after-hour calls
LOS ANGELES – When it comes to handling after-hours phone calls from patients, endocrinology fellows generally have less confidence in their decision making than their supervising faculty have in them, as measured by faculty’s reported agreement with fellows’ management plans. In addition, their confidence varies widely depending on the reason for call, results from a small, single-center study suggest.
“The research on training in telephone medicine is sparse,” lead study author Ramya Punati, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Our field relies on blood sugars and patient monitoring at home. We get a large volume of such calls, so while supervising faculty are always available for questions overnight, I think it would be useful to have a formal curriculum or feedback process in place at all major medical centers for fellows to learn how to appropriately manage outpatient calls.”
In October 2018, 6 endocrinology fellows and 13 endocrinology faculty members at the Hospital of the University of Pennsylvania, Philadelphia, completed baseline surveys. Fellows were asked how often they felt confident on after-hours calls managing specific conditions, such as problems with insulin pumps, positive ketones, and hyperglycemia and hypoglycemia. Faculty were asked how often they agreed with the fellows’ management of the same conditions.
One month later, the researchers implemented a two-part intervention. Part one consisted of a 1-hour didactic session for the six fellows about how to handle common outpatient diabetes-related calls. Part two involved a process by which faculty gave feedback through the EMR on decisions that fellows make on after-hours calls. Assistance provided in real time by supervising faculty was not measured.
In April 2019, the researchers used the same surveys to reassess the fellows’ and the faculty’s confidence. In addition, “pre- and postintervention, fellows were asked two questions to reflect on the perceived utility of taking outpatient calls,” said Dr. Punati, who is an endocrinology fellow at the Hospital of the University of Pennsylvania. “One was, ‘Do you feel that taking outpatient calls allows you to impact patient care in a meaningful way?’ The other was, ‘Do you feel that taking after-hours calls is educational for you?’ ”
At baseline, all fellows reported that they rarely received feedback from outpatient faculty on decisions they make on after-hours calls. Following implementation of the intervention, most fellows reported a slight increase in the feedback received. Pre- and postintervention, most fellows said that they were able to affect care in a meaningful way by handling after-hours calls, but felt that taking such calls had more limited educational value.
She and her colleagues found that faculty confidence in after-hour decision making by endocrine fellows is generally higher than fellows’ reported confidence in the same domains. At baseline, both faculty and fellows had highest confidence in the ability of fellows to manage calls related to fluctuations in blood glucose, and both groups had lowest ratings in management of insulin pump problems and diabetic ketoacidosis. After the intervention, both fellows and faculty had increased confidence in the ability of fellows to manage all types of calls, compared with baseline.
“It’s hard to say how much of the improvement is due to the intervention versus the passage of time and experience,” Dr. Punati said. “By the nature of taking more calls and getting more experience, fellows are going to get more confident as the year goes on.”
Fellows’ responses about their confidence in handling after-hours calls and their perception of the educational value of that responsibility highlight the need for a more formalized curriculum in telephone medicine and feedback process, she said.
Dr. Punati recommends a combination of didactic instruction early in endocrinology fellowship training and ongoing feedback for decisions that fellows make during after-hours calls.
“That process of feedback is the only way fellows will improve their knowledge and their confidence in handling these calls,” she said. In fact, as a result of the study, the university’s endocrinology fellowship program has already implemented changes in the academic curriculum to enhance the fellows’ educational experience and provide them with tools they need to confidently manage these calls.
Dr. Punati reported having no financial disclosures.
LOS ANGELES – When it comes to handling after-hours phone calls from patients, endocrinology fellows generally have less confidence in their decision making than their supervising faculty have in them, as measured by faculty’s reported agreement with fellows’ management plans. In addition, their confidence varies widely depending on the reason for call, results from a small, single-center study suggest.
“The research on training in telephone medicine is sparse,” lead study author Ramya Punati, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Our field relies on blood sugars and patient monitoring at home. We get a large volume of such calls, so while supervising faculty are always available for questions overnight, I think it would be useful to have a formal curriculum or feedback process in place at all major medical centers for fellows to learn how to appropriately manage outpatient calls.”
In October 2018, 6 endocrinology fellows and 13 endocrinology faculty members at the Hospital of the University of Pennsylvania, Philadelphia, completed baseline surveys. Fellows were asked how often they felt confident on after-hours calls managing specific conditions, such as problems with insulin pumps, positive ketones, and hyperglycemia and hypoglycemia. Faculty were asked how often they agreed with the fellows’ management of the same conditions.
One month later, the researchers implemented a two-part intervention. Part one consisted of a 1-hour didactic session for the six fellows about how to handle common outpatient diabetes-related calls. Part two involved a process by which faculty gave feedback through the EMR on decisions that fellows make on after-hours calls. Assistance provided in real time by supervising faculty was not measured.
In April 2019, the researchers used the same surveys to reassess the fellows’ and the faculty’s confidence. In addition, “pre- and postintervention, fellows were asked two questions to reflect on the perceived utility of taking outpatient calls,” said Dr. Punati, who is an endocrinology fellow at the Hospital of the University of Pennsylvania. “One was, ‘Do you feel that taking outpatient calls allows you to impact patient care in a meaningful way?’ The other was, ‘Do you feel that taking after-hours calls is educational for you?’ ”
At baseline, all fellows reported that they rarely received feedback from outpatient faculty on decisions they make on after-hours calls. Following implementation of the intervention, most fellows reported a slight increase in the feedback received. Pre- and postintervention, most fellows said that they were able to affect care in a meaningful way by handling after-hours calls, but felt that taking such calls had more limited educational value.
She and her colleagues found that faculty confidence in after-hour decision making by endocrine fellows is generally higher than fellows’ reported confidence in the same domains. At baseline, both faculty and fellows had highest confidence in the ability of fellows to manage calls related to fluctuations in blood glucose, and both groups had lowest ratings in management of insulin pump problems and diabetic ketoacidosis. After the intervention, both fellows and faculty had increased confidence in the ability of fellows to manage all types of calls, compared with baseline.
“It’s hard to say how much of the improvement is due to the intervention versus the passage of time and experience,” Dr. Punati said. “By the nature of taking more calls and getting more experience, fellows are going to get more confident as the year goes on.”
Fellows’ responses about their confidence in handling after-hours calls and their perception of the educational value of that responsibility highlight the need for a more formalized curriculum in telephone medicine and feedback process, she said.
Dr. Punati recommends a combination of didactic instruction early in endocrinology fellowship training and ongoing feedback for decisions that fellows make during after-hours calls.
“That process of feedback is the only way fellows will improve their knowledge and their confidence in handling these calls,” she said. In fact, as a result of the study, the university’s endocrinology fellowship program has already implemented changes in the academic curriculum to enhance the fellows’ educational experience and provide them with tools they need to confidently manage these calls.
Dr. Punati reported having no financial disclosures.
LOS ANGELES – When it comes to handling after-hours phone calls from patients, endocrinology fellows generally have less confidence in their decision making than their supervising faculty have in them, as measured by faculty’s reported agreement with fellows’ management plans. In addition, their confidence varies widely depending on the reason for call, results from a small, single-center study suggest.
“The research on training in telephone medicine is sparse,” lead study author Ramya Punati, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Our field relies on blood sugars and patient monitoring at home. We get a large volume of such calls, so while supervising faculty are always available for questions overnight, I think it would be useful to have a formal curriculum or feedback process in place at all major medical centers for fellows to learn how to appropriately manage outpatient calls.”
In October 2018, 6 endocrinology fellows and 13 endocrinology faculty members at the Hospital of the University of Pennsylvania, Philadelphia, completed baseline surveys. Fellows were asked how often they felt confident on after-hours calls managing specific conditions, such as problems with insulin pumps, positive ketones, and hyperglycemia and hypoglycemia. Faculty were asked how often they agreed with the fellows’ management of the same conditions.
One month later, the researchers implemented a two-part intervention. Part one consisted of a 1-hour didactic session for the six fellows about how to handle common outpatient diabetes-related calls. Part two involved a process by which faculty gave feedback through the EMR on decisions that fellows make on after-hours calls. Assistance provided in real time by supervising faculty was not measured.
In April 2019, the researchers used the same surveys to reassess the fellows’ and the faculty’s confidence. In addition, “pre- and postintervention, fellows were asked two questions to reflect on the perceived utility of taking outpatient calls,” said Dr. Punati, who is an endocrinology fellow at the Hospital of the University of Pennsylvania. “One was, ‘Do you feel that taking outpatient calls allows you to impact patient care in a meaningful way?’ The other was, ‘Do you feel that taking after-hours calls is educational for you?’ ”
At baseline, all fellows reported that they rarely received feedback from outpatient faculty on decisions they make on after-hours calls. Following implementation of the intervention, most fellows reported a slight increase in the feedback received. Pre- and postintervention, most fellows said that they were able to affect care in a meaningful way by handling after-hours calls, but felt that taking such calls had more limited educational value.
She and her colleagues found that faculty confidence in after-hour decision making by endocrine fellows is generally higher than fellows’ reported confidence in the same domains. At baseline, both faculty and fellows had highest confidence in the ability of fellows to manage calls related to fluctuations in blood glucose, and both groups had lowest ratings in management of insulin pump problems and diabetic ketoacidosis. After the intervention, both fellows and faculty had increased confidence in the ability of fellows to manage all types of calls, compared with baseline.
“It’s hard to say how much of the improvement is due to the intervention versus the passage of time and experience,” Dr. Punati said. “By the nature of taking more calls and getting more experience, fellows are going to get more confident as the year goes on.”
Fellows’ responses about their confidence in handling after-hours calls and their perception of the educational value of that responsibility highlight the need for a more formalized curriculum in telephone medicine and feedback process, she said.
Dr. Punati recommends a combination of didactic instruction early in endocrinology fellowship training and ongoing feedback for decisions that fellows make during after-hours calls.
“That process of feedback is the only way fellows will improve their knowledge and their confidence in handling these calls,” she said. In fact, as a result of the study, the university’s endocrinology fellowship program has already implemented changes in the academic curriculum to enhance the fellows’ educational experience and provide them with tools they need to confidently manage these calls.
Dr. Punati reported having no financial disclosures.
REPORTING FROM AACE 2019
Key clinical point:
Major finding: Before and after intervention, most fellows said that they were able to affect care in a meaningful way by handling after-hours calls, but felt that taking such calls had more limited educational value.
Study details: A survey of 6 endocrinology fellows and 13 endocrinology faculty members at the Hospital of the University of Pennsylvania, Philadelphia.
Disclosures: Dr. Punati reported having no financial disclosures.
New adventures of an old device: Clinic delivers cortisol via the insulin pump
LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology
“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.
“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.
Dr. Alzohaili said his clinic has tested delivering hydrocortisone via insulin pump in about 20 patients. The report presented at the conference focused on six patients who had failed oral hydrocortisone treatment for adrenal insufficiency. Testing showed that all had malabsorption of the drug.
The patients underwent training in how to use and adjust the pump, which allows dosing adjustments in increments of 1 mg. They learned how to adjust their doses based on their situation, Dr. Alzohaili said.
According to the report, the average number of adrenal crises in the patients over a 6-month period fell from a mean of 2.3 before baseline to 0.5 after treatment began. The maximum dose of hydrocortisone dose fell by 38%, while the average mean weight of patients rose from 182 pounds to 199 pounds.
In addition, the mean dose of hydrocortisone decreased with the use of the pump delivery system, from 85.8 mg with oral treatment to 32.4 mg on pump therapy, and the mean level of cortisol increased from 11.8 mcg/dL with oral treatment to 12.3 mcg/dL on pump therapy.
The researchers said that the pump provides better delivery of the medication compared with the oral route, and that the patients experienced fewer interactions with other medications.
Some patients developed skin reactions to the pump, but those adverse events were resolved by changing the pump’s location on the body and by using hypoallergenic needles, Dr. Alzohaili said.
There were fewer cases of clogging with the pumps than is normally seen when they’re used with insulin, he added.
As for expense, Dr. Alzohaili said the pumps cost thousands of dollars and supplies can cost between $100 and $150 a month. In the first couple of cases, patients paid for the treatment themselves, he said, but in later cases, insurers were willing to pay for the treatment once they learned about the results.
Other researchers have successfully used insulin pumps to deliver hydrocortisone to small numbers of patients with adrenal insufficiency, including British and U.S. teams that reported positive results in 2015 and 2018, respectively.
The next step, Dr. Alzohaili said, is to attract the interest of insulin pump manufacturers by using the treatment in more patients. “I’ve spoken to CEOs, but none of them is interested in using cortisol in their pumps,” he said. “If you don’t have the company supporting the research, it becomes difficult for it to become standard of care. So I’m trying to build awareness [of its use] and the number of patients [who use the pump].”
Dr. Alzohaili reported no financial conflicts of interest or disclosures.
LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology
“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.
“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.
Dr. Alzohaili said his clinic has tested delivering hydrocortisone via insulin pump in about 20 patients. The report presented at the conference focused on six patients who had failed oral hydrocortisone treatment for adrenal insufficiency. Testing showed that all had malabsorption of the drug.
The patients underwent training in how to use and adjust the pump, which allows dosing adjustments in increments of 1 mg. They learned how to adjust their doses based on their situation, Dr. Alzohaili said.
According to the report, the average number of adrenal crises in the patients over a 6-month period fell from a mean of 2.3 before baseline to 0.5 after treatment began. The maximum dose of hydrocortisone dose fell by 38%, while the average mean weight of patients rose from 182 pounds to 199 pounds.
In addition, the mean dose of hydrocortisone decreased with the use of the pump delivery system, from 85.8 mg with oral treatment to 32.4 mg on pump therapy, and the mean level of cortisol increased from 11.8 mcg/dL with oral treatment to 12.3 mcg/dL on pump therapy.
The researchers said that the pump provides better delivery of the medication compared with the oral route, and that the patients experienced fewer interactions with other medications.
Some patients developed skin reactions to the pump, but those adverse events were resolved by changing the pump’s location on the body and by using hypoallergenic needles, Dr. Alzohaili said.
There were fewer cases of clogging with the pumps than is normally seen when they’re used with insulin, he added.
As for expense, Dr. Alzohaili said the pumps cost thousands of dollars and supplies can cost between $100 and $150 a month. In the first couple of cases, patients paid for the treatment themselves, he said, but in later cases, insurers were willing to pay for the treatment once they learned about the results.
Other researchers have successfully used insulin pumps to deliver hydrocortisone to small numbers of patients with adrenal insufficiency, including British and U.S. teams that reported positive results in 2015 and 2018, respectively.
The next step, Dr. Alzohaili said, is to attract the interest of insulin pump manufacturers by using the treatment in more patients. “I’ve spoken to CEOs, but none of them is interested in using cortisol in their pumps,” he said. “If you don’t have the company supporting the research, it becomes difficult for it to become standard of care. So I’m trying to build awareness [of its use] and the number of patients [who use the pump].”
Dr. Alzohaili reported no financial conflicts of interest or disclosures.
LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology
“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.
Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.
“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.
Dr. Alzohaili said his clinic has tested delivering hydrocortisone via insulin pump in about 20 patients. The report presented at the conference focused on six patients who had failed oral hydrocortisone treatment for adrenal insufficiency. Testing showed that all had malabsorption of the drug.
The patients underwent training in how to use and adjust the pump, which allows dosing adjustments in increments of 1 mg. They learned how to adjust their doses based on their situation, Dr. Alzohaili said.
According to the report, the average number of adrenal crises in the patients over a 6-month period fell from a mean of 2.3 before baseline to 0.5 after treatment began. The maximum dose of hydrocortisone dose fell by 38%, while the average mean weight of patients rose from 182 pounds to 199 pounds.
In addition, the mean dose of hydrocortisone decreased with the use of the pump delivery system, from 85.8 mg with oral treatment to 32.4 mg on pump therapy, and the mean level of cortisol increased from 11.8 mcg/dL with oral treatment to 12.3 mcg/dL on pump therapy.
The researchers said that the pump provides better delivery of the medication compared with the oral route, and that the patients experienced fewer interactions with other medications.
Some patients developed skin reactions to the pump, but those adverse events were resolved by changing the pump’s location on the body and by using hypoallergenic needles, Dr. Alzohaili said.
There were fewer cases of clogging with the pumps than is normally seen when they’re used with insulin, he added.
As for expense, Dr. Alzohaili said the pumps cost thousands of dollars and supplies can cost between $100 and $150 a month. In the first couple of cases, patients paid for the treatment themselves, he said, but in later cases, insurers were willing to pay for the treatment once they learned about the results.
Other researchers have successfully used insulin pumps to deliver hydrocortisone to small numbers of patients with adrenal insufficiency, including British and U.S. teams that reported positive results in 2015 and 2018, respectively.
The next step, Dr. Alzohaili said, is to attract the interest of insulin pump manufacturers by using the treatment in more patients. “I’ve spoken to CEOs, but none of them is interested in using cortisol in their pumps,” he said. “If you don’t have the company supporting the research, it becomes difficult for it to become standard of care. So I’m trying to build awareness [of its use] and the number of patients [who use the pump].”
Dr. Alzohaili reported no financial conflicts of interest or disclosures.
REPORTING FROM AACE 2019
Type 2 diabetes bumps up short-term risk for bone fracture
LOS ANGELES – results from a large community-based study have shown.
“Osteoporotic fractures are a significant public health burden, causing high morbidity, mortality, and associated health care costs,” Elizabeth J. Samelson, PhD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Risk of fractures are higher in patients with type 2 diabetes. Further, outcomes are worse in type 2 diabetes patients, with greater frequency of complications following a fracture.”
Given the projected increase in type 2 diabetes in the U.S. population, Dr. Samelson, an associate scientist at the Marcus Institute for Aging Research at Hebrew SeniorLife and Harvard Medical School, Boston, and colleagues set out to evaluate the short- and long-term risks of bone fractures associated with the disease. They drew from 2,105 women and 1,130 men who participated in the Framingham Original and Offspring Cohorts and whose baseline osteoporosis visit was around 1990. Type 2 diabetes was defined as having a fasting plasma glucose of greater than 125 mg/dL or being on treatment for the disease. Incident fractures excluded finger, toe, skull, face, and pathologic fractures, and the researchers used repeated measures analyses to estimate hazard ratios for the association between type 2 diabetes, type 2 diabetes medication use, and type 2 diabetes duration and incident fracture, adjusted for age, sex, height, and weight.
The mean age of the study participants was 67 years, and the mean follow-up was 9 years. The prevalence of type 2 diabetes in women and men was 7% and 13%, respectively, and 63% and 51% of those were on medication for the disease. The mean duration of diabetes was 8 years.
Dr. Samelson and colleagues found that the cumulative incidence of fracture was 37% in women with type 2 diabetes and 30% in those without the disease. Meanwhile, the cumulative incidence of fracture was 11% in men with type 2 diabetes and 16% in those without the disease. The researchers also found that type 2 diabetes was associated with 1-year fracture risk in women (hazard ratio, 2.23), but not in men.
In the entire study population, longer duration of type 2 diabetes increased the 2-year fracture risk (HR, 1.28), as did the use of any type 2 diabetes medication (HR, 1.70). The researchers observed no statistically significant differences between type 2 diabetes and long-term incidence of fracture.
“Previous studies have contributed to understanding the higher incidence of fractures and worse outcomes in type 2 diabetes, [but] the current study demonstrated that patients [with type 2 diabetes] have 50% to 100% higher short-term [1- to 2-year] risk of fracture independent of clinical risk factors, whereas long-term [10-year] risk of fracture was similar in [patients with] type 2 diabetes and those who do not have [the disease],” Dr. Samelson said. “The current study has some inherent limitations of observational studies, including a lack of definitive determination of causality and that the results are not generalizable to patients with similar demographics. The study, however, is robust in the availability of detailed clinical information, which allows for control of multiple confounding variables.”
Dr. Samelson reported having no financial disclosures. Coauthors Setareh Williams, PhD, and Rich Weiss, MD, are employees and shareholders of Radius Health Inc.
LOS ANGELES – results from a large community-based study have shown.
“Osteoporotic fractures are a significant public health burden, causing high morbidity, mortality, and associated health care costs,” Elizabeth J. Samelson, PhD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Risk of fractures are higher in patients with type 2 diabetes. Further, outcomes are worse in type 2 diabetes patients, with greater frequency of complications following a fracture.”
Given the projected increase in type 2 diabetes in the U.S. population, Dr. Samelson, an associate scientist at the Marcus Institute for Aging Research at Hebrew SeniorLife and Harvard Medical School, Boston, and colleagues set out to evaluate the short- and long-term risks of bone fractures associated with the disease. They drew from 2,105 women and 1,130 men who participated in the Framingham Original and Offspring Cohorts and whose baseline osteoporosis visit was around 1990. Type 2 diabetes was defined as having a fasting plasma glucose of greater than 125 mg/dL or being on treatment for the disease. Incident fractures excluded finger, toe, skull, face, and pathologic fractures, and the researchers used repeated measures analyses to estimate hazard ratios for the association between type 2 diabetes, type 2 diabetes medication use, and type 2 diabetes duration and incident fracture, adjusted for age, sex, height, and weight.
The mean age of the study participants was 67 years, and the mean follow-up was 9 years. The prevalence of type 2 diabetes in women and men was 7% and 13%, respectively, and 63% and 51% of those were on medication for the disease. The mean duration of diabetes was 8 years.
Dr. Samelson and colleagues found that the cumulative incidence of fracture was 37% in women with type 2 diabetes and 30% in those without the disease. Meanwhile, the cumulative incidence of fracture was 11% in men with type 2 diabetes and 16% in those without the disease. The researchers also found that type 2 diabetes was associated with 1-year fracture risk in women (hazard ratio, 2.23), but not in men.
In the entire study population, longer duration of type 2 diabetes increased the 2-year fracture risk (HR, 1.28), as did the use of any type 2 diabetes medication (HR, 1.70). The researchers observed no statistically significant differences between type 2 diabetes and long-term incidence of fracture.
“Previous studies have contributed to understanding the higher incidence of fractures and worse outcomes in type 2 diabetes, [but] the current study demonstrated that patients [with type 2 diabetes] have 50% to 100% higher short-term [1- to 2-year] risk of fracture independent of clinical risk factors, whereas long-term [10-year] risk of fracture was similar in [patients with] type 2 diabetes and those who do not have [the disease],” Dr. Samelson said. “The current study has some inherent limitations of observational studies, including a lack of definitive determination of causality and that the results are not generalizable to patients with similar demographics. The study, however, is robust in the availability of detailed clinical information, which allows for control of multiple confounding variables.”
Dr. Samelson reported having no financial disclosures. Coauthors Setareh Williams, PhD, and Rich Weiss, MD, are employees and shareholders of Radius Health Inc.
LOS ANGELES – results from a large community-based study have shown.
“Osteoporotic fractures are a significant public health burden, causing high morbidity, mortality, and associated health care costs,” Elizabeth J. Samelson, PhD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Risk of fractures are higher in patients with type 2 diabetes. Further, outcomes are worse in type 2 diabetes patients, with greater frequency of complications following a fracture.”
Given the projected increase in type 2 diabetes in the U.S. population, Dr. Samelson, an associate scientist at the Marcus Institute for Aging Research at Hebrew SeniorLife and Harvard Medical School, Boston, and colleagues set out to evaluate the short- and long-term risks of bone fractures associated with the disease. They drew from 2,105 women and 1,130 men who participated in the Framingham Original and Offspring Cohorts and whose baseline osteoporosis visit was around 1990. Type 2 diabetes was defined as having a fasting plasma glucose of greater than 125 mg/dL or being on treatment for the disease. Incident fractures excluded finger, toe, skull, face, and pathologic fractures, and the researchers used repeated measures analyses to estimate hazard ratios for the association between type 2 diabetes, type 2 diabetes medication use, and type 2 diabetes duration and incident fracture, adjusted for age, sex, height, and weight.
The mean age of the study participants was 67 years, and the mean follow-up was 9 years. The prevalence of type 2 diabetes in women and men was 7% and 13%, respectively, and 63% and 51% of those were on medication for the disease. The mean duration of diabetes was 8 years.
Dr. Samelson and colleagues found that the cumulative incidence of fracture was 37% in women with type 2 diabetes and 30% in those without the disease. Meanwhile, the cumulative incidence of fracture was 11% in men with type 2 diabetes and 16% in those without the disease. The researchers also found that type 2 diabetes was associated with 1-year fracture risk in women (hazard ratio, 2.23), but not in men.
In the entire study population, longer duration of type 2 diabetes increased the 2-year fracture risk (HR, 1.28), as did the use of any type 2 diabetes medication (HR, 1.70). The researchers observed no statistically significant differences between type 2 diabetes and long-term incidence of fracture.
“Previous studies have contributed to understanding the higher incidence of fractures and worse outcomes in type 2 diabetes, [but] the current study demonstrated that patients [with type 2 diabetes] have 50% to 100% higher short-term [1- to 2-year] risk of fracture independent of clinical risk factors, whereas long-term [10-year] risk of fracture was similar in [patients with] type 2 diabetes and those who do not have [the disease],” Dr. Samelson said. “The current study has some inherent limitations of observational studies, including a lack of definitive determination of causality and that the results are not generalizable to patients with similar demographics. The study, however, is robust in the availability of detailed clinical information, which allows for control of multiple confounding variables.”
Dr. Samelson reported having no financial disclosures. Coauthors Setareh Williams, PhD, and Rich Weiss, MD, are employees and shareholders of Radius Health Inc.
REPORTING FROM AACE 2019
VIDEO: Physicians fall short on adequate sleep, consumption of fruits and vegetables
LOS ANGELES – Physicians appear to meet Centers for Disease Control and Prevention guidelines for exercise, but they fall short when it comes to getting enough sleep and consuming an adequate amount of fruits and vegetables.
Those are key findings from a survey of 20 Tennessee-based physicians from a variety of medical specialties whom Deepti G. Bulchandani, MD, presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
Inspired by her daughter, Eesha Nachnani, Dr. Bulchandani, an endocrinologist with Saint Thomas Medical Partners in Hendersonville, Tenn., created a survey in which physicians were asked about their nutritional habits, as well as how much sleep and exercise they were getting. The duo found that only half of the survey respondents were eating at least 1.5-2 cups of fruit and 2-3 cups of vegetables a day, as recommended by the CDC, and only half were consuming less than 2,300 mg of sodium per day. They also found that only one in four physicians were sleeping more than 7 hours a day on a regular basis. The good news? All respondents met the recommended CDC guidelines for exercise.
“What was most neglected was sleep,” Dr. Bulchandani said. “[Electronic medical reports are] taking a lot of time. We do have [work hours] protection for residents, but physicians don’t have rules that are set for them. I think that is taking a toll.”
Dr. Bulchandani reported having no financial disclosures.
LOS ANGELES – Physicians appear to meet Centers for Disease Control and Prevention guidelines for exercise, but they fall short when it comes to getting enough sleep and consuming an adequate amount of fruits and vegetables.
Those are key findings from a survey of 20 Tennessee-based physicians from a variety of medical specialties whom Deepti G. Bulchandani, MD, presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
Inspired by her daughter, Eesha Nachnani, Dr. Bulchandani, an endocrinologist with Saint Thomas Medical Partners in Hendersonville, Tenn., created a survey in which physicians were asked about their nutritional habits, as well as how much sleep and exercise they were getting. The duo found that only half of the survey respondents were eating at least 1.5-2 cups of fruit and 2-3 cups of vegetables a day, as recommended by the CDC, and only half were consuming less than 2,300 mg of sodium per day. They also found that only one in four physicians were sleeping more than 7 hours a day on a regular basis. The good news? All respondents met the recommended CDC guidelines for exercise.
“What was most neglected was sleep,” Dr. Bulchandani said. “[Electronic medical reports are] taking a lot of time. We do have [work hours] protection for residents, but physicians don’t have rules that are set for them. I think that is taking a toll.”
Dr. Bulchandani reported having no financial disclosures.
LOS ANGELES – Physicians appear to meet Centers for Disease Control and Prevention guidelines for exercise, but they fall short when it comes to getting enough sleep and consuming an adequate amount of fruits and vegetables.
Those are key findings from a survey of 20 Tennessee-based physicians from a variety of medical specialties whom Deepti G. Bulchandani, MD, presented at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
Inspired by her daughter, Eesha Nachnani, Dr. Bulchandani, an endocrinologist with Saint Thomas Medical Partners in Hendersonville, Tenn., created a survey in which physicians were asked about their nutritional habits, as well as how much sleep and exercise they were getting. The duo found that only half of the survey respondents were eating at least 1.5-2 cups of fruit and 2-3 cups of vegetables a day, as recommended by the CDC, and only half were consuming less than 2,300 mg of sodium per day. They also found that only one in four physicians were sleeping more than 7 hours a day on a regular basis. The good news? All respondents met the recommended CDC guidelines for exercise.
“What was most neglected was sleep,” Dr. Bulchandani said. “[Electronic medical reports are] taking a lot of time. We do have [work hours] protection for residents, but physicians don’t have rules that are set for them. I think that is taking a toll.”
Dr. Bulchandani reported having no financial disclosures.
REPORTING FROM AACE 2019
Older women with ESRD face higher mortality, compared with male counterparts
LOS ANGELES – In patients with end-stage renal disease, women older than 50 years have a significantly higher mortality, compared with their male counterparts, results from an analysis of national data showed.
“The racial and ethnic disparities in the prevalence, treatment, risks, and outcomes of [hypertension] in patients with CKD [chronic kidney disease], are well recognized,” the study’s senior author, Ricardo Correa, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Whites have better control of blood pressure, compared with Hispanics or African Americans with CKD, for example. On the other hand, gender differences in the outcome of blood pressure control and mortality across the different CKD stages have been very poorly studied, with conflicting results.”
The importance of gender difference has been mostly the focus in cardiovascular diseases, he continued, with compelling data revealing a higher incidence in men than in women of similar age, and a menopause-associated increase in cardiovascular disease in women.
“Whether the same can be said for hypertension, remains to be elucidated,” said Dr. Correa, an endocrinologist who directs the diabetes and metabolism fellowship at the University of Arizona in Phoenix.
In what he said is the first study of its kind, Dr. Correa and his colleagues set out to determine if gender in the U.S. population and menopausal age affect the inpatient survival rate in hypertensive patients across different stages of CKD. They drew from the 2005-2012 National Inpatient Sample to identify 2,121,750 hospitalized hypertensive patients and compared a number of factors between men and women, including crude mortality and mortality per CKD stage, menopausal age, length of stay, and total hospital charges.
Of the 2,121,750 patients, 1,092,931 (52%) were men and 1,028,819 (48%) were women; their mean age was 65 years. Among women, 32% had stage 3 CKD, 15% had stage 4 disease, 3% had stage 5 CKD, and 54% had end-stage renal disease (ESRD). Among men, 33% had stage 3 CKD, 13% had stage 4 disease, 3% had stage 5 CKD, and 51% had ESRD. The researchers observed that in-hospital crude mortality was significantly higher for men, compared with a matched group of women at CKD stages 3 and 4 (3.09% vs. 3.29% for CDK 3; P less than .0001 and 4.05% vs. 4.36% for CDK 4; P = .0004), yet was nonsignificant among those with ESRD (4.68% vs. 4.83%; P = .45).
When the researchers factored in menopausal age, they found that women with stage 3, 4, or 5 CKD who were aged 50 years or younger had a mortality rate similar to that of men with same stage disease, whereas women older than 50 years with ESRD had a significantly higher mortality, compared with their male counterparts, especially those of Asian, African American, and Hispanic descent (P less than .001, compared with those of white, non-Hispanic descent).
“One could hypothesize that cardiac remodeling in hemodialysis women may be different than that in hemodialysis men to the extent that it affects mortality,” Dr. Correa said. “However, it is unclear if the survival benefit for dialysis men is owing to the possibility of a selection bias or not. Dialysis women may not be receiving equal access to cardiovascular procedures or surgical interventions (arteriovenous fistula, for example) or women may not be offered adequate hemodialysis to the same extent as men are. Further investigations regarding sex-based differences in dialysis treatment are required.”
He acknowledged certain limitations of the study, including its observational design. “We lacked detailed information regarding the cause of death, dialysis efficiency, types of dialysis accesses, and left ventricular hypertrophy measurements. We did not account for transitions between different hemodialysis modalities [and] we do not have information about distances or traveling time to dialysis units.”
The study’s first author was Kelvin Tran, MD. The researchers reported having no financial disclosures.
LOS ANGELES – In patients with end-stage renal disease, women older than 50 years have a significantly higher mortality, compared with their male counterparts, results from an analysis of national data showed.
“The racial and ethnic disparities in the prevalence, treatment, risks, and outcomes of [hypertension] in patients with CKD [chronic kidney disease], are well recognized,” the study’s senior author, Ricardo Correa, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Whites have better control of blood pressure, compared with Hispanics or African Americans with CKD, for example. On the other hand, gender differences in the outcome of blood pressure control and mortality across the different CKD stages have been very poorly studied, with conflicting results.”
The importance of gender difference has been mostly the focus in cardiovascular diseases, he continued, with compelling data revealing a higher incidence in men than in women of similar age, and a menopause-associated increase in cardiovascular disease in women.
“Whether the same can be said for hypertension, remains to be elucidated,” said Dr. Correa, an endocrinologist who directs the diabetes and metabolism fellowship at the University of Arizona in Phoenix.
In what he said is the first study of its kind, Dr. Correa and his colleagues set out to determine if gender in the U.S. population and menopausal age affect the inpatient survival rate in hypertensive patients across different stages of CKD. They drew from the 2005-2012 National Inpatient Sample to identify 2,121,750 hospitalized hypertensive patients and compared a number of factors between men and women, including crude mortality and mortality per CKD stage, menopausal age, length of stay, and total hospital charges.
Of the 2,121,750 patients, 1,092,931 (52%) were men and 1,028,819 (48%) were women; their mean age was 65 years. Among women, 32% had stage 3 CKD, 15% had stage 4 disease, 3% had stage 5 CKD, and 54% had end-stage renal disease (ESRD). Among men, 33% had stage 3 CKD, 13% had stage 4 disease, 3% had stage 5 CKD, and 51% had ESRD. The researchers observed that in-hospital crude mortality was significantly higher for men, compared with a matched group of women at CKD stages 3 and 4 (3.09% vs. 3.29% for CDK 3; P less than .0001 and 4.05% vs. 4.36% for CDK 4; P = .0004), yet was nonsignificant among those with ESRD (4.68% vs. 4.83%; P = .45).
When the researchers factored in menopausal age, they found that women with stage 3, 4, or 5 CKD who were aged 50 years or younger had a mortality rate similar to that of men with same stage disease, whereas women older than 50 years with ESRD had a significantly higher mortality, compared with their male counterparts, especially those of Asian, African American, and Hispanic descent (P less than .001, compared with those of white, non-Hispanic descent).
“One could hypothesize that cardiac remodeling in hemodialysis women may be different than that in hemodialysis men to the extent that it affects mortality,” Dr. Correa said. “However, it is unclear if the survival benefit for dialysis men is owing to the possibility of a selection bias or not. Dialysis women may not be receiving equal access to cardiovascular procedures or surgical interventions (arteriovenous fistula, for example) or women may not be offered adequate hemodialysis to the same extent as men are. Further investigations regarding sex-based differences in dialysis treatment are required.”
He acknowledged certain limitations of the study, including its observational design. “We lacked detailed information regarding the cause of death, dialysis efficiency, types of dialysis accesses, and left ventricular hypertrophy measurements. We did not account for transitions between different hemodialysis modalities [and] we do not have information about distances or traveling time to dialysis units.”
The study’s first author was Kelvin Tran, MD. The researchers reported having no financial disclosures.
LOS ANGELES – In patients with end-stage renal disease, women older than 50 years have a significantly higher mortality, compared with their male counterparts, results from an analysis of national data showed.
“The racial and ethnic disparities in the prevalence, treatment, risks, and outcomes of [hypertension] in patients with CKD [chronic kidney disease], are well recognized,” the study’s senior author, Ricardo Correa, MD, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “Whites have better control of blood pressure, compared with Hispanics or African Americans with CKD, for example. On the other hand, gender differences in the outcome of blood pressure control and mortality across the different CKD stages have been very poorly studied, with conflicting results.”
The importance of gender difference has been mostly the focus in cardiovascular diseases, he continued, with compelling data revealing a higher incidence in men than in women of similar age, and a menopause-associated increase in cardiovascular disease in women.
“Whether the same can be said for hypertension, remains to be elucidated,” said Dr. Correa, an endocrinologist who directs the diabetes and metabolism fellowship at the University of Arizona in Phoenix.
In what he said is the first study of its kind, Dr. Correa and his colleagues set out to determine if gender in the U.S. population and menopausal age affect the inpatient survival rate in hypertensive patients across different stages of CKD. They drew from the 2005-2012 National Inpatient Sample to identify 2,121,750 hospitalized hypertensive patients and compared a number of factors between men and women, including crude mortality and mortality per CKD stage, menopausal age, length of stay, and total hospital charges.
Of the 2,121,750 patients, 1,092,931 (52%) were men and 1,028,819 (48%) were women; their mean age was 65 years. Among women, 32% had stage 3 CKD, 15% had stage 4 disease, 3% had stage 5 CKD, and 54% had end-stage renal disease (ESRD). Among men, 33% had stage 3 CKD, 13% had stage 4 disease, 3% had stage 5 CKD, and 51% had ESRD. The researchers observed that in-hospital crude mortality was significantly higher for men, compared with a matched group of women at CKD stages 3 and 4 (3.09% vs. 3.29% for CDK 3; P less than .0001 and 4.05% vs. 4.36% for CDK 4; P = .0004), yet was nonsignificant among those with ESRD (4.68% vs. 4.83%; P = .45).
When the researchers factored in menopausal age, they found that women with stage 3, 4, or 5 CKD who were aged 50 years or younger had a mortality rate similar to that of men with same stage disease, whereas women older than 50 years with ESRD had a significantly higher mortality, compared with their male counterparts, especially those of Asian, African American, and Hispanic descent (P less than .001, compared with those of white, non-Hispanic descent).
“One could hypothesize that cardiac remodeling in hemodialysis women may be different than that in hemodialysis men to the extent that it affects mortality,” Dr. Correa said. “However, it is unclear if the survival benefit for dialysis men is owing to the possibility of a selection bias or not. Dialysis women may not be receiving equal access to cardiovascular procedures or surgical interventions (arteriovenous fistula, for example) or women may not be offered adequate hemodialysis to the same extent as men are. Further investigations regarding sex-based differences in dialysis treatment are required.”
He acknowledged certain limitations of the study, including its observational design. “We lacked detailed information regarding the cause of death, dialysis efficiency, types of dialysis accesses, and left ventricular hypertrophy measurements. We did not account for transitions between different hemodialysis modalities [and] we do not have information about distances or traveling time to dialysis units.”
The study’s first author was Kelvin Tran, MD. The researchers reported having no financial disclosures.
REPORTING FROM AACE 2019
Key clinical point: .
Major finding: Women older than 50 years with end-stage renal disease had significantly higher mortality, compared with their male counterparts, especially those of Asian, African American, and Hispanic descent (P less than .001 vs. those of white, non-Hispanic descent).
Study details: An observational study of more than 2 million hypertensive patients from the Nationwide Inpatient Sample.
Disclosures: Dr. Correa reported having no financial disclosures.
‘Mammogram of the heart’: Inside coronary artery calcium scores
LOS ANGELES – according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.
In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”
According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.
In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.
Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.
“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”
And this advice holds up regardless of the gender, age, or ethnicity of a patient.
However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”
What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.
What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.
CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.
“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.
Dr. Budoff offered other insights into CAC and diabetes.
First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).
However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.
Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).
“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”
The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”
Dr. Budoff reported receiving grant funding from GE Healthcare.
LOS ANGELES – according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.
In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”
According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.
In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.
Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.
“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”
And this advice holds up regardless of the gender, age, or ethnicity of a patient.
However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”
What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.
What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.
CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.
“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.
Dr. Budoff offered other insights into CAC and diabetes.
First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).
However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.
Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).
“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”
The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”
Dr. Budoff reported receiving grant funding from GE Healthcare.
LOS ANGELES – according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.
In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.
“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”
According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.
In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.
Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.
“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”
And this advice holds up regardless of the gender, age, or ethnicity of a patient.
However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”
What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.
What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.
CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.
“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.
Dr. Budoff offered other insights into CAC and diabetes.
First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).
However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.
Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).
“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”
The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”
Dr. Budoff reported receiving grant funding from GE Healthcare.
REPORTING FROM AACE 2019
Anxiety, not depression, commonly afflicts euthyroid patients with thyroid disease
LOS ANGELES – results from a cross-sectional study have shown.
“Thyroid disease is often associated with impaired quality of life and psychological well-being,” lead study author Anette Merke, MD, MS, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “In daily practice, anxiety and depression complaints are common in patients with thyroid dysfunctions. While depressive symptoms are often associated with hypothyroidism, anxiety is claimed to be mainly linked to hyperthyroidism. Data on euthyroid patients with thyroid disease are controversial. Some studies point out that autoimmunity itself contributes to psychosomatic malfunctions. Overall, the mechanisms underlying the interaction between thyroid dysfunction and neuropsychiatric processes are still unknown.”
Dr. Merke, of the Thyroid Center Bergstrasse in Bensheim, Germany, and her husband/coauthor Jüergen Merke, MD, PhD, used the self-administered German version of the validated Hospital Anxiety and Depression Scale (HADS-D) to perform a cross-sectional study of 215 euthyroid adults with thyroid disease between January and February of 2019. Of the 14 items on the measure, half relate to anxiety and the other half to depression. Each item on the HADS-D is scored from 0-3, and a score of 10 or higher is considered a positive case of anxiety or depression. Patients completed the HADS-D within 3 months of routine lab testing, and the researchers collected the patients’ demographic data after they had assessed the individual scores.
Of the 215 study participants, most (89%) were women, the mean age was 47 years, and the mean anxiety and depression scores were 6.68 and 4.68, respectively (P = .0001). There was no significant difference in severity with respect to anxiety or depression. Of the 70 patients (33%) with antibody-positive Hashimoto’s thyroiditis, the mean anxiety and depression scores were 7.26 and 4.17.
In patients with HADS-D scores of 10 or greater, 50 (23%) had prominent anxiety scores (mean, 12.4), whereas 22 (10%) had prominent depression scores (mean, 13.18). Among the subset of Hashimoto’s thyroiditis patients, 18 (26%) had a mean anxiety score of 12.6 and 8 (11%) had a mean depression score of 13.18. Overall, significantly more cases were found in those who met criteria for anxiety, compared with those who met criteria for depression (P = .0001), with no significant difference in severity of either condition.
Depressive symptoms are usually more closely associated with thyroid disease, and there are more studies that have examined that relationship, so “we were surprised to find no significant difference in depressive symptoms between our study cohort and the German general population,” Dr. Merke said. “We were also surprised that anxiety had a significantly higher incidence in the cohort.”
The findings suggest that clinicians should focus on signs of anxiety symptoms when dealing with euthyroid patients with thyroid disease who report psychosomatic impairments, she continued, especially when patients complain of not being able to relax and release somatic tension.
“According to HADS, fears and worries are an expression of anxiety, and not of depression,” Dr. Merke said. “With this in mind, doctors [should] actively ask [about] the above-mentioned symptoms and advise patients to learn relaxation techniques to improve their quality of life. Interdisciplinary collaboration is needed between clinicians and psychotherapeutic professionals for the sake of the patients and to evaluate a cause-and-effect relationship and potential risk factors for development of psychosomatic cofactors in thyroid and other chronic somatic diseases. We should all be aware that misinterpretation or even denial of psychosomatic complaints may lead to complications and even a higher mortality of somatic diseases, as shown for chronic heart failure. This could also be true for thyroid disease.”
Dr Merke acknowledged certain limitations of the study, including the fact that neither the duration of thyroid disease nor the use of specific thyroid medications was assessed. In addition, “the definition of euthyroidism in our study is somewhat broad, especially compared with the recommendations of the [American Association of Clinical Endocrinologists],” she said. “Division of the respective thyroid hormone status into quartiles may be helpful to indicate the critical thyroid hormone serum concentration, which may be associated with clinically relevant anxiety symptoms in euthyroid patients.”
Dr. Merke reported having no financial disclosures or conflict of interest.
LOS ANGELES – results from a cross-sectional study have shown.
“Thyroid disease is often associated with impaired quality of life and psychological well-being,” lead study author Anette Merke, MD, MS, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “In daily practice, anxiety and depression complaints are common in patients with thyroid dysfunctions. While depressive symptoms are often associated with hypothyroidism, anxiety is claimed to be mainly linked to hyperthyroidism. Data on euthyroid patients with thyroid disease are controversial. Some studies point out that autoimmunity itself contributes to psychosomatic malfunctions. Overall, the mechanisms underlying the interaction between thyroid dysfunction and neuropsychiatric processes are still unknown.”
Dr. Merke, of the Thyroid Center Bergstrasse in Bensheim, Germany, and her husband/coauthor Jüergen Merke, MD, PhD, used the self-administered German version of the validated Hospital Anxiety and Depression Scale (HADS-D) to perform a cross-sectional study of 215 euthyroid adults with thyroid disease between January and February of 2019. Of the 14 items on the measure, half relate to anxiety and the other half to depression. Each item on the HADS-D is scored from 0-3, and a score of 10 or higher is considered a positive case of anxiety or depression. Patients completed the HADS-D within 3 months of routine lab testing, and the researchers collected the patients’ demographic data after they had assessed the individual scores.
Of the 215 study participants, most (89%) were women, the mean age was 47 years, and the mean anxiety and depression scores were 6.68 and 4.68, respectively (P = .0001). There was no significant difference in severity with respect to anxiety or depression. Of the 70 patients (33%) with antibody-positive Hashimoto’s thyroiditis, the mean anxiety and depression scores were 7.26 and 4.17.
In patients with HADS-D scores of 10 or greater, 50 (23%) had prominent anxiety scores (mean, 12.4), whereas 22 (10%) had prominent depression scores (mean, 13.18). Among the subset of Hashimoto’s thyroiditis patients, 18 (26%) had a mean anxiety score of 12.6 and 8 (11%) had a mean depression score of 13.18. Overall, significantly more cases were found in those who met criteria for anxiety, compared with those who met criteria for depression (P = .0001), with no significant difference in severity of either condition.
Depressive symptoms are usually more closely associated with thyroid disease, and there are more studies that have examined that relationship, so “we were surprised to find no significant difference in depressive symptoms between our study cohort and the German general population,” Dr. Merke said. “We were also surprised that anxiety had a significantly higher incidence in the cohort.”
The findings suggest that clinicians should focus on signs of anxiety symptoms when dealing with euthyroid patients with thyroid disease who report psychosomatic impairments, she continued, especially when patients complain of not being able to relax and release somatic tension.
“According to HADS, fears and worries are an expression of anxiety, and not of depression,” Dr. Merke said. “With this in mind, doctors [should] actively ask [about] the above-mentioned symptoms and advise patients to learn relaxation techniques to improve their quality of life. Interdisciplinary collaboration is needed between clinicians and psychotherapeutic professionals for the sake of the patients and to evaluate a cause-and-effect relationship and potential risk factors for development of psychosomatic cofactors in thyroid and other chronic somatic diseases. We should all be aware that misinterpretation or even denial of psychosomatic complaints may lead to complications and even a higher mortality of somatic diseases, as shown for chronic heart failure. This could also be true for thyroid disease.”
Dr Merke acknowledged certain limitations of the study, including the fact that neither the duration of thyroid disease nor the use of specific thyroid medications was assessed. In addition, “the definition of euthyroidism in our study is somewhat broad, especially compared with the recommendations of the [American Association of Clinical Endocrinologists],” she said. “Division of the respective thyroid hormone status into quartiles may be helpful to indicate the critical thyroid hormone serum concentration, which may be associated with clinically relevant anxiety symptoms in euthyroid patients.”
Dr. Merke reported having no financial disclosures or conflict of interest.
LOS ANGELES – results from a cross-sectional study have shown.
“Thyroid disease is often associated with impaired quality of life and psychological well-being,” lead study author Anette Merke, MD, MS, said in an interview in advance of the annual scientific and clinical congress of the American Association of Clinical Endocrinologists. “In daily practice, anxiety and depression complaints are common in patients with thyroid dysfunctions. While depressive symptoms are often associated with hypothyroidism, anxiety is claimed to be mainly linked to hyperthyroidism. Data on euthyroid patients with thyroid disease are controversial. Some studies point out that autoimmunity itself contributes to psychosomatic malfunctions. Overall, the mechanisms underlying the interaction between thyroid dysfunction and neuropsychiatric processes are still unknown.”
Dr. Merke, of the Thyroid Center Bergstrasse in Bensheim, Germany, and her husband/coauthor Jüergen Merke, MD, PhD, used the self-administered German version of the validated Hospital Anxiety and Depression Scale (HADS-D) to perform a cross-sectional study of 215 euthyroid adults with thyroid disease between January and February of 2019. Of the 14 items on the measure, half relate to anxiety and the other half to depression. Each item on the HADS-D is scored from 0-3, and a score of 10 or higher is considered a positive case of anxiety or depression. Patients completed the HADS-D within 3 months of routine lab testing, and the researchers collected the patients’ demographic data after they had assessed the individual scores.
Of the 215 study participants, most (89%) were women, the mean age was 47 years, and the mean anxiety and depression scores were 6.68 and 4.68, respectively (P = .0001). There was no significant difference in severity with respect to anxiety or depression. Of the 70 patients (33%) with antibody-positive Hashimoto’s thyroiditis, the mean anxiety and depression scores were 7.26 and 4.17.
In patients with HADS-D scores of 10 or greater, 50 (23%) had prominent anxiety scores (mean, 12.4), whereas 22 (10%) had prominent depression scores (mean, 13.18). Among the subset of Hashimoto’s thyroiditis patients, 18 (26%) had a mean anxiety score of 12.6 and 8 (11%) had a mean depression score of 13.18. Overall, significantly more cases were found in those who met criteria for anxiety, compared with those who met criteria for depression (P = .0001), with no significant difference in severity of either condition.
Depressive symptoms are usually more closely associated with thyroid disease, and there are more studies that have examined that relationship, so “we were surprised to find no significant difference in depressive symptoms between our study cohort and the German general population,” Dr. Merke said. “We were also surprised that anxiety had a significantly higher incidence in the cohort.”
The findings suggest that clinicians should focus on signs of anxiety symptoms when dealing with euthyroid patients with thyroid disease who report psychosomatic impairments, she continued, especially when patients complain of not being able to relax and release somatic tension.
“According to HADS, fears and worries are an expression of anxiety, and not of depression,” Dr. Merke said. “With this in mind, doctors [should] actively ask [about] the above-mentioned symptoms and advise patients to learn relaxation techniques to improve their quality of life. Interdisciplinary collaboration is needed between clinicians and psychotherapeutic professionals for the sake of the patients and to evaluate a cause-and-effect relationship and potential risk factors for development of psychosomatic cofactors in thyroid and other chronic somatic diseases. We should all be aware that misinterpretation or even denial of psychosomatic complaints may lead to complications and even a higher mortality of somatic diseases, as shown for chronic heart failure. This could also be true for thyroid disease.”
Dr Merke acknowledged certain limitations of the study, including the fact that neither the duration of thyroid disease nor the use of specific thyroid medications was assessed. In addition, “the definition of euthyroidism in our study is somewhat broad, especially compared with the recommendations of the [American Association of Clinical Endocrinologists],” she said. “Division of the respective thyroid hormone status into quartiles may be helpful to indicate the critical thyroid hormone serum concentration, which may be associated with clinically relevant anxiety symptoms in euthyroid patients.”
Dr. Merke reported having no financial disclosures or conflict of interest.
REPORTING FROM AACE 2019
Key clinical point: Anxiety in patients with thyroid disease might have a pathological pathway different from depressive disorders.
Major finding: In patients with HADS-D scores of 10 or greater, 50 (23%) had prominent anxiety scores (mean, 12.4) and 22 (10%) had prominent depression scores (mean, 13.18).
Study details: A cross-sectional study of 215 euthyroid patients with thyroid disease.
Disclosures: Dr. Merke reported having no financial disclosures or conflicts of interest.