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Expert shares key facts about keloid therapy
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
although few understand what this process entails, according to Hilary E. Baldwin, MD, of Rutgers Robert Wood Johnson Medical School, New Brunswick, N.J.
A key point to keep in mind about keloids is that, while they result from trauma, however slight, trauma alone does not cause them, Dr. Baldwin said in a presentation at the virtual MedscapeLive’s annual Las Vegas Dermatology Seminar.
In general, people with darker skin form keloids more easily and consistently than those with lighter skin, but keloids in people with darker skin are often easier to treat, Dr. Baldwin added. Also worth noting is the fact that earlobe keloids recur less frequently, she said.
Most patients with keloids are not surgical candidates, and they need convincing to pursue alternative options, Dr. Baldwin said.
However, successful management of keloids starts with sorting out what the patient wants. Some want “eradication with normal skin,” which is not realistic, versus simply flattening, lightening, or eradication of the keloid and leaving a scar, she noted. “That skin is never going to look normal,” she said. “Very often, they don’t need the whole thing gone, they just want to be better, and not itch or cause them to think about it all the time.”
Quality clinical research on the management of keloids is limited, Dr. Baldwin continued. “If you are holding out for a good randomized, placebo-controlled, double-blind study with a healthy ‘N,’ adequate follow-up rational conclusions, don’t hold your breath,” she said. The few literature reviews on keloids in recent decades concluded that modalities used to treat keloids are based on anecdotal evidence rather than rigorous research, she noted.
Size (and shape) matters
The decision to cut a keloid depends on several factors, including lesion size, shape, age, and location, but especially patient commitment to follow up and postsurgery care, said Dr. Baldwin.
She noted that larger keloids are no more difficult to remove than smaller ones, and patients tend to be more satisfied with the outcome with larger keloids. In terms of shape, pedunculated lesions are most amenable to surgery because of their small footprint. “Often the base does not contain keloidal tissue, and the patient gets the maximum benefit for the least risk,” she said. In addition, the residue from the removal of large keloids is often more acceptable.
Options for adjunctive therapy when excising keloids include corticosteroids, radiation, interferon, pressure dressings, dextran hydrogel scaffolding, and possibly botulinum toxin A, Dr. Baldwin said.
Adjunctive treatment alternatives
Intralesional corticosteroids can prevent the recurrence of keloids, and Dr. Baldwin recommends a 40 mg/cc injection into the base and walls of the excision site immediately postop, with repeat injections every 2 weeks for 2 months regardless of the patient’s clinical appearance. However, appearance determines the dose and concentration during 6 months of monthly follow-up, she said.
Radiation therapy, while not an effective monotherapy for keloids, can be used as an adjunct. A short radiation treatment plan may improve compliance, and no local malignancies linked to radiation therapy for keloids have been reported, she said. Dr. Baldwin also shared details of using an in-office superficial radiation therapy with the SRT-100 device, which she said has shown some ability to reduce recurrence of keloids.
Interferon, which can reduce production of collagen and increase collagenase can be used in an amount of 1.5 million units per linear cm around the base and walls of a keloid excision (maximum is 5 million units a day). Be aware that patients can develop flulike symptoms within a day or so, and warn patients to take it easy and monitor for symptoms, she said.
Studies of imiquimod for keloid recurrence have yielded mixed results, and a 2020 literature review concluded that it is not recommended as a treatment option for keloids, said Dr. Baldwin. Pressure dressings also have not shown effectiveness on existing lesions.
Botulinum toxin A has been studied as a way to prevent hypertrophic scars and keloids and potentially for preventing recurrence by injecting at the wound edges, she said. A meta-analysis showed that botulinum toxin was superior to corticosteroids for treating keloids, but “there were a lot of problems with the studies,” she said.
One other option for postexcision keloid treatment is dextran hydrogel scaffolding, which involves a triple-stranded collagen denatured by heat, with the addition of dextran to form a scaffold for fibroblasts, Dr. Baldwin said. This product, when injected prior to the final closure of surgical excision of keloids, may improve outcomes in certain areas, such as the earlobe, she said.
Dr. Baldwin concluded with comments about preventing other keloids from getting out of hand, which is extraordinarily challenging. However, treatment with dupilumab might provide an answer, although data are limited and more research is needed. She cited a case study of a male patient who had severe atopic dermatitis, with two keloids that improved after 7 months on dupilumab. The Th2 cytokines interleukin (IL)–4 and IL-13 have been implicated as key mediators in the pathogenesis of fibroproliferative disorders, which may respond to dupilumab, which targets Th2, she noted.
Dr. Baldwin had no relevant financial conflicts to disclose.
MedscapeLive and this news organization are owned by the same parent company.
FROM MEDSCAPELIVE LAS VEGAS DERMATOLOGY SEMINAR
Don’t miss cardiovascular risk factors in transgender patients
Cardiovascular disease risk is elevated among transgender individuals seeking gender-affirming hormone therapy, according to a retrospective study in 427 patients.
The transgender population often experiences socioeconomic and health disparities, including reduced access to care, Kara J. Denby, MD, said in an interview.
Previous research suggests that the use of gender-affirming hormone therapy (GAHT) may place transgender persons at increased cardiovascular risk, she said.
To identify the potential risk for transgender individuals, the researchers identified baseline cardiovascular risk in patients who had not yet undergone GAHT. Study participants were enrolled in a multidisciplinary transgender program, and the researchers collected data on demographics, medical history, vitals, medications, and laboratory results. The average age of the participants was 26 years, 172 identified as men, 236 as women, and 20 as nonbinary.
Overall, 55% of the participants had a chronic medical condition at baseline. Of these, 74 patients had hypertension, 41 had hyperlipidemia, 2 had a history of stroke, 7 had coronary artery disease, and 4 had chronic obstructive pulmonary disease.
For all patients who did not have documented atherosclerotic cardiovascular disease, their American College of Cardiology/American Heart Association ASCVD and QRISK3 risk scores were calculated. “The incidence of undiagnosed hypertension and hyperlipidemia was 6.8% and 11.3% respectively, and of these cases, only 64% and 24% were on appropriate therapies,” noted Dr. Denby of the Cleveland (Ohio) Clinic.
She reported the results Nov. 13 in a presentation at the at the virtual American Heart Association scientific sessions.
The findings were limited by the observational nature of the study.
However, the results suggest that transgender patients “appear to be at higher risk than their age-matched historical cohorts regardless of gender,” said Dr. Denby. More research is needed, but cardiovascular disease–prevention efforts may be inadequate in the transgender population given the elevated risk observed in this study, she concluded.
Growing transgender population is medically underserved
The transgender population is growing in the United States and internationally, said Dr. Denby. “This group has a history of being marginalized as a result of their transgender status with socioeconomic and health repercussions,” she said. “It is well known that transgender patients are less likely to have access to health care or utilize health care for a variety of reasons, including stigma and fear of mistreatment. This often leads transgender individuals to present to care late in disease processes which makes their disease harder to treat and often leads to emergent medical conditions,” she added.
“Transgender men and women are at high risk for cardiovascular disease and often aren’t screened at recommended intervals because of decreased health care use compared to their cisgender counterparts,” she said. “This may lead to untreated diseases that make them even more likely to suffer poor health outcomes.”
The current study is important because there are “almost no prior data regarding the cardiovascular health status of this population prior to gender-affirming care,” Dr. Denby emphasized. “There are data that gay, lesbian, and bisexual individuals are at higher risk for poor cardiovascular outcomes, but the same data are lacking in the transgender group,” she said.
“As transgender individuals have frequent physician visits while on hormonal therapy, this seems like the opportune time to screen for cardiovascular risk factors and treat previously undiagnosed diseases that can lead to poor health outcomes in the future,” Dr. Denby explained. “If we are able to intervene at an earlier age, perhaps we can help prevent poor health outcomes down the road,” she said.
Additional research can inform practice
Dr. Denby said she was not surprised by the findings. “This is a very high-risk population that often doesn’t follow closely in the health care system,” she said. “These data are very important in thinking holistically about transgender patients.” Clinicians can “use the opportunities we have when they present for gender-affirming care to optimize their overall health status, promote long-term health, and reduce the risks associated with hormonal therapy and gender-affirming surgeries,” she noted. “We hope to use this information to change our practice at the Cleveland Clinic and nationally as well. Transgender patients should be screened and aggressively treated for cardiovascular disease and risk factors,” she said.
Key barriers to overcome include determining the best way to reach out to transgender individuals and then making them feel comfortable in the clinical setting, Dr. Denby said. “This means that we must set up clinics that are approachable and safe for all comers. The lack of laws in many states that protect this vulnerable population also contributes to lack of access to care,” she added.
“We hope to continue research in this arena about how to effectively screen and treat transgender patients as they present to care, not only in the transgender clinic, but also to primary care providers (ob.gyn., internal medicine, family medicine, pediatrics) who also care for this population” since no specific guidelines currently exist to direct the screening for cardiovascular patients in particular, she said.
Findings offer foundation for LGBTQ cardiovascular studies
“This [study] provides us with a good rationale for why we should be considering cardiovascular health in transgender adults,” Billy A. Caceres, PhD, RN, of Columbia University School of Nursing, New York, said in an interview. “It is largely descriptive, but I think that that’s a good step in terms of at least understanding the magnitude of this problem. In addition, I think that what this abstract might do is help lead to future research that examines potentially the associations between not only gender-affirming hormone therapies but other potential social determinants like discrimination or poverty on the cardiovascular health of transgender people,” he noted.
Dr. Caceres served as chair of the writing group for the recent American Heart Association Scientific Statement: LGBTQ Heart Health published in Circulation. He had no financial conflicts to disclose.
The study received no outside funding. Dr. Denby had no financial conflicts to disclose.
SOURCE: Denby KJ et al. AHA 2020, Presentation P2274.
Cardiovascular disease risk is elevated among transgender individuals seeking gender-affirming hormone therapy, according to a retrospective study in 427 patients.
The transgender population often experiences socioeconomic and health disparities, including reduced access to care, Kara J. Denby, MD, said in an interview.
Previous research suggests that the use of gender-affirming hormone therapy (GAHT) may place transgender persons at increased cardiovascular risk, she said.
To identify the potential risk for transgender individuals, the researchers identified baseline cardiovascular risk in patients who had not yet undergone GAHT. Study participants were enrolled in a multidisciplinary transgender program, and the researchers collected data on demographics, medical history, vitals, medications, and laboratory results. The average age of the participants was 26 years, 172 identified as men, 236 as women, and 20 as nonbinary.
Overall, 55% of the participants had a chronic medical condition at baseline. Of these, 74 patients had hypertension, 41 had hyperlipidemia, 2 had a history of stroke, 7 had coronary artery disease, and 4 had chronic obstructive pulmonary disease.
For all patients who did not have documented atherosclerotic cardiovascular disease, their American College of Cardiology/American Heart Association ASCVD and QRISK3 risk scores were calculated. “The incidence of undiagnosed hypertension and hyperlipidemia was 6.8% and 11.3% respectively, and of these cases, only 64% and 24% were on appropriate therapies,” noted Dr. Denby of the Cleveland (Ohio) Clinic.
She reported the results Nov. 13 in a presentation at the at the virtual American Heart Association scientific sessions.
The findings were limited by the observational nature of the study.
However, the results suggest that transgender patients “appear to be at higher risk than their age-matched historical cohorts regardless of gender,” said Dr. Denby. More research is needed, but cardiovascular disease–prevention efforts may be inadequate in the transgender population given the elevated risk observed in this study, she concluded.
Growing transgender population is medically underserved
The transgender population is growing in the United States and internationally, said Dr. Denby. “This group has a history of being marginalized as a result of their transgender status with socioeconomic and health repercussions,” she said. “It is well known that transgender patients are less likely to have access to health care or utilize health care for a variety of reasons, including stigma and fear of mistreatment. This often leads transgender individuals to present to care late in disease processes which makes their disease harder to treat and often leads to emergent medical conditions,” she added.
“Transgender men and women are at high risk for cardiovascular disease and often aren’t screened at recommended intervals because of decreased health care use compared to their cisgender counterparts,” she said. “This may lead to untreated diseases that make them even more likely to suffer poor health outcomes.”
The current study is important because there are “almost no prior data regarding the cardiovascular health status of this population prior to gender-affirming care,” Dr. Denby emphasized. “There are data that gay, lesbian, and bisexual individuals are at higher risk for poor cardiovascular outcomes, but the same data are lacking in the transgender group,” she said.
“As transgender individuals have frequent physician visits while on hormonal therapy, this seems like the opportune time to screen for cardiovascular risk factors and treat previously undiagnosed diseases that can lead to poor health outcomes in the future,” Dr. Denby explained. “If we are able to intervene at an earlier age, perhaps we can help prevent poor health outcomes down the road,” she said.
Additional research can inform practice
Dr. Denby said she was not surprised by the findings. “This is a very high-risk population that often doesn’t follow closely in the health care system,” she said. “These data are very important in thinking holistically about transgender patients.” Clinicians can “use the opportunities we have when they present for gender-affirming care to optimize their overall health status, promote long-term health, and reduce the risks associated with hormonal therapy and gender-affirming surgeries,” she noted. “We hope to use this information to change our practice at the Cleveland Clinic and nationally as well. Transgender patients should be screened and aggressively treated for cardiovascular disease and risk factors,” she said.
Key barriers to overcome include determining the best way to reach out to transgender individuals and then making them feel comfortable in the clinical setting, Dr. Denby said. “This means that we must set up clinics that are approachable and safe for all comers. The lack of laws in many states that protect this vulnerable population also contributes to lack of access to care,” she added.
“We hope to continue research in this arena about how to effectively screen and treat transgender patients as they present to care, not only in the transgender clinic, but also to primary care providers (ob.gyn., internal medicine, family medicine, pediatrics) who also care for this population” since no specific guidelines currently exist to direct the screening for cardiovascular patients in particular, she said.
Findings offer foundation for LGBTQ cardiovascular studies
“This [study] provides us with a good rationale for why we should be considering cardiovascular health in transgender adults,” Billy A. Caceres, PhD, RN, of Columbia University School of Nursing, New York, said in an interview. “It is largely descriptive, but I think that that’s a good step in terms of at least understanding the magnitude of this problem. In addition, I think that what this abstract might do is help lead to future research that examines potentially the associations between not only gender-affirming hormone therapies but other potential social determinants like discrimination or poverty on the cardiovascular health of transgender people,” he noted.
Dr. Caceres served as chair of the writing group for the recent American Heart Association Scientific Statement: LGBTQ Heart Health published in Circulation. He had no financial conflicts to disclose.
The study received no outside funding. Dr. Denby had no financial conflicts to disclose.
SOURCE: Denby KJ et al. AHA 2020, Presentation P2274.
Cardiovascular disease risk is elevated among transgender individuals seeking gender-affirming hormone therapy, according to a retrospective study in 427 patients.
The transgender population often experiences socioeconomic and health disparities, including reduced access to care, Kara J. Denby, MD, said in an interview.
Previous research suggests that the use of gender-affirming hormone therapy (GAHT) may place transgender persons at increased cardiovascular risk, she said.
To identify the potential risk for transgender individuals, the researchers identified baseline cardiovascular risk in patients who had not yet undergone GAHT. Study participants were enrolled in a multidisciplinary transgender program, and the researchers collected data on demographics, medical history, vitals, medications, and laboratory results. The average age of the participants was 26 years, 172 identified as men, 236 as women, and 20 as nonbinary.
Overall, 55% of the participants had a chronic medical condition at baseline. Of these, 74 patients had hypertension, 41 had hyperlipidemia, 2 had a history of stroke, 7 had coronary artery disease, and 4 had chronic obstructive pulmonary disease.
For all patients who did not have documented atherosclerotic cardiovascular disease, their American College of Cardiology/American Heart Association ASCVD and QRISK3 risk scores were calculated. “The incidence of undiagnosed hypertension and hyperlipidemia was 6.8% and 11.3% respectively, and of these cases, only 64% and 24% were on appropriate therapies,” noted Dr. Denby of the Cleveland (Ohio) Clinic.
She reported the results Nov. 13 in a presentation at the at the virtual American Heart Association scientific sessions.
The findings were limited by the observational nature of the study.
However, the results suggest that transgender patients “appear to be at higher risk than their age-matched historical cohorts regardless of gender,” said Dr. Denby. More research is needed, but cardiovascular disease–prevention efforts may be inadequate in the transgender population given the elevated risk observed in this study, she concluded.
Growing transgender population is medically underserved
The transgender population is growing in the United States and internationally, said Dr. Denby. “This group has a history of being marginalized as a result of their transgender status with socioeconomic and health repercussions,” she said. “It is well known that transgender patients are less likely to have access to health care or utilize health care for a variety of reasons, including stigma and fear of mistreatment. This often leads transgender individuals to present to care late in disease processes which makes their disease harder to treat and often leads to emergent medical conditions,” she added.
“Transgender men and women are at high risk for cardiovascular disease and often aren’t screened at recommended intervals because of decreased health care use compared to their cisgender counterparts,” she said. “This may lead to untreated diseases that make them even more likely to suffer poor health outcomes.”
The current study is important because there are “almost no prior data regarding the cardiovascular health status of this population prior to gender-affirming care,” Dr. Denby emphasized. “There are data that gay, lesbian, and bisexual individuals are at higher risk for poor cardiovascular outcomes, but the same data are lacking in the transgender group,” she said.
“As transgender individuals have frequent physician visits while on hormonal therapy, this seems like the opportune time to screen for cardiovascular risk factors and treat previously undiagnosed diseases that can lead to poor health outcomes in the future,” Dr. Denby explained. “If we are able to intervene at an earlier age, perhaps we can help prevent poor health outcomes down the road,” she said.
Additional research can inform practice
Dr. Denby said she was not surprised by the findings. “This is a very high-risk population that often doesn’t follow closely in the health care system,” she said. “These data are very important in thinking holistically about transgender patients.” Clinicians can “use the opportunities we have when they present for gender-affirming care to optimize their overall health status, promote long-term health, and reduce the risks associated with hormonal therapy and gender-affirming surgeries,” she noted. “We hope to use this information to change our practice at the Cleveland Clinic and nationally as well. Transgender patients should be screened and aggressively treated for cardiovascular disease and risk factors,” she said.
Key barriers to overcome include determining the best way to reach out to transgender individuals and then making them feel comfortable in the clinical setting, Dr. Denby said. “This means that we must set up clinics that are approachable and safe for all comers. The lack of laws in many states that protect this vulnerable population also contributes to lack of access to care,” she added.
“We hope to continue research in this arena about how to effectively screen and treat transgender patients as they present to care, not only in the transgender clinic, but also to primary care providers (ob.gyn., internal medicine, family medicine, pediatrics) who also care for this population” since no specific guidelines currently exist to direct the screening for cardiovascular patients in particular, she said.
Findings offer foundation for LGBTQ cardiovascular studies
“This [study] provides us with a good rationale for why we should be considering cardiovascular health in transgender adults,” Billy A. Caceres, PhD, RN, of Columbia University School of Nursing, New York, said in an interview. “It is largely descriptive, but I think that that’s a good step in terms of at least understanding the magnitude of this problem. In addition, I think that what this abstract might do is help lead to future research that examines potentially the associations between not only gender-affirming hormone therapies but other potential social determinants like discrimination or poverty on the cardiovascular health of transgender people,” he noted.
Dr. Caceres served as chair of the writing group for the recent American Heart Association Scientific Statement: LGBTQ Heart Health published in Circulation. He had no financial conflicts to disclose.
The study received no outside funding. Dr. Denby had no financial conflicts to disclose.
SOURCE: Denby KJ et al. AHA 2020, Presentation P2274.
FROM AHA 2020
Don’t miss postpartum thyroiditis
All patients with postpartum depression should be screened for thyroid dysfunction, as postpartum thyroiditis is often missed and misdiagnosed, according to Christine Kessler, CNS, ANP.
Postpartum thyroiditis (PPT) is “an inflammatory, autoimmune thyroid condition,” Ms. Kessler said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education. This dysfunction can involve high or low thyroid-stimulating hormone and may occur during the first postpartum year in women who were euthyroid prior to pregnancy. Women with PPT will be thyroid peroxidase (TPO) antibody positive. Postpartum thyroiditis also can occur after a miscarriage.
PPT can occur when the immune system rebounds after pregnancy following immune suppression during pregnancy. “Autoimmune destruction of the thyroid gland leads to initial release of stored thyroid hormone,” Ms. Kessler said. Notably, “patients with a predisposition for Hashimoto’s will have an attack on the thyroid gland. Don’t miss this in your patients.”
PPT is the most common endocrine disease in premenopausal women, with an incidence of 8%-14% in the United States, noted Ms. Kessler, a nurse practitioner in private practice in Virginia. However, the symptoms are often attributed to anxiety, depression, or the stress of new motherhood.
Women with PPT have positive thyroid peroxidase antibodies, said Ms. Kessler, and the higher the antibody, the higher the risk for PPT. Other risk factors include the presence of autoimmune disorders prior to pregnancy, a patient or family history of thyroid dysfunction, and a history of PPT.
Roughly one-third of women with PPT present with hyperthyroidism alone, another third present with hypothyroidism alone, and another third have the classic presentation of PPT, which starts with a transient hyperthyroid phase that usually occurs 1-4 months post partum, followed by a hypothyroid phase and euthyroid phase that is usually achieved within the first 12-18 months post partum, she said.
Patients presenting with PPT in the hyperthyroid phase display symptoms including insomnia, anxiety, irritability, heat intolerance, fatigue, and palpitations, Ms. Kessler said. These women “are often told they have postpartum depression; they aren’t sleeping well, and they feel like they are failing as a mom.”
Patients in the hypothyroid phase may present with fatigue, depression, cold intolerance, dry skin, impaired concentration, and paresthesias, she noted.
Treatment for PPT depends on the stage patients are in when they present. For patients in the hyperthyroid phase, Ms. Kessler recommended beta-blockers for relief of symptoms including tremor and palpitations, but these should be tapered as symptoms decrease. “There is no need for antithyroid drugs for women in the hyperthyroid phase.”
For patients presenting in the hypothyroid phase, Ms. Kessler recommended levothyroxine for 6-12 months if needed, but the drug should be tapered and discontinued after PPT, as about 80% of patients will become euthyroid. However, approximately 50% of women with PPT will develop hypothyroidism in 2-10 years, so ongoing follow-up is essential for these patients.
Ms. Kessler disclosed serving as an adviser/speaker for Novo Nordisk, serving as a speaker for Salix and Acella, and serving as National Study Chair of probiotic use with antibiotics for Clarion Brand. Global Academy and this news organization are owned by the same parent company.
All patients with postpartum depression should be screened for thyroid dysfunction, as postpartum thyroiditis is often missed and misdiagnosed, according to Christine Kessler, CNS, ANP.
Postpartum thyroiditis (PPT) is “an inflammatory, autoimmune thyroid condition,” Ms. Kessler said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education. This dysfunction can involve high or low thyroid-stimulating hormone and may occur during the first postpartum year in women who were euthyroid prior to pregnancy. Women with PPT will be thyroid peroxidase (TPO) antibody positive. Postpartum thyroiditis also can occur after a miscarriage.
PPT can occur when the immune system rebounds after pregnancy following immune suppression during pregnancy. “Autoimmune destruction of the thyroid gland leads to initial release of stored thyroid hormone,” Ms. Kessler said. Notably, “patients with a predisposition for Hashimoto’s will have an attack on the thyroid gland. Don’t miss this in your patients.”
PPT is the most common endocrine disease in premenopausal women, with an incidence of 8%-14% in the United States, noted Ms. Kessler, a nurse practitioner in private practice in Virginia. However, the symptoms are often attributed to anxiety, depression, or the stress of new motherhood.
Women with PPT have positive thyroid peroxidase antibodies, said Ms. Kessler, and the higher the antibody, the higher the risk for PPT. Other risk factors include the presence of autoimmune disorders prior to pregnancy, a patient or family history of thyroid dysfunction, and a history of PPT.
Roughly one-third of women with PPT present with hyperthyroidism alone, another third present with hypothyroidism alone, and another third have the classic presentation of PPT, which starts with a transient hyperthyroid phase that usually occurs 1-4 months post partum, followed by a hypothyroid phase and euthyroid phase that is usually achieved within the first 12-18 months post partum, she said.
Patients presenting with PPT in the hyperthyroid phase display symptoms including insomnia, anxiety, irritability, heat intolerance, fatigue, and palpitations, Ms. Kessler said. These women “are often told they have postpartum depression; they aren’t sleeping well, and they feel like they are failing as a mom.”
Patients in the hypothyroid phase may present with fatigue, depression, cold intolerance, dry skin, impaired concentration, and paresthesias, she noted.
Treatment for PPT depends on the stage patients are in when they present. For patients in the hyperthyroid phase, Ms. Kessler recommended beta-blockers for relief of symptoms including tremor and palpitations, but these should be tapered as symptoms decrease. “There is no need for antithyroid drugs for women in the hyperthyroid phase.”
For patients presenting in the hypothyroid phase, Ms. Kessler recommended levothyroxine for 6-12 months if needed, but the drug should be tapered and discontinued after PPT, as about 80% of patients will become euthyroid. However, approximately 50% of women with PPT will develop hypothyroidism in 2-10 years, so ongoing follow-up is essential for these patients.
Ms. Kessler disclosed serving as an adviser/speaker for Novo Nordisk, serving as a speaker for Salix and Acella, and serving as National Study Chair of probiotic use with antibiotics for Clarion Brand. Global Academy and this news organization are owned by the same parent company.
All patients with postpartum depression should be screened for thyroid dysfunction, as postpartum thyroiditis is often missed and misdiagnosed, according to Christine Kessler, CNS, ANP.
Postpartum thyroiditis (PPT) is “an inflammatory, autoimmune thyroid condition,” Ms. Kessler said at the Metabolic & Endocrine Disease Summit by Global Academy for Medical Education. This dysfunction can involve high or low thyroid-stimulating hormone and may occur during the first postpartum year in women who were euthyroid prior to pregnancy. Women with PPT will be thyroid peroxidase (TPO) antibody positive. Postpartum thyroiditis also can occur after a miscarriage.
PPT can occur when the immune system rebounds after pregnancy following immune suppression during pregnancy. “Autoimmune destruction of the thyroid gland leads to initial release of stored thyroid hormone,” Ms. Kessler said. Notably, “patients with a predisposition for Hashimoto’s will have an attack on the thyroid gland. Don’t miss this in your patients.”
PPT is the most common endocrine disease in premenopausal women, with an incidence of 8%-14% in the United States, noted Ms. Kessler, a nurse practitioner in private practice in Virginia. However, the symptoms are often attributed to anxiety, depression, or the stress of new motherhood.
Women with PPT have positive thyroid peroxidase antibodies, said Ms. Kessler, and the higher the antibody, the higher the risk for PPT. Other risk factors include the presence of autoimmune disorders prior to pregnancy, a patient or family history of thyroid dysfunction, and a history of PPT.
Roughly one-third of women with PPT present with hyperthyroidism alone, another third present with hypothyroidism alone, and another third have the classic presentation of PPT, which starts with a transient hyperthyroid phase that usually occurs 1-4 months post partum, followed by a hypothyroid phase and euthyroid phase that is usually achieved within the first 12-18 months post partum, she said.
Patients presenting with PPT in the hyperthyroid phase display symptoms including insomnia, anxiety, irritability, heat intolerance, fatigue, and palpitations, Ms. Kessler said. These women “are often told they have postpartum depression; they aren’t sleeping well, and they feel like they are failing as a mom.”
Patients in the hypothyroid phase may present with fatigue, depression, cold intolerance, dry skin, impaired concentration, and paresthesias, she noted.
Treatment for PPT depends on the stage patients are in when they present. For patients in the hyperthyroid phase, Ms. Kessler recommended beta-blockers for relief of symptoms including tremor and palpitations, but these should be tapered as symptoms decrease. “There is no need for antithyroid drugs for women in the hyperthyroid phase.”
For patients presenting in the hypothyroid phase, Ms. Kessler recommended levothyroxine for 6-12 months if needed, but the drug should be tapered and discontinued after PPT, as about 80% of patients will become euthyroid. However, approximately 50% of women with PPT will develop hypothyroidism in 2-10 years, so ongoing follow-up is essential for these patients.
Ms. Kessler disclosed serving as an adviser/speaker for Novo Nordisk, serving as a speaker for Salix and Acella, and serving as National Study Chair of probiotic use with antibiotics for Clarion Brand. Global Academy and this news organization are owned by the same parent company.
FROM MEDS 2020
Fertility delay varied with contraceptive method in study
according to a new prospective cohort study.
Women who used hormonal intrauterine devices, copper intrauterine devices, and implants had the shortest delays, based on the same research project, which involved analyzing data from approximately 18,000 women in North America and Denmark.
“Most research on the use of contraceptives and fertility has focused on the effect of oral contraceptives on fecundability,” and data on the association between fertility and other contraceptive methods are limited, wrote Jennifer J. Yland, MS, of Boston University School of Public Health and colleagues.
“Given the increasing popularity of long acting reversible contraceptive methods and other alternatives to oral contraceptives, more research into their short- and long-term effects on fertility is needed,” the researchers noted.
In the study, which was published in the BMJ, the researchers reviewed data from a total of 17,954 women from three cohort studies of individuals planning pregnancies between 2007 and 2019. Participants reported their contraceptive use and typical menstrual cycle at baseline, then responded to questionnaires every 2 months for up to a year or until pregnancy.
On average, users of injectable contraceptives had the longest delay in return of normal fertility (five to eight menstrual cycles), compared with four cycles for patch contraceptives, three cycles for oral and ring contraceptives, and two cycles for hormonal and copper intrauterine devices and implants.
A total of 10,729 pregnancies were reported within 66,759 menstrual cycles; approximately 77% of the women conceived within 12 months, and 56% conceived within 6 months.
Oral contraceptives were the most common method of contraception (38%), followed by barrier methods (31%), natural methods (15%), and long-acting reversible contraceptives (13%). Intrauterine devices were the most frequently used of long-acting reversible contraceptives (8% hormonal, 4% copper).
The time until fertility returned after discontinuing contraceptives was not associated with duration of contraceptive use.
The study findings were limited by several factors including the potential misclassification of menstrual cycles and the use of self-reports for the time of contraceptive discontinuation, especially for users of injectable contraceptives, the researchers noted.
However, the results were strengthened by the large study size and show “little or no lasting effect” of long-term use of any of the reported contraceptive methods on fertility, the researchers noted. “Understanding the comparative effects of different contraceptives on fecundity is essential for family planning, counseling for contraception, and management of infertility,” they said.
Comparison of contraceptives can inform counseling
The study is important because the use of long-acting reversible contraceptive (LARC) methods (IUDs, implants, patches, and injectable contraceptives) has become increasingly common worldwide, corresponding author Jennifer J. Yland, MS, said in an interview. “Many women are concerned about the potential effects of contraception on future fertility. However, previous research on this topic has focused mostly on oral contraceptives,” she said.
Ms. Yland said that the findings on oral and injectable contraceptives were consistent with previous publications. However, “we were surprised to find that women who had recently used the hormonal IUD had a shorter time to pregnancy, compared with women who used barrier methods,” she said.
The take-home message for clinicians is that delays in the return to normal fertility were temporary for all hormonal contraceptive methods, Ms. Yland emphasized. “However, delays in the return of fertility after discontinuing certain hormonal methods, such as injectables, were considerably longer than that shown for oral contraceptives. These findings should be taken into account when women are considering contraceptive choice in the context of family planning and infertility management,” she noted.
“Future research should evaluate the potential associations between recent use of hormonal contraceptives and perinatal outcomes,” she added.
Managing expectations helps patients plan
“The question of return to fertility is one that many patients who use contraception have unless they have completed their child bearing,” said Sarah W. Prager, MD, of the University of Washington, Seattle, in an interview. “For patients who want to plan a pregnancy, knowing what to expect in terms of return to fertility is important so they can make sure they are in the space and place they want to be with their health, life, job, and partner,” she said.
Dr. Prager said she was not surprised by the study findings because they agree with previously published data. “Overall, except for the injection, people using any form of contraception are back to their baseline fertility within a few months,” she noted. “It also makes perfect sense for return to fertility to be longer with the injection, as it is designed to prevent pregnancy for 16 weeks after the injection is given. Unlike all the other methods, it cannot be removed from the body once given,” she said.
“Clinicians should continue to advise patients that their return to baseline fertility is relatively rapid with any contraception other than the Depo-Provera injection,” said Dr. Prager. “There are no data to support a benefit in switching from an IUD or implant to a combination hormonal method (pills, patch, ring) before starting to try to conceive,” she said.
“This study tries to account for differences in baseline fertility for people using the different methods, but since the choice of method was not randomized, there could still be baseline differences that were not measured or accounted for,” Dr. Prager noted. “A randomized study would certainly eliminate some of these biases; however, I don’t think the differences found in this study are so profound as to require such study,” she said. “Generally speaking, almost 80% of people using any form of contraception were able to conceive within 1 year of trying, which has been the stated fertility data for decades,” she said.
The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Lead author Ms. Yland had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose.
SOURCE: Yland JJ et al. BMJ. 2020 Nov 12. doi: 10.1136/bmj.m3966.
according to a new prospective cohort study.
Women who used hormonal intrauterine devices, copper intrauterine devices, and implants had the shortest delays, based on the same research project, which involved analyzing data from approximately 18,000 women in North America and Denmark.
“Most research on the use of contraceptives and fertility has focused on the effect of oral contraceptives on fecundability,” and data on the association between fertility and other contraceptive methods are limited, wrote Jennifer J. Yland, MS, of Boston University School of Public Health and colleagues.
“Given the increasing popularity of long acting reversible contraceptive methods and other alternatives to oral contraceptives, more research into their short- and long-term effects on fertility is needed,” the researchers noted.
In the study, which was published in the BMJ, the researchers reviewed data from a total of 17,954 women from three cohort studies of individuals planning pregnancies between 2007 and 2019. Participants reported their contraceptive use and typical menstrual cycle at baseline, then responded to questionnaires every 2 months for up to a year or until pregnancy.
On average, users of injectable contraceptives had the longest delay in return of normal fertility (five to eight menstrual cycles), compared with four cycles for patch contraceptives, three cycles for oral and ring contraceptives, and two cycles for hormonal and copper intrauterine devices and implants.
A total of 10,729 pregnancies were reported within 66,759 menstrual cycles; approximately 77% of the women conceived within 12 months, and 56% conceived within 6 months.
Oral contraceptives were the most common method of contraception (38%), followed by barrier methods (31%), natural methods (15%), and long-acting reversible contraceptives (13%). Intrauterine devices were the most frequently used of long-acting reversible contraceptives (8% hormonal, 4% copper).
The time until fertility returned after discontinuing contraceptives was not associated with duration of contraceptive use.
The study findings were limited by several factors including the potential misclassification of menstrual cycles and the use of self-reports for the time of contraceptive discontinuation, especially for users of injectable contraceptives, the researchers noted.
However, the results were strengthened by the large study size and show “little or no lasting effect” of long-term use of any of the reported contraceptive methods on fertility, the researchers noted. “Understanding the comparative effects of different contraceptives on fecundity is essential for family planning, counseling for contraception, and management of infertility,” they said.
Comparison of contraceptives can inform counseling
The study is important because the use of long-acting reversible contraceptive (LARC) methods (IUDs, implants, patches, and injectable contraceptives) has become increasingly common worldwide, corresponding author Jennifer J. Yland, MS, said in an interview. “Many women are concerned about the potential effects of contraception on future fertility. However, previous research on this topic has focused mostly on oral contraceptives,” she said.
Ms. Yland said that the findings on oral and injectable contraceptives were consistent with previous publications. However, “we were surprised to find that women who had recently used the hormonal IUD had a shorter time to pregnancy, compared with women who used barrier methods,” she said.
The take-home message for clinicians is that delays in the return to normal fertility were temporary for all hormonal contraceptive methods, Ms. Yland emphasized. “However, delays in the return of fertility after discontinuing certain hormonal methods, such as injectables, were considerably longer than that shown for oral contraceptives. These findings should be taken into account when women are considering contraceptive choice in the context of family planning and infertility management,” she noted.
“Future research should evaluate the potential associations between recent use of hormonal contraceptives and perinatal outcomes,” she added.
Managing expectations helps patients plan
“The question of return to fertility is one that many patients who use contraception have unless they have completed their child bearing,” said Sarah W. Prager, MD, of the University of Washington, Seattle, in an interview. “For patients who want to plan a pregnancy, knowing what to expect in terms of return to fertility is important so they can make sure they are in the space and place they want to be with their health, life, job, and partner,” she said.
Dr. Prager said she was not surprised by the study findings because they agree with previously published data. “Overall, except for the injection, people using any form of contraception are back to their baseline fertility within a few months,” she noted. “It also makes perfect sense for return to fertility to be longer with the injection, as it is designed to prevent pregnancy for 16 weeks after the injection is given. Unlike all the other methods, it cannot be removed from the body once given,” she said.
“Clinicians should continue to advise patients that their return to baseline fertility is relatively rapid with any contraception other than the Depo-Provera injection,” said Dr. Prager. “There are no data to support a benefit in switching from an IUD or implant to a combination hormonal method (pills, patch, ring) before starting to try to conceive,” she said.
“This study tries to account for differences in baseline fertility for people using the different methods, but since the choice of method was not randomized, there could still be baseline differences that were not measured or accounted for,” Dr. Prager noted. “A randomized study would certainly eliminate some of these biases; however, I don’t think the differences found in this study are so profound as to require such study,” she said. “Generally speaking, almost 80% of people using any form of contraception were able to conceive within 1 year of trying, which has been the stated fertility data for decades,” she said.
The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Lead author Ms. Yland had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose.
SOURCE: Yland JJ et al. BMJ. 2020 Nov 12. doi: 10.1136/bmj.m3966.
according to a new prospective cohort study.
Women who used hormonal intrauterine devices, copper intrauterine devices, and implants had the shortest delays, based on the same research project, which involved analyzing data from approximately 18,000 women in North America and Denmark.
“Most research on the use of contraceptives and fertility has focused on the effect of oral contraceptives on fecundability,” and data on the association between fertility and other contraceptive methods are limited, wrote Jennifer J. Yland, MS, of Boston University School of Public Health and colleagues.
“Given the increasing popularity of long acting reversible contraceptive methods and other alternatives to oral contraceptives, more research into their short- and long-term effects on fertility is needed,” the researchers noted.
In the study, which was published in the BMJ, the researchers reviewed data from a total of 17,954 women from three cohort studies of individuals planning pregnancies between 2007 and 2019. Participants reported their contraceptive use and typical menstrual cycle at baseline, then responded to questionnaires every 2 months for up to a year or until pregnancy.
On average, users of injectable contraceptives had the longest delay in return of normal fertility (five to eight menstrual cycles), compared with four cycles for patch contraceptives, three cycles for oral and ring contraceptives, and two cycles for hormonal and copper intrauterine devices and implants.
A total of 10,729 pregnancies were reported within 66,759 menstrual cycles; approximately 77% of the women conceived within 12 months, and 56% conceived within 6 months.
Oral contraceptives were the most common method of contraception (38%), followed by barrier methods (31%), natural methods (15%), and long-acting reversible contraceptives (13%). Intrauterine devices were the most frequently used of long-acting reversible contraceptives (8% hormonal, 4% copper).
The time until fertility returned after discontinuing contraceptives was not associated with duration of contraceptive use.
The study findings were limited by several factors including the potential misclassification of menstrual cycles and the use of self-reports for the time of contraceptive discontinuation, especially for users of injectable contraceptives, the researchers noted.
However, the results were strengthened by the large study size and show “little or no lasting effect” of long-term use of any of the reported contraceptive methods on fertility, the researchers noted. “Understanding the comparative effects of different contraceptives on fecundity is essential for family planning, counseling for contraception, and management of infertility,” they said.
Comparison of contraceptives can inform counseling
The study is important because the use of long-acting reversible contraceptive (LARC) methods (IUDs, implants, patches, and injectable contraceptives) has become increasingly common worldwide, corresponding author Jennifer J. Yland, MS, said in an interview. “Many women are concerned about the potential effects of contraception on future fertility. However, previous research on this topic has focused mostly on oral contraceptives,” she said.
Ms. Yland said that the findings on oral and injectable contraceptives were consistent with previous publications. However, “we were surprised to find that women who had recently used the hormonal IUD had a shorter time to pregnancy, compared with women who used barrier methods,” she said.
The take-home message for clinicians is that delays in the return to normal fertility were temporary for all hormonal contraceptive methods, Ms. Yland emphasized. “However, delays in the return of fertility after discontinuing certain hormonal methods, such as injectables, were considerably longer than that shown for oral contraceptives. These findings should be taken into account when women are considering contraceptive choice in the context of family planning and infertility management,” she noted.
“Future research should evaluate the potential associations between recent use of hormonal contraceptives and perinatal outcomes,” she added.
Managing expectations helps patients plan
“The question of return to fertility is one that many patients who use contraception have unless they have completed their child bearing,” said Sarah W. Prager, MD, of the University of Washington, Seattle, in an interview. “For patients who want to plan a pregnancy, knowing what to expect in terms of return to fertility is important so they can make sure they are in the space and place they want to be with their health, life, job, and partner,” she said.
Dr. Prager said she was not surprised by the study findings because they agree with previously published data. “Overall, except for the injection, people using any form of contraception are back to their baseline fertility within a few months,” she noted. “It also makes perfect sense for return to fertility to be longer with the injection, as it is designed to prevent pregnancy for 16 weeks after the injection is given. Unlike all the other methods, it cannot be removed from the body once given,” she said.
“Clinicians should continue to advise patients that their return to baseline fertility is relatively rapid with any contraception other than the Depo-Provera injection,” said Dr. Prager. “There are no data to support a benefit in switching from an IUD or implant to a combination hormonal method (pills, patch, ring) before starting to try to conceive,” she said.
“This study tries to account for differences in baseline fertility for people using the different methods, but since the choice of method was not randomized, there could still be baseline differences that were not measured or accounted for,” Dr. Prager noted. “A randomized study would certainly eliminate some of these biases; however, I don’t think the differences found in this study are so profound as to require such study,” she said. “Generally speaking, almost 80% of people using any form of contraception were able to conceive within 1 year of trying, which has been the stated fertility data for decades,” she said.
The study was supported by the Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health. Lead author Ms. Yland had no financial conflicts to disclose. Dr. Prager had no financial conflicts to disclose.
SOURCE: Yland JJ et al. BMJ. 2020 Nov 12. doi: 10.1136/bmj.m3966.
FROM THE BMJ
Lipid profiles distinguish obese and nonobese NAFLD patients
Both obese and nonobese individuals can develop nonalcoholic fatty liver disease (NAFLD), and lipid profiles were effective predictors in both groups, based on data from a cross-sectional study of 361 individuals.
Given the strong association between obesity and NAFLD, previous research on lipidomic profiles have focused on obese White patients, wrote Youngae Jung, MD, of the Korea Basic Science Institute, Seoul, and colleagues.
“However, there are insufficient data on circulating lipidomics of nonobese NAFLD patients,” they added.
In a study published in Alimentary Pharmacology and Therapeutics, the researchers identified 295 adults with NAFLD and 66 controls. Overall, 130 participants were nonobese (body mass index <25 kg/m2) and 231 were obese (BMI, 25 or higher). The nonobese group included 51 patients with NAFL, 31 with nonalcoholic steatohepatitis , and 48 controls; the obese group included 106 patients with NAFL, 107 with NASH, and 18 controls.
Lipid profiles show predictive promise
Overall, changes in diacylglycerol (DAG) and triacylglycerol (TAG) appeared in both obese and nonobese patients with increases from NAFL to NASH, the researchers noted.
“Levels of DAGs with relatively short chains and a low degree of desaturation significantly increased in NAFL versus no NAFLD, regardless of obesity,” the researchers said. “In contrast, levels of DAGs with relatively long chains and a high degree of desaturation significantly decreased in NASH versus NAFL in the obese group, which was not observed in the nonobese group,” they noted.
In addition, saturated sphingomyelin (SM) species were significantly associated with visceral adiposity in nonobese NAFLD patients, but not in obese NAFLD patients, and SM levels were significantly associated with both systemic and adipose tissue insulin resistance.
The researchers identified five potential lipid metabolites for nonobese subjects and seven potential lipids for obese subjects that included DAGs, TAGs, and SMs that were distinct between NAFL and NASH patients in order to predict the histologic severity of NAFLD. Overall, these metabolite combinations were effective predictors of NAFLD/NASH in nonobese and obese patients. The areas under the receiver operator characteristic curve were 0.916 versus 0.813 for NAFLD versus non-NAFLD in nonobese patients, and 0.967 versus 0.812 for NAFLD versus non-NAFLD in the obese patients.
More BMI groups may yield more information
The key study limitation was the cross-sectional study design, the researchers noted. In addition, dividing patients into only two groups based on BMI may not reveal any distinct biology among lean NAFLD patients, who were included with overweight patients in the nonobese group.
However, the results were strengthened by the large amount of data and the confirmed diagnoses of NASH and fibrosis by an expert liver pathologist, they added.
“Therefore, our findings provide new insights that aid in the understanding of pathophysiological mechanisms responsible for the development and severity of nonobese NAFLD, which are relevant to precision medicine and personalized therapy based on various phenotypes of NAFLD,” they concluded.
Validation needed in other populations
“Liver biopsy remains the gold standard for diagnosing NAFLD/NASH but has its own limitations and risks, so many researchers in this field are looking for a noninvasive alternative to help with diagnosis,” Zachary Henry, MD, of the University of Virginia, Charlottesville, said in an interview. “Imaging methods such as transient elastography and MR-elastography have been introduced and many biochemical markers have been evaluated, yet all have their limitations. In the current study, the authors report a high diagnostic accuracy for evaluating NAFLD using lipidomic profiles, which could introduce a new noninvasive measurement of NAFLD.”
Dr. Henry said that he was not surprised by the study findings. However, “I believe they are important as they define a lipid profile that shows differences between patients with NASH versus patients with NAFLD versus patients without NAFLD,” he said. “NAFLD is a disease of disordered lipid metabolism in hepatocytes, and although it stands to reason there would be differences in lipid profiles, it is interesting to see the changes between DAGs and TAGs especially as disease progresses from NAFLD to NASH.
“Clinically, I do not think this really changes practice right now since it needs to be validated in other populations of NAFLD. However, it certainly adds to a growing armamentarium of noninvasive testing. Hopefully, we are able to combine some of these noninvasive tests in the future to better predict NAFLD and NASH as well as outcomes such as cirrhosis and hepatocellular carcinoma,” he said.
“I think these lipidomic profiles need to be validated in non-Korean populations of patients with NAFLD to determine if these changes are ubiquitous to everyone or if a different profile exists based upon different genetics and environment,” Dr. Henry added. “As the authors note in their paper, there have been previously published differences between populations of NAFLD in Asia as compared to Western countries and it is unclear how, if at all, these lipidomic profiles relate to those differences.”
The study was funded by the Korea Basic Science Institute, the Korea Health Industry Department Institute, and the National Research Foundation of Korea. The researchers had no financial conflicts to disclose. Dr. Henry had no financial conflicts to disclose.
SOURCE: Jung Y et al. Aliment Pharmacol Ther. 2020 Sep 6. doi: 10.1111/apt.16066.
Both obese and nonobese individuals can develop nonalcoholic fatty liver disease (NAFLD), and lipid profiles were effective predictors in both groups, based on data from a cross-sectional study of 361 individuals.
Given the strong association between obesity and NAFLD, previous research on lipidomic profiles have focused on obese White patients, wrote Youngae Jung, MD, of the Korea Basic Science Institute, Seoul, and colleagues.
“However, there are insufficient data on circulating lipidomics of nonobese NAFLD patients,” they added.
In a study published in Alimentary Pharmacology and Therapeutics, the researchers identified 295 adults with NAFLD and 66 controls. Overall, 130 participants were nonobese (body mass index <25 kg/m2) and 231 were obese (BMI, 25 or higher). The nonobese group included 51 patients with NAFL, 31 with nonalcoholic steatohepatitis , and 48 controls; the obese group included 106 patients with NAFL, 107 with NASH, and 18 controls.
Lipid profiles show predictive promise
Overall, changes in diacylglycerol (DAG) and triacylglycerol (TAG) appeared in both obese and nonobese patients with increases from NAFL to NASH, the researchers noted.
“Levels of DAGs with relatively short chains and a low degree of desaturation significantly increased in NAFL versus no NAFLD, regardless of obesity,” the researchers said. “In contrast, levels of DAGs with relatively long chains and a high degree of desaturation significantly decreased in NASH versus NAFL in the obese group, which was not observed in the nonobese group,” they noted.
In addition, saturated sphingomyelin (SM) species were significantly associated with visceral adiposity in nonobese NAFLD patients, but not in obese NAFLD patients, and SM levels were significantly associated with both systemic and adipose tissue insulin resistance.
The researchers identified five potential lipid metabolites for nonobese subjects and seven potential lipids for obese subjects that included DAGs, TAGs, and SMs that were distinct between NAFL and NASH patients in order to predict the histologic severity of NAFLD. Overall, these metabolite combinations were effective predictors of NAFLD/NASH in nonobese and obese patients. The areas under the receiver operator characteristic curve were 0.916 versus 0.813 for NAFLD versus non-NAFLD in nonobese patients, and 0.967 versus 0.812 for NAFLD versus non-NAFLD in the obese patients.
More BMI groups may yield more information
The key study limitation was the cross-sectional study design, the researchers noted. In addition, dividing patients into only two groups based on BMI may not reveal any distinct biology among lean NAFLD patients, who were included with overweight patients in the nonobese group.
However, the results were strengthened by the large amount of data and the confirmed diagnoses of NASH and fibrosis by an expert liver pathologist, they added.
“Therefore, our findings provide new insights that aid in the understanding of pathophysiological mechanisms responsible for the development and severity of nonobese NAFLD, which are relevant to precision medicine and personalized therapy based on various phenotypes of NAFLD,” they concluded.
Validation needed in other populations
“Liver biopsy remains the gold standard for diagnosing NAFLD/NASH but has its own limitations and risks, so many researchers in this field are looking for a noninvasive alternative to help with diagnosis,” Zachary Henry, MD, of the University of Virginia, Charlottesville, said in an interview. “Imaging methods such as transient elastography and MR-elastography have been introduced and many biochemical markers have been evaluated, yet all have their limitations. In the current study, the authors report a high diagnostic accuracy for evaluating NAFLD using lipidomic profiles, which could introduce a new noninvasive measurement of NAFLD.”
Dr. Henry said that he was not surprised by the study findings. However, “I believe they are important as they define a lipid profile that shows differences between patients with NASH versus patients with NAFLD versus patients without NAFLD,” he said. “NAFLD is a disease of disordered lipid metabolism in hepatocytes, and although it stands to reason there would be differences in lipid profiles, it is interesting to see the changes between DAGs and TAGs especially as disease progresses from NAFLD to NASH.
“Clinically, I do not think this really changes practice right now since it needs to be validated in other populations of NAFLD. However, it certainly adds to a growing armamentarium of noninvasive testing. Hopefully, we are able to combine some of these noninvasive tests in the future to better predict NAFLD and NASH as well as outcomes such as cirrhosis and hepatocellular carcinoma,” he said.
“I think these lipidomic profiles need to be validated in non-Korean populations of patients with NAFLD to determine if these changes are ubiquitous to everyone or if a different profile exists based upon different genetics and environment,” Dr. Henry added. “As the authors note in their paper, there have been previously published differences between populations of NAFLD in Asia as compared to Western countries and it is unclear how, if at all, these lipidomic profiles relate to those differences.”
The study was funded by the Korea Basic Science Institute, the Korea Health Industry Department Institute, and the National Research Foundation of Korea. The researchers had no financial conflicts to disclose. Dr. Henry had no financial conflicts to disclose.
SOURCE: Jung Y et al. Aliment Pharmacol Ther. 2020 Sep 6. doi: 10.1111/apt.16066.
Both obese and nonobese individuals can develop nonalcoholic fatty liver disease (NAFLD), and lipid profiles were effective predictors in both groups, based on data from a cross-sectional study of 361 individuals.
Given the strong association between obesity and NAFLD, previous research on lipidomic profiles have focused on obese White patients, wrote Youngae Jung, MD, of the Korea Basic Science Institute, Seoul, and colleagues.
“However, there are insufficient data on circulating lipidomics of nonobese NAFLD patients,” they added.
In a study published in Alimentary Pharmacology and Therapeutics, the researchers identified 295 adults with NAFLD and 66 controls. Overall, 130 participants were nonobese (body mass index <25 kg/m2) and 231 were obese (BMI, 25 or higher). The nonobese group included 51 patients with NAFL, 31 with nonalcoholic steatohepatitis , and 48 controls; the obese group included 106 patients with NAFL, 107 with NASH, and 18 controls.
Lipid profiles show predictive promise
Overall, changes in diacylglycerol (DAG) and triacylglycerol (TAG) appeared in both obese and nonobese patients with increases from NAFL to NASH, the researchers noted.
“Levels of DAGs with relatively short chains and a low degree of desaturation significantly increased in NAFL versus no NAFLD, regardless of obesity,” the researchers said. “In contrast, levels of DAGs with relatively long chains and a high degree of desaturation significantly decreased in NASH versus NAFL in the obese group, which was not observed in the nonobese group,” they noted.
In addition, saturated sphingomyelin (SM) species were significantly associated with visceral adiposity in nonobese NAFLD patients, but not in obese NAFLD patients, and SM levels were significantly associated with both systemic and adipose tissue insulin resistance.
The researchers identified five potential lipid metabolites for nonobese subjects and seven potential lipids for obese subjects that included DAGs, TAGs, and SMs that were distinct between NAFL and NASH patients in order to predict the histologic severity of NAFLD. Overall, these metabolite combinations were effective predictors of NAFLD/NASH in nonobese and obese patients. The areas under the receiver operator characteristic curve were 0.916 versus 0.813 for NAFLD versus non-NAFLD in nonobese patients, and 0.967 versus 0.812 for NAFLD versus non-NAFLD in the obese patients.
More BMI groups may yield more information
The key study limitation was the cross-sectional study design, the researchers noted. In addition, dividing patients into only two groups based on BMI may not reveal any distinct biology among lean NAFLD patients, who were included with overweight patients in the nonobese group.
However, the results were strengthened by the large amount of data and the confirmed diagnoses of NASH and fibrosis by an expert liver pathologist, they added.
“Therefore, our findings provide new insights that aid in the understanding of pathophysiological mechanisms responsible for the development and severity of nonobese NAFLD, which are relevant to precision medicine and personalized therapy based on various phenotypes of NAFLD,” they concluded.
Validation needed in other populations
“Liver biopsy remains the gold standard for diagnosing NAFLD/NASH but has its own limitations and risks, so many researchers in this field are looking for a noninvasive alternative to help with diagnosis,” Zachary Henry, MD, of the University of Virginia, Charlottesville, said in an interview. “Imaging methods such as transient elastography and MR-elastography have been introduced and many biochemical markers have been evaluated, yet all have their limitations. In the current study, the authors report a high diagnostic accuracy for evaluating NAFLD using lipidomic profiles, which could introduce a new noninvasive measurement of NAFLD.”
Dr. Henry said that he was not surprised by the study findings. However, “I believe they are important as they define a lipid profile that shows differences between patients with NASH versus patients with NAFLD versus patients without NAFLD,” he said. “NAFLD is a disease of disordered lipid metabolism in hepatocytes, and although it stands to reason there would be differences in lipid profiles, it is interesting to see the changes between DAGs and TAGs especially as disease progresses from NAFLD to NASH.
“Clinically, I do not think this really changes practice right now since it needs to be validated in other populations of NAFLD. However, it certainly adds to a growing armamentarium of noninvasive testing. Hopefully, we are able to combine some of these noninvasive tests in the future to better predict NAFLD and NASH as well as outcomes such as cirrhosis and hepatocellular carcinoma,” he said.
“I think these lipidomic profiles need to be validated in non-Korean populations of patients with NAFLD to determine if these changes are ubiquitous to everyone or if a different profile exists based upon different genetics and environment,” Dr. Henry added. “As the authors note in their paper, there have been previously published differences between populations of NAFLD in Asia as compared to Western countries and it is unclear how, if at all, these lipidomic profiles relate to those differences.”
The study was funded by the Korea Basic Science Institute, the Korea Health Industry Department Institute, and the National Research Foundation of Korea. The researchers had no financial conflicts to disclose. Dr. Henry had no financial conflicts to disclose.
SOURCE: Jung Y et al. Aliment Pharmacol Ther. 2020 Sep 6. doi: 10.1111/apt.16066.
FROM ALIMENTARY PHARMACOLOGY & THERAPEUTICS
Life expectancy gap persists for IBD patients
Life expectancy increased for adults with inflammatory bowel disease (IBD) over recent decades, but still remained lower than life expectancy for individuals without IBD, according to data from a retrospective cohort study using Canadian health databases.
“Management of IBD has improved through increased access to specialist care, biologic therapies, and a treat-to-target approach,” wrote M. Ellen Kuenzig, PhD, of the Children’s Hospital of Eastern Ontario and colleagues. However, “Most studies evaluating mortality were conducted before the biologic era, and none evaluated life expectancy or health-adjusted life expectancy,” they said.
In a study published in the Canadian Medical Association Journal, the researchers used Canadian databases to identify a study population of 32,818 people with IBD matched to 163,284 people without IBD in 1996 that increased to 83,672 people with IBD matched to 418,360 people without IBD in 2011.
Life expectancy increases, but with caveats
Overall, life expectancy for IBD patients increased from 75.5 years to 78.4 years for women and from 72.2 years to 75.5 years for men between 1996 and 2011.
However, health-adjusted life expectancy, defined as the number of years a person is expected to live in full health, decreased by 3.9 years for men with IBD between 1996 and 2008, but did not change significantly for women with IBD, although the gap in health-adjusted life expectancy increased between women with IBD and women without IBD.
Both life expectancy and health-adjusted life expectancy remained consistently lower for individuals with IBD compared to those without IBD. Differences in life expectancy for women with and without IBD ranged from 6.6 to 8.1 years and from 5.0 to 6.1 years for men with and without IBD, depending on the year.
Differences in health-adjusted life expectancy ranged from 9.5 to 13.5 years in women with and without IBD, and from 2.6 years to 6.7 years in men with and without IBD depending on the year, the researchers said.
In addition, the researchers used the pain-attributed utility of the Health Utility Index (HUI) to calculate health-adjusted life expectancy with the effect of pain on health status. The health-adjusted life expectancy using HUI for pain was stable in women with IBD, but increased over time for women without IBD. This pattern was similar for individuals with Crohn’s disease but stable for women with and without ulcerative colitis. In men, health-adjusted life expectancy using the pain-attributed utility of the HUI was stable for those with IBD, decreased in those with Crohn’s disease, and increased among those with ulcerative colitis.
The study findings were limited by several factors including potential confounding by disease phenotype and severity, as well as lack of data on medication use for individuals younger than 65 years and limited data on confounders including smoking, ethnicity, and environmental factors, the researchers said.
In addition, “mortality may increase with disease duration, which would violate the assumption that age- and sex-specific mortality rates remain constant over a person’s lifetime that is required when using lifetables,” they said.
Future research should pursue effect of pain
The results support the persistence of a gap in life expectancy between individuals with and without IBD and suggest the need for improving pain management in IBD patients, given the contribution of pain to reduced health-adjusted life expectancy, they concluded. Additional research is needed to determine the effect of comorbid conditions and medication use on the difference in life expectancy for those with and without IBD, they added.
The study was supported by the Institute for Clinical Evaluative Services (Canada). Lead author Dr. Kuenzig received a Post-Doctoral Fellowship Award from the Canadian Institutes of Health Research, Canadian Association of Gastroenterology, and Crohn’s and Colitis Canada. The researchers had no financial conflicts to disclose.
SOURCE: Kuenzig ME et al. CMAJ. 2020 Nov 9. doi: 10.1503/cmaj.190976.
Life expectancy increased for adults with inflammatory bowel disease (IBD) over recent decades, but still remained lower than life expectancy for individuals without IBD, according to data from a retrospective cohort study using Canadian health databases.
“Management of IBD has improved through increased access to specialist care, biologic therapies, and a treat-to-target approach,” wrote M. Ellen Kuenzig, PhD, of the Children’s Hospital of Eastern Ontario and colleagues. However, “Most studies evaluating mortality were conducted before the biologic era, and none evaluated life expectancy or health-adjusted life expectancy,” they said.
In a study published in the Canadian Medical Association Journal, the researchers used Canadian databases to identify a study population of 32,818 people with IBD matched to 163,284 people without IBD in 1996 that increased to 83,672 people with IBD matched to 418,360 people without IBD in 2011.
Life expectancy increases, but with caveats
Overall, life expectancy for IBD patients increased from 75.5 years to 78.4 years for women and from 72.2 years to 75.5 years for men between 1996 and 2011.
However, health-adjusted life expectancy, defined as the number of years a person is expected to live in full health, decreased by 3.9 years for men with IBD between 1996 and 2008, but did not change significantly for women with IBD, although the gap in health-adjusted life expectancy increased between women with IBD and women without IBD.
Both life expectancy and health-adjusted life expectancy remained consistently lower for individuals with IBD compared to those without IBD. Differences in life expectancy for women with and without IBD ranged from 6.6 to 8.1 years and from 5.0 to 6.1 years for men with and without IBD, depending on the year.
Differences in health-adjusted life expectancy ranged from 9.5 to 13.5 years in women with and without IBD, and from 2.6 years to 6.7 years in men with and without IBD depending on the year, the researchers said.
In addition, the researchers used the pain-attributed utility of the Health Utility Index (HUI) to calculate health-adjusted life expectancy with the effect of pain on health status. The health-adjusted life expectancy using HUI for pain was stable in women with IBD, but increased over time for women without IBD. This pattern was similar for individuals with Crohn’s disease but stable for women with and without ulcerative colitis. In men, health-adjusted life expectancy using the pain-attributed utility of the HUI was stable for those with IBD, decreased in those with Crohn’s disease, and increased among those with ulcerative colitis.
The study findings were limited by several factors including potential confounding by disease phenotype and severity, as well as lack of data on medication use for individuals younger than 65 years and limited data on confounders including smoking, ethnicity, and environmental factors, the researchers said.
In addition, “mortality may increase with disease duration, which would violate the assumption that age- and sex-specific mortality rates remain constant over a person’s lifetime that is required when using lifetables,” they said.
Future research should pursue effect of pain
The results support the persistence of a gap in life expectancy between individuals with and without IBD and suggest the need for improving pain management in IBD patients, given the contribution of pain to reduced health-adjusted life expectancy, they concluded. Additional research is needed to determine the effect of comorbid conditions and medication use on the difference in life expectancy for those with and without IBD, they added.
The study was supported by the Institute for Clinical Evaluative Services (Canada). Lead author Dr. Kuenzig received a Post-Doctoral Fellowship Award from the Canadian Institutes of Health Research, Canadian Association of Gastroenterology, and Crohn’s and Colitis Canada. The researchers had no financial conflicts to disclose.
SOURCE: Kuenzig ME et al. CMAJ. 2020 Nov 9. doi: 10.1503/cmaj.190976.
Life expectancy increased for adults with inflammatory bowel disease (IBD) over recent decades, but still remained lower than life expectancy for individuals without IBD, according to data from a retrospective cohort study using Canadian health databases.
“Management of IBD has improved through increased access to specialist care, biologic therapies, and a treat-to-target approach,” wrote M. Ellen Kuenzig, PhD, of the Children’s Hospital of Eastern Ontario and colleagues. However, “Most studies evaluating mortality were conducted before the biologic era, and none evaluated life expectancy or health-adjusted life expectancy,” they said.
In a study published in the Canadian Medical Association Journal, the researchers used Canadian databases to identify a study population of 32,818 people with IBD matched to 163,284 people without IBD in 1996 that increased to 83,672 people with IBD matched to 418,360 people without IBD in 2011.
Life expectancy increases, but with caveats
Overall, life expectancy for IBD patients increased from 75.5 years to 78.4 years for women and from 72.2 years to 75.5 years for men between 1996 and 2011.
However, health-adjusted life expectancy, defined as the number of years a person is expected to live in full health, decreased by 3.9 years for men with IBD between 1996 and 2008, but did not change significantly for women with IBD, although the gap in health-adjusted life expectancy increased between women with IBD and women without IBD.
Both life expectancy and health-adjusted life expectancy remained consistently lower for individuals with IBD compared to those without IBD. Differences in life expectancy for women with and without IBD ranged from 6.6 to 8.1 years and from 5.0 to 6.1 years for men with and without IBD, depending on the year.
Differences in health-adjusted life expectancy ranged from 9.5 to 13.5 years in women with and without IBD, and from 2.6 years to 6.7 years in men with and without IBD depending on the year, the researchers said.
In addition, the researchers used the pain-attributed utility of the Health Utility Index (HUI) to calculate health-adjusted life expectancy with the effect of pain on health status. The health-adjusted life expectancy using HUI for pain was stable in women with IBD, but increased over time for women without IBD. This pattern was similar for individuals with Crohn’s disease but stable for women with and without ulcerative colitis. In men, health-adjusted life expectancy using the pain-attributed utility of the HUI was stable for those with IBD, decreased in those with Crohn’s disease, and increased among those with ulcerative colitis.
The study findings were limited by several factors including potential confounding by disease phenotype and severity, as well as lack of data on medication use for individuals younger than 65 years and limited data on confounders including smoking, ethnicity, and environmental factors, the researchers said.
In addition, “mortality may increase with disease duration, which would violate the assumption that age- and sex-specific mortality rates remain constant over a person’s lifetime that is required when using lifetables,” they said.
Future research should pursue effect of pain
The results support the persistence of a gap in life expectancy between individuals with and without IBD and suggest the need for improving pain management in IBD patients, given the contribution of pain to reduced health-adjusted life expectancy, they concluded. Additional research is needed to determine the effect of comorbid conditions and medication use on the difference in life expectancy for those with and without IBD, they added.
The study was supported by the Institute for Clinical Evaluative Services (Canada). Lead author Dr. Kuenzig received a Post-Doctoral Fellowship Award from the Canadian Institutes of Health Research, Canadian Association of Gastroenterology, and Crohn’s and Colitis Canada. The researchers had no financial conflicts to disclose.
SOURCE: Kuenzig ME et al. CMAJ. 2020 Nov 9. doi: 10.1503/cmaj.190976.
FROM THE CANADIAN MEDICAL ASSOCIATION JOURNAL
COVID-19 in pregnancy raises risk of preterm birth and severe disease
based on data from two studies published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.
In a study of birth and infant outcomes, rates of preterm birth (less than 37 weeks’ gestational age) were higher among women with confirmed SARS-CoV-2 infections compared with the national average (12.9% vs. 10.2%) wrote Kate R. Woodworth, MD, and colleagues of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team.
The researchers collected information on pregnancy and infant outcomes from 16 jurisdictions through the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). The study included 5,252 women with laboratory-confirmed SARS-CoV-2 infection reported during March 29–Oct. 14, 2020.
Overall, 12.9% of the 3,912 live births with known gestational age were preterm. A total of 610 infants were tested for SARS-CoV-2, and 2.6% were positive. Most of these perinatal infections (85%) occurred among infants born to women with SARS-CoV-2 infection within 1 week of delivery.
Half of the infants with positive test results were preterm, possibly reflecting higher screening rates in the ICU, the researchers said. “These findings also support the growing evidence that although severe COVID-19 does occur in neonates the majority of term neonates experience asymptomatic infection or mild disease; however, information on long term outcomes among exposed infants is unknown.”
Address disparities that amplify risk
The study findings were limited by several factors including inconsistent symptom reporting, overrepresentation of Hispanic women, and incomplete information on pregnancy loss, Dr. Woodworth and associates noted. However, the results add to the knowledge about the impact of COVID-19 disease on pregnancy by providing a large, population-based cohort with completed pregnancy outcomes as well as infant testing.
“SET-NET will continue to follow pregnancies affected by SARS-CoV-2 through completion of pregnancy and infants until age 6 months to guide clinical and public health practice,” the researchers noted. “Longer-term investigation into solutions to alleviate underlying inequities in social determinants of health associated with disparities in maternal morbidity, mortality, and adverse pregnancy outcomes, and effectively addressing these inequities, could reduce the prevalence of conditions and experiences that might amplify risks from COVID-19,” they added.
Severe disease and death increased in pregnant women
In a second study published in the MMWR, Laura D. Zambrano, PhD, and colleagues, also of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team, compared data on 23,434 reportedly pregnant and 386,028 nonpregnant women of reproductive age (15-44 years) with confirmed and symptomatic SARS-CoV-2 infections reported to the CDC between Jan. 22, 2020, and Oct. 3, 2020.
After adjustment for age, race, and underlying medical conditions, pregnant women with COVID-19 disease were significantly more likely than were nonpregnant women to be admitted to intensive care (10.5 per 1,000 cases vs. 3.9 per 1,000 cases), to receive invasive ventilation (2.9 vs. 1.1), receive extracorporeal membrane oxygenation (0.7 vs. 0.3) and to die (1.5 vs. 1.2).
“Irrespective of pregnancy status, ICU admissions, receipt of invasive ventilation, and death occurred more often among women aged 35-44 years than among those aged 15-24 years,” Dr. Zambrano and associates noted. In addition, non-Hispanic Black and Black women comprised 14.1% of the study population but accounted for 36.6% of deaths overall (9 in pregnant women and 167 in nonpregnant women).
The findings in the study of characteristics were limited by several factors including the voluntary reporting of COVID-19 cases, potential reporting bias, and inadequate time to assess severe cases, the researchers noted. However, “data from previous influenza pandemics, including 2009 H1N1, have shown that pregnant women are at increased risk for severe outcomes including death and the absolute risks for severe outcomes were higher than in this study of COVID-19 during pregnancy.”
“Pregnant women should be informed of their risk for severe COVID-19–associated illness and the warning signs of severe COVID-19,” Dr. Zambrano and associates said. “Providers who care for pregnant women should be familiar with guidelines for medical management of COVID-19, including considerations for management of COVID-19 in pregnancy.”
More data needed for informed counseling
“It is important to conduct research trials involving pregnant women so that we have reliable data regarding outcomes with which to counsel women,” Angela Bianco, MD, a maternal fetal medicine specialist at Mount Sinai Hospital in New York, said in an interview.
“Often pregnant women are excluded from research trials, but the impact of the current public health crisis affects all persons regardless of pregnancy status,” she said.
Dr. Bianco said that she was not surprised by the findings of either study. “In fact, our own research produced similar results.”
“These recent publications found that age-matched pregnant versus nonpregnant women had more severe manifestations of COVID-19, and specifically that pregnant women had a higher risk of requiring ventilation and intensive care admission, as well as higher risk of death,” she said. “Previous studies examining the effect of other SARS viruses have demonstrated that pregnancy is associated with worse outcomes; these findings are likely attributable to the relative state of immunosuppression in pregnancy.” Also, “one of these trials found a greater risk of premature birth in women with COVID-19; this may largely be attributable to iatrogenic delivery due to maternal illness as opposed to spontaneous preterm birth,” Dr. Bianco explained.
“Data are emerging regarding the impact of SARS-CoV-2 on pregnancy outcomes, however information remains limited,” Dr. Bianco noted. “Clinicians need to make patients aware that SARS-CoV-2 infection during pregnancy is associated with a greater risk of severe illness requiring intensive care and/or ventilatory support and even death; however, the precise rates remain unknown. “COVID-19 during pregnancy may result in a preterm birth, but at this time the rate of fetal infection remains unknown,” she said. “Clinicians need to reinforce the importance of physical distancing, mask use, and proper hand hygiene, particularly in this vulnerable population.”
Dr. Bianco emphasized: “Longitudinal studies assessing the impact of SARS-CoV-2 infection at various gestational age periods are needed, as at this time most of the available data includes women with SARS-CoV-2 infection around the time of delivery. Long-term infant outcomes are needed, as well as studies assessing the risk of fetal infection.”
The studies were supported by the Centers for Disease Control and Prevention. The researchers had no financial conflicts to disclose. Dr. Bianco had no relevant financial disclosures.
SOURCE: Woodworth KR et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e2; Zambrano LD et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e3.
based on data from two studies published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.
In a study of birth and infant outcomes, rates of preterm birth (less than 37 weeks’ gestational age) were higher among women with confirmed SARS-CoV-2 infections compared with the national average (12.9% vs. 10.2%) wrote Kate R. Woodworth, MD, and colleagues of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team.
The researchers collected information on pregnancy and infant outcomes from 16 jurisdictions through the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). The study included 5,252 women with laboratory-confirmed SARS-CoV-2 infection reported during March 29–Oct. 14, 2020.
Overall, 12.9% of the 3,912 live births with known gestational age were preterm. A total of 610 infants were tested for SARS-CoV-2, and 2.6% were positive. Most of these perinatal infections (85%) occurred among infants born to women with SARS-CoV-2 infection within 1 week of delivery.
Half of the infants with positive test results were preterm, possibly reflecting higher screening rates in the ICU, the researchers said. “These findings also support the growing evidence that although severe COVID-19 does occur in neonates the majority of term neonates experience asymptomatic infection or mild disease; however, information on long term outcomes among exposed infants is unknown.”
Address disparities that amplify risk
The study findings were limited by several factors including inconsistent symptom reporting, overrepresentation of Hispanic women, and incomplete information on pregnancy loss, Dr. Woodworth and associates noted. However, the results add to the knowledge about the impact of COVID-19 disease on pregnancy by providing a large, population-based cohort with completed pregnancy outcomes as well as infant testing.
“SET-NET will continue to follow pregnancies affected by SARS-CoV-2 through completion of pregnancy and infants until age 6 months to guide clinical and public health practice,” the researchers noted. “Longer-term investigation into solutions to alleviate underlying inequities in social determinants of health associated with disparities in maternal morbidity, mortality, and adverse pregnancy outcomes, and effectively addressing these inequities, could reduce the prevalence of conditions and experiences that might amplify risks from COVID-19,” they added.
Severe disease and death increased in pregnant women
In a second study published in the MMWR, Laura D. Zambrano, PhD, and colleagues, also of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team, compared data on 23,434 reportedly pregnant and 386,028 nonpregnant women of reproductive age (15-44 years) with confirmed and symptomatic SARS-CoV-2 infections reported to the CDC between Jan. 22, 2020, and Oct. 3, 2020.
After adjustment for age, race, and underlying medical conditions, pregnant women with COVID-19 disease were significantly more likely than were nonpregnant women to be admitted to intensive care (10.5 per 1,000 cases vs. 3.9 per 1,000 cases), to receive invasive ventilation (2.9 vs. 1.1), receive extracorporeal membrane oxygenation (0.7 vs. 0.3) and to die (1.5 vs. 1.2).
“Irrespective of pregnancy status, ICU admissions, receipt of invasive ventilation, and death occurred more often among women aged 35-44 years than among those aged 15-24 years,” Dr. Zambrano and associates noted. In addition, non-Hispanic Black and Black women comprised 14.1% of the study population but accounted for 36.6% of deaths overall (9 in pregnant women and 167 in nonpregnant women).
The findings in the study of characteristics were limited by several factors including the voluntary reporting of COVID-19 cases, potential reporting bias, and inadequate time to assess severe cases, the researchers noted. However, “data from previous influenza pandemics, including 2009 H1N1, have shown that pregnant women are at increased risk for severe outcomes including death and the absolute risks for severe outcomes were higher than in this study of COVID-19 during pregnancy.”
“Pregnant women should be informed of their risk for severe COVID-19–associated illness and the warning signs of severe COVID-19,” Dr. Zambrano and associates said. “Providers who care for pregnant women should be familiar with guidelines for medical management of COVID-19, including considerations for management of COVID-19 in pregnancy.”
More data needed for informed counseling
“It is important to conduct research trials involving pregnant women so that we have reliable data regarding outcomes with which to counsel women,” Angela Bianco, MD, a maternal fetal medicine specialist at Mount Sinai Hospital in New York, said in an interview.
“Often pregnant women are excluded from research trials, but the impact of the current public health crisis affects all persons regardless of pregnancy status,” she said.
Dr. Bianco said that she was not surprised by the findings of either study. “In fact, our own research produced similar results.”
“These recent publications found that age-matched pregnant versus nonpregnant women had more severe manifestations of COVID-19, and specifically that pregnant women had a higher risk of requiring ventilation and intensive care admission, as well as higher risk of death,” she said. “Previous studies examining the effect of other SARS viruses have demonstrated that pregnancy is associated with worse outcomes; these findings are likely attributable to the relative state of immunosuppression in pregnancy.” Also, “one of these trials found a greater risk of premature birth in women with COVID-19; this may largely be attributable to iatrogenic delivery due to maternal illness as opposed to spontaneous preterm birth,” Dr. Bianco explained.
“Data are emerging regarding the impact of SARS-CoV-2 on pregnancy outcomes, however information remains limited,” Dr. Bianco noted. “Clinicians need to make patients aware that SARS-CoV-2 infection during pregnancy is associated with a greater risk of severe illness requiring intensive care and/or ventilatory support and even death; however, the precise rates remain unknown. “COVID-19 during pregnancy may result in a preterm birth, but at this time the rate of fetal infection remains unknown,” she said. “Clinicians need to reinforce the importance of physical distancing, mask use, and proper hand hygiene, particularly in this vulnerable population.”
Dr. Bianco emphasized: “Longitudinal studies assessing the impact of SARS-CoV-2 infection at various gestational age periods are needed, as at this time most of the available data includes women with SARS-CoV-2 infection around the time of delivery. Long-term infant outcomes are needed, as well as studies assessing the risk of fetal infection.”
The studies were supported by the Centers for Disease Control and Prevention. The researchers had no financial conflicts to disclose. Dr. Bianco had no relevant financial disclosures.
SOURCE: Woodworth KR et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e2; Zambrano LD et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e3.
based on data from two studies published in the Centers for Disease Control and Prevention’s Morbidity and Mortality Weekly Report.
In a study of birth and infant outcomes, rates of preterm birth (less than 37 weeks’ gestational age) were higher among women with confirmed SARS-CoV-2 infections compared with the national average (12.9% vs. 10.2%) wrote Kate R. Woodworth, MD, and colleagues of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team.
The researchers collected information on pregnancy and infant outcomes from 16 jurisdictions through the Surveillance for Emerging Threats to Mothers and Babies Network (SET-NET). The study included 5,252 women with laboratory-confirmed SARS-CoV-2 infection reported during March 29–Oct. 14, 2020.
Overall, 12.9% of the 3,912 live births with known gestational age were preterm. A total of 610 infants were tested for SARS-CoV-2, and 2.6% were positive. Most of these perinatal infections (85%) occurred among infants born to women with SARS-CoV-2 infection within 1 week of delivery.
Half of the infants with positive test results were preterm, possibly reflecting higher screening rates in the ICU, the researchers said. “These findings also support the growing evidence that although severe COVID-19 does occur in neonates the majority of term neonates experience asymptomatic infection or mild disease; however, information on long term outcomes among exposed infants is unknown.”
Address disparities that amplify risk
The study findings were limited by several factors including inconsistent symptom reporting, overrepresentation of Hispanic women, and incomplete information on pregnancy loss, Dr. Woodworth and associates noted. However, the results add to the knowledge about the impact of COVID-19 disease on pregnancy by providing a large, population-based cohort with completed pregnancy outcomes as well as infant testing.
“SET-NET will continue to follow pregnancies affected by SARS-CoV-2 through completion of pregnancy and infants until age 6 months to guide clinical and public health practice,” the researchers noted. “Longer-term investigation into solutions to alleviate underlying inequities in social determinants of health associated with disparities in maternal morbidity, mortality, and adverse pregnancy outcomes, and effectively addressing these inequities, could reduce the prevalence of conditions and experiences that might amplify risks from COVID-19,” they added.
Severe disease and death increased in pregnant women
In a second study published in the MMWR, Laura D. Zambrano, PhD, and colleagues, also of the CDC COVID-19 Response Pregnancy and Linked Outcomes Team, compared data on 23,434 reportedly pregnant and 386,028 nonpregnant women of reproductive age (15-44 years) with confirmed and symptomatic SARS-CoV-2 infections reported to the CDC between Jan. 22, 2020, and Oct. 3, 2020.
After adjustment for age, race, and underlying medical conditions, pregnant women with COVID-19 disease were significantly more likely than were nonpregnant women to be admitted to intensive care (10.5 per 1,000 cases vs. 3.9 per 1,000 cases), to receive invasive ventilation (2.9 vs. 1.1), receive extracorporeal membrane oxygenation (0.7 vs. 0.3) and to die (1.5 vs. 1.2).
“Irrespective of pregnancy status, ICU admissions, receipt of invasive ventilation, and death occurred more often among women aged 35-44 years than among those aged 15-24 years,” Dr. Zambrano and associates noted. In addition, non-Hispanic Black and Black women comprised 14.1% of the study population but accounted for 36.6% of deaths overall (9 in pregnant women and 167 in nonpregnant women).
The findings in the study of characteristics were limited by several factors including the voluntary reporting of COVID-19 cases, potential reporting bias, and inadequate time to assess severe cases, the researchers noted. However, “data from previous influenza pandemics, including 2009 H1N1, have shown that pregnant women are at increased risk for severe outcomes including death and the absolute risks for severe outcomes were higher than in this study of COVID-19 during pregnancy.”
“Pregnant women should be informed of their risk for severe COVID-19–associated illness and the warning signs of severe COVID-19,” Dr. Zambrano and associates said. “Providers who care for pregnant women should be familiar with guidelines for medical management of COVID-19, including considerations for management of COVID-19 in pregnancy.”
More data needed for informed counseling
“It is important to conduct research trials involving pregnant women so that we have reliable data regarding outcomes with which to counsel women,” Angela Bianco, MD, a maternal fetal medicine specialist at Mount Sinai Hospital in New York, said in an interview.
“Often pregnant women are excluded from research trials, but the impact of the current public health crisis affects all persons regardless of pregnancy status,” she said.
Dr. Bianco said that she was not surprised by the findings of either study. “In fact, our own research produced similar results.”
“These recent publications found that age-matched pregnant versus nonpregnant women had more severe manifestations of COVID-19, and specifically that pregnant women had a higher risk of requiring ventilation and intensive care admission, as well as higher risk of death,” she said. “Previous studies examining the effect of other SARS viruses have demonstrated that pregnancy is associated with worse outcomes; these findings are likely attributable to the relative state of immunosuppression in pregnancy.” Also, “one of these trials found a greater risk of premature birth in women with COVID-19; this may largely be attributable to iatrogenic delivery due to maternal illness as opposed to spontaneous preterm birth,” Dr. Bianco explained.
“Data are emerging regarding the impact of SARS-CoV-2 on pregnancy outcomes, however information remains limited,” Dr. Bianco noted. “Clinicians need to make patients aware that SARS-CoV-2 infection during pregnancy is associated with a greater risk of severe illness requiring intensive care and/or ventilatory support and even death; however, the precise rates remain unknown. “COVID-19 during pregnancy may result in a preterm birth, but at this time the rate of fetal infection remains unknown,” she said. “Clinicians need to reinforce the importance of physical distancing, mask use, and proper hand hygiene, particularly in this vulnerable population.”
Dr. Bianco emphasized: “Longitudinal studies assessing the impact of SARS-CoV-2 infection at various gestational age periods are needed, as at this time most of the available data includes women with SARS-CoV-2 infection around the time of delivery. Long-term infant outcomes are needed, as well as studies assessing the risk of fetal infection.”
The studies were supported by the Centers for Disease Control and Prevention. The researchers had no financial conflicts to disclose. Dr. Bianco had no relevant financial disclosures.
SOURCE: Woodworth KR et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e2; Zambrano LD et al. MMWR. 2020 Nov 2. doi: 10.15585/mmwr.mm6944e3.
FROM MMWR
OTC topical ivermectin lotion earns FDA approval for head lice
in patients aged 6 months and older.
Ivermectin was approved as a prescription treatment for head lice in February 2012, according to an FDA press release, and is now approved as an over-the-counter treatment through an “Rx-to-OTC” switch process. The approval was granted to Arbor Pharmaceuticals.
The expanded approval for ivermectin increases access to effective care for head lice, which is estimated to affect between 6 million and 12 million children each year in the United States, according to the Centers for Disease Control and Prevention.
“The Rx-to-OTC switch process aims to promote public health by increasing consumer access to drugs that would otherwise only be available by prescription,” Theresa Michele, MD, acting director of the Office of Nonprescription Drugs in the FDA’s Center for Drug Evaluation and Research, said in the press release.
The FDA also noted in the press release that “Sklice, and its active ingredient ivermectin, have not been shown to be safe or effective for the treatment or prevention of COVID-19 and they are not FDA-approved for this use.”
The drug is approved only for treating head lice, and should be used on the scalp and dry hair, according to the labeling. In the wake of the approval, ivermectin will no longer be available as a prescription drug, according to the FDA, and patients currently using prescription versions should contact their health care providers.
An Rx-to-OTC switch is contingent on the manufacturer’s data showing that the drug is safe and effective when used as directed. In addition, “the manufacturer must show that consumers can understand how to use the drug safely and effectively without the supervision of a health care professional,” according to the FDA.
in patients aged 6 months and older.
Ivermectin was approved as a prescription treatment for head lice in February 2012, according to an FDA press release, and is now approved as an over-the-counter treatment through an “Rx-to-OTC” switch process. The approval was granted to Arbor Pharmaceuticals.
The expanded approval for ivermectin increases access to effective care for head lice, which is estimated to affect between 6 million and 12 million children each year in the United States, according to the Centers for Disease Control and Prevention.
“The Rx-to-OTC switch process aims to promote public health by increasing consumer access to drugs that would otherwise only be available by prescription,” Theresa Michele, MD, acting director of the Office of Nonprescription Drugs in the FDA’s Center for Drug Evaluation and Research, said in the press release.
The FDA also noted in the press release that “Sklice, and its active ingredient ivermectin, have not been shown to be safe or effective for the treatment or prevention of COVID-19 and they are not FDA-approved for this use.”
The drug is approved only for treating head lice, and should be used on the scalp and dry hair, according to the labeling. In the wake of the approval, ivermectin will no longer be available as a prescription drug, according to the FDA, and patients currently using prescription versions should contact their health care providers.
An Rx-to-OTC switch is contingent on the manufacturer’s data showing that the drug is safe and effective when used as directed. In addition, “the manufacturer must show that consumers can understand how to use the drug safely and effectively without the supervision of a health care professional,” according to the FDA.
in patients aged 6 months and older.
Ivermectin was approved as a prescription treatment for head lice in February 2012, according to an FDA press release, and is now approved as an over-the-counter treatment through an “Rx-to-OTC” switch process. The approval was granted to Arbor Pharmaceuticals.
The expanded approval for ivermectin increases access to effective care for head lice, which is estimated to affect between 6 million and 12 million children each year in the United States, according to the Centers for Disease Control and Prevention.
“The Rx-to-OTC switch process aims to promote public health by increasing consumer access to drugs that would otherwise only be available by prescription,” Theresa Michele, MD, acting director of the Office of Nonprescription Drugs in the FDA’s Center for Drug Evaluation and Research, said in the press release.
The FDA also noted in the press release that “Sklice, and its active ingredient ivermectin, have not been shown to be safe or effective for the treatment or prevention of COVID-19 and they are not FDA-approved for this use.”
The drug is approved only for treating head lice, and should be used on the scalp and dry hair, according to the labeling. In the wake of the approval, ivermectin will no longer be available as a prescription drug, according to the FDA, and patients currently using prescription versions should contact their health care providers.
An Rx-to-OTC switch is contingent on the manufacturer’s data showing that the drug is safe and effective when used as directed. In addition, “the manufacturer must show that consumers can understand how to use the drug safely and effectively without the supervision of a health care professional,” according to the FDA.
Avoid pituitary pitfalls in hyperprolactinemia
,” Ashlyn Smith, PA-C, of Endocrinology Associates, Scottsdale, Ariz., said in a presentation at the at the virtual meeting of the annual Metabolic and Endocrine Disease Summit held by Global Academy for Medical Education.
The most common demographic for pituitary disorders is women in their 30s and 40s, Ms. Smith said. Early red flags for pituitary problems include patients presenting with headaches and/or blurred or double vision, which could signal bitemporal hemianopsia, she said.
Roughly two-thirds of pituitary adenomas are functional, meaning that they secrete pituitary hormones and cause clinical syndromes, Ms. Smith said. The most common reason for hypersecretion is hyperprolactinemia, she said.
Hyperprolactinemia, like most pituitary conditions, is more common in women than men, Ms. Smith noted. However, symptoms may include not only galactorrhea, but also gynecomastia, and hypogonadism, which may be red flags in men, she noted.
“Prolactin inhibits the gonadal pathway, so we see low gonadal hormones. For example, if men present with atypical hypogonadism for their age, or women present with changes in the menstrual cycle, check the prolactin levels,” she said.
The etiologies of hyperprolactinemia include physiologic reasons such as breastfeeding and pregnancy, as well as intercourse and breast manipulation, stress, and sleep issues. Pathologic reasons for prolactin elevation include prolactinoma, gonad-hormone secreting tumor, hypothyroidism, and renal insufficiency, Ms. Smith said.
Evaluation of patients with suspected hyperprolactinemia includes screening for physiologic causes, renal function and thyroid function tests, and a thyroid-specific MRI. Ordering a dedicated MRI of the pituitary gland is important to help identify compression of the optic nerve, noted Ms. Smith.
A medication review also is essential in evaluating hyperprolactinemia, and especially in the setting of the COVID-19 pandemic, because patients may have made changes to psychiatric medications, said Ms. Smith. Neuroleptics and antipsychotics including risperidone, haloperidol, chlorpromazine, and thiothixene can be associated with hyperprolactinemia, as can benzodiazepines and various analgesics and antidepressants, she said.
Treatment in cases of medication-induced hyperprolactinemia can be challenging if the patients are unable to change a medication, said Ms. Smith. However, patients with hypogonadism or low bone mineral density who can’t change medications may benefit from exogenous gonadal hormones, she said.
Some patients with hyperprolactinemia benefit from treatment with dopamine agonists, which may ease symptoms and reduce the size of the prolactinoma, she explained. However, patients on dopamine agonists should be alert to side effects including constipation and orthostasis. Ms. Smith said she recommends that patients on dopamine agonists for hyperprolactinemia take the medication at night so they are lying down if orthostasis occurs.
Monitor prolactin levels at 1 month, and taper or discontinue if the prolactin returns to normal and the adenoma resolves, which can take approximately 2 years, she said. Ms. Smith then advised follow-up every 3 months for 1 year, then annual prolactin checks.
The risk of recurrence ranges from 26% to 69%, Ms. Smith said, and is higher in patients with higher prolactin levels and larger adenomas, she noted. Recurrence is most likely within a year of withdrawal from treatment, she said.
Ms. Smith disclosed serving as an adviser and speaker for Abbott Nutrition, a speaker for Xeris Pharmaceuticals, and an adviser for Sanofi and Radius.
Global Academy for Medical Education and this news organization are owned by the same parent company.
SOURCE: Smith A. MEDS 2020.
,” Ashlyn Smith, PA-C, of Endocrinology Associates, Scottsdale, Ariz., said in a presentation at the at the virtual meeting of the annual Metabolic and Endocrine Disease Summit held by Global Academy for Medical Education.
The most common demographic for pituitary disorders is women in their 30s and 40s, Ms. Smith said. Early red flags for pituitary problems include patients presenting with headaches and/or blurred or double vision, which could signal bitemporal hemianopsia, she said.
Roughly two-thirds of pituitary adenomas are functional, meaning that they secrete pituitary hormones and cause clinical syndromes, Ms. Smith said. The most common reason for hypersecretion is hyperprolactinemia, she said.
Hyperprolactinemia, like most pituitary conditions, is more common in women than men, Ms. Smith noted. However, symptoms may include not only galactorrhea, but also gynecomastia, and hypogonadism, which may be red flags in men, she noted.
“Prolactin inhibits the gonadal pathway, so we see low gonadal hormones. For example, if men present with atypical hypogonadism for their age, or women present with changes in the menstrual cycle, check the prolactin levels,” she said.
The etiologies of hyperprolactinemia include physiologic reasons such as breastfeeding and pregnancy, as well as intercourse and breast manipulation, stress, and sleep issues. Pathologic reasons for prolactin elevation include prolactinoma, gonad-hormone secreting tumor, hypothyroidism, and renal insufficiency, Ms. Smith said.
Evaluation of patients with suspected hyperprolactinemia includes screening for physiologic causes, renal function and thyroid function tests, and a thyroid-specific MRI. Ordering a dedicated MRI of the pituitary gland is important to help identify compression of the optic nerve, noted Ms. Smith.
A medication review also is essential in evaluating hyperprolactinemia, and especially in the setting of the COVID-19 pandemic, because patients may have made changes to psychiatric medications, said Ms. Smith. Neuroleptics and antipsychotics including risperidone, haloperidol, chlorpromazine, and thiothixene can be associated with hyperprolactinemia, as can benzodiazepines and various analgesics and antidepressants, she said.
Treatment in cases of medication-induced hyperprolactinemia can be challenging if the patients are unable to change a medication, said Ms. Smith. However, patients with hypogonadism or low bone mineral density who can’t change medications may benefit from exogenous gonadal hormones, she said.
Some patients with hyperprolactinemia benefit from treatment with dopamine agonists, which may ease symptoms and reduce the size of the prolactinoma, she explained. However, patients on dopamine agonists should be alert to side effects including constipation and orthostasis. Ms. Smith said she recommends that patients on dopamine agonists for hyperprolactinemia take the medication at night so they are lying down if orthostasis occurs.
Monitor prolactin levels at 1 month, and taper or discontinue if the prolactin returns to normal and the adenoma resolves, which can take approximately 2 years, she said. Ms. Smith then advised follow-up every 3 months for 1 year, then annual prolactin checks.
The risk of recurrence ranges from 26% to 69%, Ms. Smith said, and is higher in patients with higher prolactin levels and larger adenomas, she noted. Recurrence is most likely within a year of withdrawal from treatment, she said.
Ms. Smith disclosed serving as an adviser and speaker for Abbott Nutrition, a speaker for Xeris Pharmaceuticals, and an adviser for Sanofi and Radius.
Global Academy for Medical Education and this news organization are owned by the same parent company.
SOURCE: Smith A. MEDS 2020.
,” Ashlyn Smith, PA-C, of Endocrinology Associates, Scottsdale, Ariz., said in a presentation at the at the virtual meeting of the annual Metabolic and Endocrine Disease Summit held by Global Academy for Medical Education.
The most common demographic for pituitary disorders is women in their 30s and 40s, Ms. Smith said. Early red flags for pituitary problems include patients presenting with headaches and/or blurred or double vision, which could signal bitemporal hemianopsia, she said.
Roughly two-thirds of pituitary adenomas are functional, meaning that they secrete pituitary hormones and cause clinical syndromes, Ms. Smith said. The most common reason for hypersecretion is hyperprolactinemia, she said.
Hyperprolactinemia, like most pituitary conditions, is more common in women than men, Ms. Smith noted. However, symptoms may include not only galactorrhea, but also gynecomastia, and hypogonadism, which may be red flags in men, she noted.
“Prolactin inhibits the gonadal pathway, so we see low gonadal hormones. For example, if men present with atypical hypogonadism for their age, or women present with changes in the menstrual cycle, check the prolactin levels,” she said.
The etiologies of hyperprolactinemia include physiologic reasons such as breastfeeding and pregnancy, as well as intercourse and breast manipulation, stress, and sleep issues. Pathologic reasons for prolactin elevation include prolactinoma, gonad-hormone secreting tumor, hypothyroidism, and renal insufficiency, Ms. Smith said.
Evaluation of patients with suspected hyperprolactinemia includes screening for physiologic causes, renal function and thyroid function tests, and a thyroid-specific MRI. Ordering a dedicated MRI of the pituitary gland is important to help identify compression of the optic nerve, noted Ms. Smith.
A medication review also is essential in evaluating hyperprolactinemia, and especially in the setting of the COVID-19 pandemic, because patients may have made changes to psychiatric medications, said Ms. Smith. Neuroleptics and antipsychotics including risperidone, haloperidol, chlorpromazine, and thiothixene can be associated with hyperprolactinemia, as can benzodiazepines and various analgesics and antidepressants, she said.
Treatment in cases of medication-induced hyperprolactinemia can be challenging if the patients are unable to change a medication, said Ms. Smith. However, patients with hypogonadism or low bone mineral density who can’t change medications may benefit from exogenous gonadal hormones, she said.
Some patients with hyperprolactinemia benefit from treatment with dopamine agonists, which may ease symptoms and reduce the size of the prolactinoma, she explained. However, patients on dopamine agonists should be alert to side effects including constipation and orthostasis. Ms. Smith said she recommends that patients on dopamine agonists for hyperprolactinemia take the medication at night so they are lying down if orthostasis occurs.
Monitor prolactin levels at 1 month, and taper or discontinue if the prolactin returns to normal and the adenoma resolves, which can take approximately 2 years, she said. Ms. Smith then advised follow-up every 3 months for 1 year, then annual prolactin checks.
The risk of recurrence ranges from 26% to 69%, Ms. Smith said, and is higher in patients with higher prolactin levels and larger adenomas, she noted. Recurrence is most likely within a year of withdrawal from treatment, she said.
Ms. Smith disclosed serving as an adviser and speaker for Abbott Nutrition, a speaker for Xeris Pharmaceuticals, and an adviser for Sanofi and Radius.
Global Academy for Medical Education and this news organization are owned by the same parent company.
SOURCE: Smith A. MEDS 2020.
EXPERT ANALYSIS FROM MEDS 2020
Combine calculators and medications to manage risk in osteoporosis patients
Updated assessment and treatment options provide more tools to help clinicians manage osteoporosis and reduce fracture risk, according to Rick Pope, MPAS, PA-C.
Criteria from the National Osteoporosis Foundation for the diagnosis of osteoporosis expanded in 2020 to include a T score measure of –2.5 or less at the wrist in postmenopausal women or in men aged 50 years and older (in addition to existing criteria of –2.5 or lower T scores at the lumbar spine, femoral neck, or total hip), he said in a presentation at the virtual annual Metabolic and Endocrine Disease Summit by Global Academy for Medical Education.
Other updated diagnostic criteria for osteoporosis include a low-trauma hip fracture regardless of bone mineral density, and a history of fracture of the pelvis or wrist in the context of osteopenia (in addition to the existing criteria of fracture of the vertebrae or proximal humerus).
When a diagnosis of osteoporosis is established, the Fracture Risk Assessment Tool calculator continues to serve as useful tool that allows clinicians to easily input patient data and obtain a projection of fracture risk, Mr. Pope said.
During a clinical visit, be sure to measure patients’ height, and look for kyphosis to help evaluate fall risk. Progressive kyphosis is important because the head weight can increase to 40 pounds if the kyphosis progresses to 30 degrees, and puts further stress on the vertebrae, he emphasized. In addition, looking at gait is important, especially for older patients, said Mr. Pope. “I want to get an assessment of how steady they are on their feet.”
Vertebral fracture assessment (VFA) is a useful strategy to evaluate the spine for silent compression fractures, especially in someone who has lost 1.5 inches in height or is on chronic steroids, Mr. Pope said. VFA has several advantages, including lower cost and lower radiation exposure than plain radiographs of the spine.
In addition, trabecular bone score (TBS) allows clinicians to evaluate bone microarchitecture, and this score can serve as an important indicator of fracture risk, Mr. Pope said.
As for treatment options, managing skeletal health in osteoporosis patients includes advising patients on healthy lifestyle practices that include not only adequate calcium and vitamin D, but also smoking cessation and a combination of weight-bearing, dynamic balance, and resistive exercises, he noted.
When considering medications, patient factors determine the most appropriate drug to use, Mr. Pope emphasized.
Bisphosphonates remain an option for treatment and have shown effectiveness at reducing fracture risk in postmenopausal women with osteoporosis, but concerns persist about side effects such as osteonecrosis of the jaw and atypical femoral fractures (AFF), he noted.
Reassure patients that AFF is more of an issue with long-term bisphosphonate use, Mr. Pope said, citing a 2012 study in which the risk of atypical femoral fracture was 1.78 per 100,000 person-years among individuals with 0.1-1.9 years of bisphosphonate exposure, but this jumped to 113 per 100,000 person-years among those with 8-9.9 years of bisphosphonate exposure.
“Eight years seems to be the sweet spot,” before a significant increase, he said. In his clinic, clinicians stop patients at about 8 years of bisphosphonate treatment, and then consider restarting.
However, nonbisphosphonate treatments are also available, including the monoclonal antibody denosumab. “It is different than bisphosphonates, and the effect wears off rapidly,” said Mr. Pope. Also, creatinine clearance is not an issue with denosumab. However, when patients have gone past the 10-year mark, should be switched to an alternative treatment because of an increased fracture risk at that point.
One relatively new treatment, abaloparatide, is currently indicated only for postmenopausal women with osteoporosis. Data have shown an 86% reduction in vertebral fracture risk, but the drug carries a black-box warning for osteosarcoma, said Mr. Pope.
Romosozumab, another newcomer drug, is indicated only for postmenopausal osteoporotic women at high risk for fracture with multiple risk factors who have failed other therapies. Romosozumab carries a black-box warning for cardiovascular risk for those with a history of MI or stroke. “This is a completely different mechanism of action” from other drugs, Mr. Pope said. The drug is given twice a month for a total of 12 months, and must be administered by a health professional in an office setting.
Mr. Pope had no financial conflicts to disclose. Global Academy for Medical Education and this news organization are owned by the same parent company.
Updated assessment and treatment options provide more tools to help clinicians manage osteoporosis and reduce fracture risk, according to Rick Pope, MPAS, PA-C.
Criteria from the National Osteoporosis Foundation for the diagnosis of osteoporosis expanded in 2020 to include a T score measure of –2.5 or less at the wrist in postmenopausal women or in men aged 50 years and older (in addition to existing criteria of –2.5 or lower T scores at the lumbar spine, femoral neck, or total hip), he said in a presentation at the virtual annual Metabolic and Endocrine Disease Summit by Global Academy for Medical Education.
Other updated diagnostic criteria for osteoporosis include a low-trauma hip fracture regardless of bone mineral density, and a history of fracture of the pelvis or wrist in the context of osteopenia (in addition to the existing criteria of fracture of the vertebrae or proximal humerus).
When a diagnosis of osteoporosis is established, the Fracture Risk Assessment Tool calculator continues to serve as useful tool that allows clinicians to easily input patient data and obtain a projection of fracture risk, Mr. Pope said.
During a clinical visit, be sure to measure patients’ height, and look for kyphosis to help evaluate fall risk. Progressive kyphosis is important because the head weight can increase to 40 pounds if the kyphosis progresses to 30 degrees, and puts further stress on the vertebrae, he emphasized. In addition, looking at gait is important, especially for older patients, said Mr. Pope. “I want to get an assessment of how steady they are on their feet.”
Vertebral fracture assessment (VFA) is a useful strategy to evaluate the spine for silent compression fractures, especially in someone who has lost 1.5 inches in height or is on chronic steroids, Mr. Pope said. VFA has several advantages, including lower cost and lower radiation exposure than plain radiographs of the spine.
In addition, trabecular bone score (TBS) allows clinicians to evaluate bone microarchitecture, and this score can serve as an important indicator of fracture risk, Mr. Pope said.
As for treatment options, managing skeletal health in osteoporosis patients includes advising patients on healthy lifestyle practices that include not only adequate calcium and vitamin D, but also smoking cessation and a combination of weight-bearing, dynamic balance, and resistive exercises, he noted.
When considering medications, patient factors determine the most appropriate drug to use, Mr. Pope emphasized.
Bisphosphonates remain an option for treatment and have shown effectiveness at reducing fracture risk in postmenopausal women with osteoporosis, but concerns persist about side effects such as osteonecrosis of the jaw and atypical femoral fractures (AFF), he noted.
Reassure patients that AFF is more of an issue with long-term bisphosphonate use, Mr. Pope said, citing a 2012 study in which the risk of atypical femoral fracture was 1.78 per 100,000 person-years among individuals with 0.1-1.9 years of bisphosphonate exposure, but this jumped to 113 per 100,000 person-years among those with 8-9.9 years of bisphosphonate exposure.
“Eight years seems to be the sweet spot,” before a significant increase, he said. In his clinic, clinicians stop patients at about 8 years of bisphosphonate treatment, and then consider restarting.
However, nonbisphosphonate treatments are also available, including the monoclonal antibody denosumab. “It is different than bisphosphonates, and the effect wears off rapidly,” said Mr. Pope. Also, creatinine clearance is not an issue with denosumab. However, when patients have gone past the 10-year mark, should be switched to an alternative treatment because of an increased fracture risk at that point.
One relatively new treatment, abaloparatide, is currently indicated only for postmenopausal women with osteoporosis. Data have shown an 86% reduction in vertebral fracture risk, but the drug carries a black-box warning for osteosarcoma, said Mr. Pope.
Romosozumab, another newcomer drug, is indicated only for postmenopausal osteoporotic women at high risk for fracture with multiple risk factors who have failed other therapies. Romosozumab carries a black-box warning for cardiovascular risk for those with a history of MI or stroke. “This is a completely different mechanism of action” from other drugs, Mr. Pope said. The drug is given twice a month for a total of 12 months, and must be administered by a health professional in an office setting.
Mr. Pope had no financial conflicts to disclose. Global Academy for Medical Education and this news organization are owned by the same parent company.
Updated assessment and treatment options provide more tools to help clinicians manage osteoporosis and reduce fracture risk, according to Rick Pope, MPAS, PA-C.
Criteria from the National Osteoporosis Foundation for the diagnosis of osteoporosis expanded in 2020 to include a T score measure of –2.5 or less at the wrist in postmenopausal women or in men aged 50 years and older (in addition to existing criteria of –2.5 or lower T scores at the lumbar spine, femoral neck, or total hip), he said in a presentation at the virtual annual Metabolic and Endocrine Disease Summit by Global Academy for Medical Education.
Other updated diagnostic criteria for osteoporosis include a low-trauma hip fracture regardless of bone mineral density, and a history of fracture of the pelvis or wrist in the context of osteopenia (in addition to the existing criteria of fracture of the vertebrae or proximal humerus).
When a diagnosis of osteoporosis is established, the Fracture Risk Assessment Tool calculator continues to serve as useful tool that allows clinicians to easily input patient data and obtain a projection of fracture risk, Mr. Pope said.
During a clinical visit, be sure to measure patients’ height, and look for kyphosis to help evaluate fall risk. Progressive kyphosis is important because the head weight can increase to 40 pounds if the kyphosis progresses to 30 degrees, and puts further stress on the vertebrae, he emphasized. In addition, looking at gait is important, especially for older patients, said Mr. Pope. “I want to get an assessment of how steady they are on their feet.”
Vertebral fracture assessment (VFA) is a useful strategy to evaluate the spine for silent compression fractures, especially in someone who has lost 1.5 inches in height or is on chronic steroids, Mr. Pope said. VFA has several advantages, including lower cost and lower radiation exposure than plain radiographs of the spine.
In addition, trabecular bone score (TBS) allows clinicians to evaluate bone microarchitecture, and this score can serve as an important indicator of fracture risk, Mr. Pope said.
As for treatment options, managing skeletal health in osteoporosis patients includes advising patients on healthy lifestyle practices that include not only adequate calcium and vitamin D, but also smoking cessation and a combination of weight-bearing, dynamic balance, and resistive exercises, he noted.
When considering medications, patient factors determine the most appropriate drug to use, Mr. Pope emphasized.
Bisphosphonates remain an option for treatment and have shown effectiveness at reducing fracture risk in postmenopausal women with osteoporosis, but concerns persist about side effects such as osteonecrosis of the jaw and atypical femoral fractures (AFF), he noted.
Reassure patients that AFF is more of an issue with long-term bisphosphonate use, Mr. Pope said, citing a 2012 study in which the risk of atypical femoral fracture was 1.78 per 100,000 person-years among individuals with 0.1-1.9 years of bisphosphonate exposure, but this jumped to 113 per 100,000 person-years among those with 8-9.9 years of bisphosphonate exposure.
“Eight years seems to be the sweet spot,” before a significant increase, he said. In his clinic, clinicians stop patients at about 8 years of bisphosphonate treatment, and then consider restarting.
However, nonbisphosphonate treatments are also available, including the monoclonal antibody denosumab. “It is different than bisphosphonates, and the effect wears off rapidly,” said Mr. Pope. Also, creatinine clearance is not an issue with denosumab. However, when patients have gone past the 10-year mark, should be switched to an alternative treatment because of an increased fracture risk at that point.
One relatively new treatment, abaloparatide, is currently indicated only for postmenopausal women with osteoporosis. Data have shown an 86% reduction in vertebral fracture risk, but the drug carries a black-box warning for osteosarcoma, said Mr. Pope.
Romosozumab, another newcomer drug, is indicated only for postmenopausal osteoporotic women at high risk for fracture with multiple risk factors who have failed other therapies. Romosozumab carries a black-box warning for cardiovascular risk for those with a history of MI or stroke. “This is a completely different mechanism of action” from other drugs, Mr. Pope said. The drug is given twice a month for a total of 12 months, and must be administered by a health professional in an office setting.
Mr. Pope had no financial conflicts to disclose. Global Academy for Medical Education and this news organization are owned by the same parent company.
FROM MEDS 2020