User login
Statin disappoints for treatment-resistant depression
The randomized clinical trial findings contradict earlier, smaller studies in patients with major depressive disorder (MDD) that suggested statins may reduce symptoms.
“Given the promising results from preliminary trials of statins in MDD, I was surprised that simvastatin did not separate from placebo in our trial,” lead author M. Ishrat Husain, MBBS, MD, associate professor of psychiatry and scientific head of the Centre for Addiction and Mental Health Clinical Trials Unit at the University of Toronto, told this news organization.
“I believe that our findings suggest that statins are not effective augmentation strategies in treatment-resistant depression,” Dr. Husain said.
The findings were published online in JAMA Network Open.
Disappointing results
The double-blind, placebo-controlled randomized clinical trial was conducted in five centers in Pakistan and included 150 patients with major depressive episode whose symptoms did not improve after treatment with at least two antidepressants.
In addition to their prescribed antidepressants, participants received 20 mg/day of simvastatin (n = 77) or placebo (n = 73).
At 12 weeks, both groups reported improvements in Montgomery-Åsberg Depression Rating Scale total scores, but there was no significant difference between groups. The estimated mean difference for simvastatin vs. placebo was −0.61 (P = .7).
Researchers found similar results when they compared scores from the Generalized Anxiety Disorder Scale and Morisky Medication Adherence Scale.
“Much like several other studies in mood disorders, our study results were impacted by a large placebo response,” Dr. Husain said.
The lack of inclusion of any participants under the age of 18 and the single-country cohort were limitations of the trial. Although it is possible that could have affected the outcome, Dr. Husain said it isn’t likely.
It is also unlikely that a different statin would yield different results, he added.
“Simvastatin was selected as it is believed to be most brain penetrant of the statins given its lipophilicity,” Dr. Husain said. “Clinical trials of other statins in major depressive disorder in other settings and populations have also been congruent with our results.”
The study was funded by NIHR Biomedical Research Centre at South London and Maudsley National Health Service Foundation Trust and King’s College London. Dr. Husain reports having received grants from Compass Pathways, holds stock options in Mindset, and previously served on the Board of Trustees of the Pakistan Institute of Living and Learning. Disclosures for the other investigators are fully listed in the original article.
A version of this article first appeared on Medscape.com.
The randomized clinical trial findings contradict earlier, smaller studies in patients with major depressive disorder (MDD) that suggested statins may reduce symptoms.
“Given the promising results from preliminary trials of statins in MDD, I was surprised that simvastatin did not separate from placebo in our trial,” lead author M. Ishrat Husain, MBBS, MD, associate professor of psychiatry and scientific head of the Centre for Addiction and Mental Health Clinical Trials Unit at the University of Toronto, told this news organization.
“I believe that our findings suggest that statins are not effective augmentation strategies in treatment-resistant depression,” Dr. Husain said.
The findings were published online in JAMA Network Open.
Disappointing results
The double-blind, placebo-controlled randomized clinical trial was conducted in five centers in Pakistan and included 150 patients with major depressive episode whose symptoms did not improve after treatment with at least two antidepressants.
In addition to their prescribed antidepressants, participants received 20 mg/day of simvastatin (n = 77) or placebo (n = 73).
At 12 weeks, both groups reported improvements in Montgomery-Åsberg Depression Rating Scale total scores, but there was no significant difference between groups. The estimated mean difference for simvastatin vs. placebo was −0.61 (P = .7).
Researchers found similar results when they compared scores from the Generalized Anxiety Disorder Scale and Morisky Medication Adherence Scale.
“Much like several other studies in mood disorders, our study results were impacted by a large placebo response,” Dr. Husain said.
The lack of inclusion of any participants under the age of 18 and the single-country cohort were limitations of the trial. Although it is possible that could have affected the outcome, Dr. Husain said it isn’t likely.
It is also unlikely that a different statin would yield different results, he added.
“Simvastatin was selected as it is believed to be most brain penetrant of the statins given its lipophilicity,” Dr. Husain said. “Clinical trials of other statins in major depressive disorder in other settings and populations have also been congruent with our results.”
The study was funded by NIHR Biomedical Research Centre at South London and Maudsley National Health Service Foundation Trust and King’s College London. Dr. Husain reports having received grants from Compass Pathways, holds stock options in Mindset, and previously served on the Board of Trustees of the Pakistan Institute of Living and Learning. Disclosures for the other investigators are fully listed in the original article.
A version of this article first appeared on Medscape.com.
The randomized clinical trial findings contradict earlier, smaller studies in patients with major depressive disorder (MDD) that suggested statins may reduce symptoms.
“Given the promising results from preliminary trials of statins in MDD, I was surprised that simvastatin did not separate from placebo in our trial,” lead author M. Ishrat Husain, MBBS, MD, associate professor of psychiatry and scientific head of the Centre for Addiction and Mental Health Clinical Trials Unit at the University of Toronto, told this news organization.
“I believe that our findings suggest that statins are not effective augmentation strategies in treatment-resistant depression,” Dr. Husain said.
The findings were published online in JAMA Network Open.
Disappointing results
The double-blind, placebo-controlled randomized clinical trial was conducted in five centers in Pakistan and included 150 patients with major depressive episode whose symptoms did not improve after treatment with at least two antidepressants.
In addition to their prescribed antidepressants, participants received 20 mg/day of simvastatin (n = 77) or placebo (n = 73).
At 12 weeks, both groups reported improvements in Montgomery-Åsberg Depression Rating Scale total scores, but there was no significant difference between groups. The estimated mean difference for simvastatin vs. placebo was −0.61 (P = .7).
Researchers found similar results when they compared scores from the Generalized Anxiety Disorder Scale and Morisky Medication Adherence Scale.
“Much like several other studies in mood disorders, our study results were impacted by a large placebo response,” Dr. Husain said.
The lack of inclusion of any participants under the age of 18 and the single-country cohort were limitations of the trial. Although it is possible that could have affected the outcome, Dr. Husain said it isn’t likely.
It is also unlikely that a different statin would yield different results, he added.
“Simvastatin was selected as it is believed to be most brain penetrant of the statins given its lipophilicity,” Dr. Husain said. “Clinical trials of other statins in major depressive disorder in other settings and populations have also been congruent with our results.”
The study was funded by NIHR Biomedical Research Centre at South London and Maudsley National Health Service Foundation Trust and King’s College London. Dr. Husain reports having received grants from Compass Pathways, holds stock options in Mindset, and previously served on the Board of Trustees of the Pakistan Institute of Living and Learning. Disclosures for the other investigators are fully listed in the original article.
A version of this article first appeared on Medscape.com.
FROM JAMA NETWORK OPEN
Ketamine plus psychotherapy ‘highly effective’ for PTSD
In a systematic review and meta-analysis of four studies investigating combined use of psychotherapy and ketamine for PTSD, results showed that all the studies showed a significant reduction in PTSD symptom scores.
Overall, the treatment was “highly effective, as seen by the significant improvements in symptoms on multiple measures,” Aaron E. Philipp-Muller, BScH, Centre for Neuroscience Studies, Queen’s University, Kingston, Ont., and colleagues write.
Furthermore, the study “demonstrates the potential feasibility of this treatment model and corroborates previous work,” the investigators write.
However, a limitation they note was that only 34 participants were included in the analysis.
The findings were published online in the Journal of Clinical Psychiatry.
Emerging treatment
Ketamine is an “emerging treatment for a number of psychopathologies, such as major depressive disorder and PTSD, with a higher response than other pharmacologic agents,” the researchers write.
It is hypothesized that ketamine rapidly facilitates long-term potentiation, “thereby allowing a patient to disengage from an established pattern of thought more readily,” they write.
However, ketamine has several drawbacks, including the fact that it brings only 1 week of relief for PTSD. Also, because it must be administered intravenously, it is “impractical for long-term weekly administration,” they note.
Pharmacologically enhanced psychotherapy is a potential way to prolong ketamine’s effects. Several prior studies have investigated this model using other psychedelic medications, with encouraging results.
The current investigators decided to review all literature to date on the subject of ketamine plus psychotherapy for the treatment of PTSD.
To be included, the study had to include patients diagnosed with PTSD, an intervention involving ketamine alongside any form of psychotherapy, and assessment of all patients before and after treatment using the Clinician-Administered PTSD Scale (CAPS) or the PTSD Checklist (PCL).
Four studies met inclusion criteria. Of these, two were of “moderate” quality and two were of “low” quality, based on the GRADE assessment. The studies encompassed a total of 34 patients with “diverse traumatic experiences” and included several types of ketamine administration protocols, including one used previously for treating depression and another used previously for chronic pain.
The psychotherapy modalities also differed between the studies. In two studies, patients received 12 sessions of trauma interventions using mindfulness-based extinction and reconsolidation therapy; in a third study, patients received 10 weekly sessions of prolonged exposure therapy; and in the fourth study, patients received five daily sessions of exposure therapy.
Across the studies, the psychotherapies were paired differently with ketamine administration, such as the number of ketamine administrations in conjunction with therapy.
Despite the differences in protocols, all the studies of ketamine plus psychotherapy showed a significant reduction in PTSD symptoms, with a pooled standardized mean difference (SMD) of –7.26 (95% CI, –12.28 to –2.25; P = .005) for the CAPS and a pooled SMD of –5.17 (95% CI, –7.99 to –2.35; P < .001) for the PCL.
The researchers acknowledge that the sample size was very small “due to the novelty of this research area.” This prompted the inclusion of nonrandomized studies that “lowered the quality of the evidence,” they note.
Nevertheless, “these preliminary findings indicate the potential of ketamine-assisted psychotherapy for PTSD,” the investigators write.
A promising avenue?
In a comment, Dan Iosifescu, MD, professor of psychiatry, New York University School of Medicine, called the combination of ketamine and psychotherapy in PTSD “a very promising treatment avenue.”
Dr. Iosifescu, who was not involved with the research, noted that “several PTSD-focused psychotherapies are ultimately very effective but very hard to tolerate for participants.” For example, prolonged exposure therapy has dropout rates as high as 50%.
In addition, ketamine has rapid but not sustained effects in PTSD, he said.
“So in theory, a course of ketamine could help PTSD patients improve rapidly and tolerate the psychotherapy, which could provide sustained benefits,” he added.
However, Dr. Iosifescu cautioned that the data supporting this “is very sparse for now.”
He also noted that the meta-analysis included only “four tiny studies” and had only 34 total participants. In addition, several of the studies had no comparison group and the study designs were all different – “both with respect to the administration of ketamine and to the paired PTSD psychotherapy.”
For this reason, “any conclusions are only a very preliminary suggestion that this may be a fruitful avenue,” he said.
Dr. Iosifescu added that additional studies on this topic are ongoing. The largest one at the Veterans Administration will hopefully include 100 participants and “will provide more reliable evidence for this important topic,” he said.
The study was indirectly supported by the Internal Faculty Grant from the department of psychiatry, Queen’s University. Dr. Iosifescu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a systematic review and meta-analysis of four studies investigating combined use of psychotherapy and ketamine for PTSD, results showed that all the studies showed a significant reduction in PTSD symptom scores.
Overall, the treatment was “highly effective, as seen by the significant improvements in symptoms on multiple measures,” Aaron E. Philipp-Muller, BScH, Centre for Neuroscience Studies, Queen’s University, Kingston, Ont., and colleagues write.
Furthermore, the study “demonstrates the potential feasibility of this treatment model and corroborates previous work,” the investigators write.
However, a limitation they note was that only 34 participants were included in the analysis.
The findings were published online in the Journal of Clinical Psychiatry.
Emerging treatment
Ketamine is an “emerging treatment for a number of psychopathologies, such as major depressive disorder and PTSD, with a higher response than other pharmacologic agents,” the researchers write.
It is hypothesized that ketamine rapidly facilitates long-term potentiation, “thereby allowing a patient to disengage from an established pattern of thought more readily,” they write.
However, ketamine has several drawbacks, including the fact that it brings only 1 week of relief for PTSD. Also, because it must be administered intravenously, it is “impractical for long-term weekly administration,” they note.
Pharmacologically enhanced psychotherapy is a potential way to prolong ketamine’s effects. Several prior studies have investigated this model using other psychedelic medications, with encouraging results.
The current investigators decided to review all literature to date on the subject of ketamine plus psychotherapy for the treatment of PTSD.
To be included, the study had to include patients diagnosed with PTSD, an intervention involving ketamine alongside any form of psychotherapy, and assessment of all patients before and after treatment using the Clinician-Administered PTSD Scale (CAPS) or the PTSD Checklist (PCL).
Four studies met inclusion criteria. Of these, two were of “moderate” quality and two were of “low” quality, based on the GRADE assessment. The studies encompassed a total of 34 patients with “diverse traumatic experiences” and included several types of ketamine administration protocols, including one used previously for treating depression and another used previously for chronic pain.
The psychotherapy modalities also differed between the studies. In two studies, patients received 12 sessions of trauma interventions using mindfulness-based extinction and reconsolidation therapy; in a third study, patients received 10 weekly sessions of prolonged exposure therapy; and in the fourth study, patients received five daily sessions of exposure therapy.
Across the studies, the psychotherapies were paired differently with ketamine administration, such as the number of ketamine administrations in conjunction with therapy.
Despite the differences in protocols, all the studies of ketamine plus psychotherapy showed a significant reduction in PTSD symptoms, with a pooled standardized mean difference (SMD) of –7.26 (95% CI, –12.28 to –2.25; P = .005) for the CAPS and a pooled SMD of –5.17 (95% CI, –7.99 to –2.35; P < .001) for the PCL.
The researchers acknowledge that the sample size was very small “due to the novelty of this research area.” This prompted the inclusion of nonrandomized studies that “lowered the quality of the evidence,” they note.
Nevertheless, “these preliminary findings indicate the potential of ketamine-assisted psychotherapy for PTSD,” the investigators write.
A promising avenue?
In a comment, Dan Iosifescu, MD, professor of psychiatry, New York University School of Medicine, called the combination of ketamine and psychotherapy in PTSD “a very promising treatment avenue.”
Dr. Iosifescu, who was not involved with the research, noted that “several PTSD-focused psychotherapies are ultimately very effective but very hard to tolerate for participants.” For example, prolonged exposure therapy has dropout rates as high as 50%.
In addition, ketamine has rapid but not sustained effects in PTSD, he said.
“So in theory, a course of ketamine could help PTSD patients improve rapidly and tolerate the psychotherapy, which could provide sustained benefits,” he added.
However, Dr. Iosifescu cautioned that the data supporting this “is very sparse for now.”
He also noted that the meta-analysis included only “four tiny studies” and had only 34 total participants. In addition, several of the studies had no comparison group and the study designs were all different – “both with respect to the administration of ketamine and to the paired PTSD psychotherapy.”
For this reason, “any conclusions are only a very preliminary suggestion that this may be a fruitful avenue,” he said.
Dr. Iosifescu added that additional studies on this topic are ongoing. The largest one at the Veterans Administration will hopefully include 100 participants and “will provide more reliable evidence for this important topic,” he said.
The study was indirectly supported by the Internal Faculty Grant from the department of psychiatry, Queen’s University. Dr. Iosifescu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
In a systematic review and meta-analysis of four studies investigating combined use of psychotherapy and ketamine for PTSD, results showed that all the studies showed a significant reduction in PTSD symptom scores.
Overall, the treatment was “highly effective, as seen by the significant improvements in symptoms on multiple measures,” Aaron E. Philipp-Muller, BScH, Centre for Neuroscience Studies, Queen’s University, Kingston, Ont., and colleagues write.
Furthermore, the study “demonstrates the potential feasibility of this treatment model and corroborates previous work,” the investigators write.
However, a limitation they note was that only 34 participants were included in the analysis.
The findings were published online in the Journal of Clinical Psychiatry.
Emerging treatment
Ketamine is an “emerging treatment for a number of psychopathologies, such as major depressive disorder and PTSD, with a higher response than other pharmacologic agents,” the researchers write.
It is hypothesized that ketamine rapidly facilitates long-term potentiation, “thereby allowing a patient to disengage from an established pattern of thought more readily,” they write.
However, ketamine has several drawbacks, including the fact that it brings only 1 week of relief for PTSD. Also, because it must be administered intravenously, it is “impractical for long-term weekly administration,” they note.
Pharmacologically enhanced psychotherapy is a potential way to prolong ketamine’s effects. Several prior studies have investigated this model using other psychedelic medications, with encouraging results.
The current investigators decided to review all literature to date on the subject of ketamine plus psychotherapy for the treatment of PTSD.
To be included, the study had to include patients diagnosed with PTSD, an intervention involving ketamine alongside any form of psychotherapy, and assessment of all patients before and after treatment using the Clinician-Administered PTSD Scale (CAPS) or the PTSD Checklist (PCL).
Four studies met inclusion criteria. Of these, two were of “moderate” quality and two were of “low” quality, based on the GRADE assessment. The studies encompassed a total of 34 patients with “diverse traumatic experiences” and included several types of ketamine administration protocols, including one used previously for treating depression and another used previously for chronic pain.
The psychotherapy modalities also differed between the studies. In two studies, patients received 12 sessions of trauma interventions using mindfulness-based extinction and reconsolidation therapy; in a third study, patients received 10 weekly sessions of prolonged exposure therapy; and in the fourth study, patients received five daily sessions of exposure therapy.
Across the studies, the psychotherapies were paired differently with ketamine administration, such as the number of ketamine administrations in conjunction with therapy.
Despite the differences in protocols, all the studies of ketamine plus psychotherapy showed a significant reduction in PTSD symptoms, with a pooled standardized mean difference (SMD) of –7.26 (95% CI, –12.28 to –2.25; P = .005) for the CAPS and a pooled SMD of –5.17 (95% CI, –7.99 to –2.35; P < .001) for the PCL.
The researchers acknowledge that the sample size was very small “due to the novelty of this research area.” This prompted the inclusion of nonrandomized studies that “lowered the quality of the evidence,” they note.
Nevertheless, “these preliminary findings indicate the potential of ketamine-assisted psychotherapy for PTSD,” the investigators write.
A promising avenue?
In a comment, Dan Iosifescu, MD, professor of psychiatry, New York University School of Medicine, called the combination of ketamine and psychotherapy in PTSD “a very promising treatment avenue.”
Dr. Iosifescu, who was not involved with the research, noted that “several PTSD-focused psychotherapies are ultimately very effective but very hard to tolerate for participants.” For example, prolonged exposure therapy has dropout rates as high as 50%.
In addition, ketamine has rapid but not sustained effects in PTSD, he said.
“So in theory, a course of ketamine could help PTSD patients improve rapidly and tolerate the psychotherapy, which could provide sustained benefits,” he added.
However, Dr. Iosifescu cautioned that the data supporting this “is very sparse for now.”
He also noted that the meta-analysis included only “four tiny studies” and had only 34 total participants. In addition, several of the studies had no comparison group and the study designs were all different – “both with respect to the administration of ketamine and to the paired PTSD psychotherapy.”
For this reason, “any conclusions are only a very preliminary suggestion that this may be a fruitful avenue,” he said.
Dr. Iosifescu added that additional studies on this topic are ongoing. The largest one at the Veterans Administration will hopefully include 100 participants and “will provide more reliable evidence for this important topic,” he said.
The study was indirectly supported by the Internal Faculty Grant from the department of psychiatry, Queen’s University. Dr. Iosifescu reported no relevant financial relationships.
A version of this article first appeared on Medscape.com.
FROM THE JOURNAL OF CLINICAL PSYCHIATRY
Key takeaways from ACP’s new Tx guidelines for adults with major depressive disorder
In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).1 The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.
Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.
For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.
If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:
- Switching to CBT
- Adding on CBT while continuing the SGA
- Changing to a different SGA
- Adding a second pharmacologic agent.
6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:
• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.
• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.
• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.
• Monitor frequently for medication adverse effects.
• Monitor the patient for thoughts about self-harm for the first 2 months.
• Continue treatment for 4 to 9 months once remission is achieved.
A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.
1. Qaseem A, Owens D, Etxeandia-Ikobaltzeta I, et al; Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians. Ann Intern Med. Published online January 24, 2023. doi: 10.7326/M22-2056
In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).1 The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.
Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.
For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.
If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:
- Switching to CBT
- Adding on CBT while continuing the SGA
- Changing to a different SGA
- Adding a second pharmacologic agent.
6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:
• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.
• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.
• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.
• Monitor frequently for medication adverse effects.
• Monitor the patient for thoughts about self-harm for the first 2 months.
• Continue treatment for 4 to 9 months once remission is achieved.
A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.
In January 2023, the American College of Physicians (ACP) published updated recommendations on the treatment of adults with major depressive disorder (MDD).1 The ACP guidelines address initial treatment of patients in the acute phase of mild and moderate-to-severe MDD. Here’s what the ACP recommends, as well as 6 important takeaways.
Recommendations for initial treatment of those with mild or moderate-to-severe MDD center around cognitive behavioral therapy (CBT) and second-generation antidepressants (SGA). For patients in the acute phase of mild MDD, the recommendation is for monotherapy with CBT. However, if CBT is not an option due to cost and/or availability of services, the use of an SGA is acceptable.
For patients in the acute phase of moderate-to-severe MDD, either CBT, an SGA, or a combination of both is recommended.
If initial treatment does not work … Up to 70% of patients with moderate-to-severe MDD will not respond to the initial therapy chosen. If a patient does not respond to initial treatment with an SGA, consider 1 of the following:
- Switching to CBT
- Adding on CBT while continuing the SGA
- Changing to a different SGA
- Adding a second pharmacologic agent.
6 key takeaways. The full guideline should be read for a more complete discussion of the many clinical considerations of these treatment options. However, the most important points include:
• Employ shared clinical decision-making and consider the individual characteristics of each patient when making treatment decisions.
• Consider generic options when using an SGA; generic options appear to be as effective as more expensive brand-name products.
• Start with a low-dose SGA and increase gradually to an approved maximum dose before determining there has been no response.
• Monitor frequently for medication adverse effects.
• Monitor the patient for thoughts about self-harm for the first 2 months.
• Continue treatment for 4 to 9 months once remission is achieved.
A word about strength of evidence. While these recommendations are based on an extensive review of the best available evidence, most are based on low-certainty evidence—illustrating the amount of clinical research still needed on this topic. The exceptions are monotherapy with either CBT or SGA for initial treatment of moderate-to-severe MDD, both of which are based on moderate-strength evidence and received a strong recommendation. The panel felt there was insufficient evidence to assess complementary and alternative interventions including exercise and omega-3 fatty acids.
1. Qaseem A, Owens D, Etxeandia-Ikobaltzeta I, et al; Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians. Ann Intern Med. Published online January 24, 2023. doi: 10.7326/M22-2056
1. Qaseem A, Owens D, Etxeandia-Ikobaltzeta I, et al; Clinical Guidelines Committee of the American College of Physicians. Nonpharmacologic and pharmacologic treatments of adults in the acute phase of major depressive disorder: a living clinical guideline from the American College of Physicians. Ann Intern Med. Published online January 24, 2023. doi: 10.7326/M22-2056
Higher dementia risk in women explained?
a study suggests.
Prior research has found a higher lifetime dementia risk in women, and one explanation cited has been that women tend to live longer than men.
However, this new analysis of data from nearly 30,000 people in 18 countries found almost no evidence of sex differences in most known risk factors for dementia, including age.
The risk of dementia among women was significantly higher in poorer countries, pointing to economic disadvantages as a possible explanation.
“In general, we found that the greater dementia risk found in women compared to men was more pronounced in poorer countries, which points to the need for greater efforts to narrow the gaps in health disparities between women and men in these countries,” lead investigator Jessica Gong, MSc, a doctoral student at the George Institute for Global Health, Newtown, Australia, told this news organization. “It is likely that socioeconomic factors are potentially more important than biological factors when assessing dementia risk.”
The findings were published online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.
Global data
Most previous studies that examined sex differences in dementia risk were conducted in high-income countries, Ms. Gong noted, leaving a gap in the literature on risk in low- and middle-income countries.
To address this issue, researchers conducted an individual participant meta-analysis of 21 studies from the Cohort Studies of Memory in an International Consortium. Data analysis included information on 29,850 people from 18 countries on six continents. None of the participants had dementia at baseline, and the average age was 71.6 years.
Over a median of 4.6 years, incident dementia was reported in 2,089 people, 66% of whom were women.
Overall, women had higher dementia risk (hazard ratio, 1.12; 95% confidence interval, 1.02-1.23) than men, but the rates were highest in low- to middle-income economies (HR, 1.73; P = .03).
Dementia risk in women was higher than in men in 14 countries. Risk was highest in Nigeria, where dementia risk was more than double in women (aHR, 2.11; 95% CI, 1.46-3.04), and lowest in Brazil, where risk was 46% lower in women than in men (aHR, 0.54; 95% CI, 0.29-1.00).
In the United States, dementia risk was 7% higher in women than men (aHR, 1.07; 0.73-1.57).
Similar risk factors
In both women and men, older age, diabetes, depression, hearing impairment, and apo E–epsilon 4 carriage were associated with a greater risk of dementia, and more years of education, higher hip circumference, current alcohol use (vs. never), and high physical activity (vs. none to minimal) were associated with a lower risk of dementia.
Among all these risk factors, sex differences were only significant for longer education and former alcohol use, with both demonstrating a stronger association in men than women.
Global dementia rates are expected to triple over the next 25 years unless steps are taken to reduce risk factors. A 2020 report found that dementia risk could be reduced by addressing 12 modifiable risk factors, including obesity, air pollution, diabetes, social isolation, and hypertension. All of these risk factors are more common in low- to middle-income countries, Ms. Gong noted.
“These findings justify ongoing efforts to support programs to improve sex and gender equity in brain health, particularly in underrepresented and underserved populations, in turn to narrow the gaps within and between country,” Ms. Gong said.
Understanding the puzzle
Commenting on the findings for Medscape Medical News, Heather Snyder, PhD, Alzheimer’s Association vice president of medical and scientific relations, said the findings add to the body of work about sex differences in dementia risk.
“This is an interesting study looking at risk factors for dementia and suggests that, while some risk factors are more pronounced in men than in women, women may be more at risk of progressing to dementia,” Dr. Snyder said. “The findings outline the importance of understanding how the underlying biology, particularly biology that differs in males and females, may be contributing to risk.”
Data on the country and geographical variations highlighted in the study also point to a potential risk influencer, she said.
“Studying geography-specific risk factors is important because it helps us understand the ‘why’ behind geographic differences in dementia risk,” Dr. Snyder said. “This type of collaboration among countries and researchers is essential for us to understand these puzzle pieces.”
Funding for the study was provided by the U.K. Medical Research Council Skills Development Fellowship, Australian National Health and Medical Research Council Investigator Grant, National Institute on Aging, among others. See the original article for full funding sources. Ms. Gong reported no relevant financial conflicts. Dr. Snyder is employed by the Alzheimer’s Association.
A version of this article originally appeared on Medscape.com.
a study suggests.
Prior research has found a higher lifetime dementia risk in women, and one explanation cited has been that women tend to live longer than men.
However, this new analysis of data from nearly 30,000 people in 18 countries found almost no evidence of sex differences in most known risk factors for dementia, including age.
The risk of dementia among women was significantly higher in poorer countries, pointing to economic disadvantages as a possible explanation.
“In general, we found that the greater dementia risk found in women compared to men was more pronounced in poorer countries, which points to the need for greater efforts to narrow the gaps in health disparities between women and men in these countries,” lead investigator Jessica Gong, MSc, a doctoral student at the George Institute for Global Health, Newtown, Australia, told this news organization. “It is likely that socioeconomic factors are potentially more important than biological factors when assessing dementia risk.”
The findings were published online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.
Global data
Most previous studies that examined sex differences in dementia risk were conducted in high-income countries, Ms. Gong noted, leaving a gap in the literature on risk in low- and middle-income countries.
To address this issue, researchers conducted an individual participant meta-analysis of 21 studies from the Cohort Studies of Memory in an International Consortium. Data analysis included information on 29,850 people from 18 countries on six continents. None of the participants had dementia at baseline, and the average age was 71.6 years.
Over a median of 4.6 years, incident dementia was reported in 2,089 people, 66% of whom were women.
Overall, women had higher dementia risk (hazard ratio, 1.12; 95% confidence interval, 1.02-1.23) than men, but the rates were highest in low- to middle-income economies (HR, 1.73; P = .03).
Dementia risk in women was higher than in men in 14 countries. Risk was highest in Nigeria, where dementia risk was more than double in women (aHR, 2.11; 95% CI, 1.46-3.04), and lowest in Brazil, where risk was 46% lower in women than in men (aHR, 0.54; 95% CI, 0.29-1.00).
In the United States, dementia risk was 7% higher in women than men (aHR, 1.07; 0.73-1.57).
Similar risk factors
In both women and men, older age, diabetes, depression, hearing impairment, and apo E–epsilon 4 carriage were associated with a greater risk of dementia, and more years of education, higher hip circumference, current alcohol use (vs. never), and high physical activity (vs. none to minimal) were associated with a lower risk of dementia.
Among all these risk factors, sex differences were only significant for longer education and former alcohol use, with both demonstrating a stronger association in men than women.
Global dementia rates are expected to triple over the next 25 years unless steps are taken to reduce risk factors. A 2020 report found that dementia risk could be reduced by addressing 12 modifiable risk factors, including obesity, air pollution, diabetes, social isolation, and hypertension. All of these risk factors are more common in low- to middle-income countries, Ms. Gong noted.
“These findings justify ongoing efforts to support programs to improve sex and gender equity in brain health, particularly in underrepresented and underserved populations, in turn to narrow the gaps within and between country,” Ms. Gong said.
Understanding the puzzle
Commenting on the findings for Medscape Medical News, Heather Snyder, PhD, Alzheimer’s Association vice president of medical and scientific relations, said the findings add to the body of work about sex differences in dementia risk.
“This is an interesting study looking at risk factors for dementia and suggests that, while some risk factors are more pronounced in men than in women, women may be more at risk of progressing to dementia,” Dr. Snyder said. “The findings outline the importance of understanding how the underlying biology, particularly biology that differs in males and females, may be contributing to risk.”
Data on the country and geographical variations highlighted in the study also point to a potential risk influencer, she said.
“Studying geography-specific risk factors is important because it helps us understand the ‘why’ behind geographic differences in dementia risk,” Dr. Snyder said. “This type of collaboration among countries and researchers is essential for us to understand these puzzle pieces.”
Funding for the study was provided by the U.K. Medical Research Council Skills Development Fellowship, Australian National Health and Medical Research Council Investigator Grant, National Institute on Aging, among others. See the original article for full funding sources. Ms. Gong reported no relevant financial conflicts. Dr. Snyder is employed by the Alzheimer’s Association.
A version of this article originally appeared on Medscape.com.
a study suggests.
Prior research has found a higher lifetime dementia risk in women, and one explanation cited has been that women tend to live longer than men.
However, this new analysis of data from nearly 30,000 people in 18 countries found almost no evidence of sex differences in most known risk factors for dementia, including age.
The risk of dementia among women was significantly higher in poorer countries, pointing to economic disadvantages as a possible explanation.
“In general, we found that the greater dementia risk found in women compared to men was more pronounced in poorer countries, which points to the need for greater efforts to narrow the gaps in health disparities between women and men in these countries,” lead investigator Jessica Gong, MSc, a doctoral student at the George Institute for Global Health, Newtown, Australia, told this news organization. “It is likely that socioeconomic factors are potentially more important than biological factors when assessing dementia risk.”
The findings were published online in Alzheimer’s & Dementia: The Journal of the Alzheimer’s Association.
Global data
Most previous studies that examined sex differences in dementia risk were conducted in high-income countries, Ms. Gong noted, leaving a gap in the literature on risk in low- and middle-income countries.
To address this issue, researchers conducted an individual participant meta-analysis of 21 studies from the Cohort Studies of Memory in an International Consortium. Data analysis included information on 29,850 people from 18 countries on six continents. None of the participants had dementia at baseline, and the average age was 71.6 years.
Over a median of 4.6 years, incident dementia was reported in 2,089 people, 66% of whom were women.
Overall, women had higher dementia risk (hazard ratio, 1.12; 95% confidence interval, 1.02-1.23) than men, but the rates were highest in low- to middle-income economies (HR, 1.73; P = .03).
Dementia risk in women was higher than in men in 14 countries. Risk was highest in Nigeria, where dementia risk was more than double in women (aHR, 2.11; 95% CI, 1.46-3.04), and lowest in Brazil, where risk was 46% lower in women than in men (aHR, 0.54; 95% CI, 0.29-1.00).
In the United States, dementia risk was 7% higher in women than men (aHR, 1.07; 0.73-1.57).
Similar risk factors
In both women and men, older age, diabetes, depression, hearing impairment, and apo E–epsilon 4 carriage were associated with a greater risk of dementia, and more years of education, higher hip circumference, current alcohol use (vs. never), and high physical activity (vs. none to minimal) were associated with a lower risk of dementia.
Among all these risk factors, sex differences were only significant for longer education and former alcohol use, with both demonstrating a stronger association in men than women.
Global dementia rates are expected to triple over the next 25 years unless steps are taken to reduce risk factors. A 2020 report found that dementia risk could be reduced by addressing 12 modifiable risk factors, including obesity, air pollution, diabetes, social isolation, and hypertension. All of these risk factors are more common in low- to middle-income countries, Ms. Gong noted.
“These findings justify ongoing efforts to support programs to improve sex and gender equity in brain health, particularly in underrepresented and underserved populations, in turn to narrow the gaps within and between country,” Ms. Gong said.
Understanding the puzzle
Commenting on the findings for Medscape Medical News, Heather Snyder, PhD, Alzheimer’s Association vice president of medical and scientific relations, said the findings add to the body of work about sex differences in dementia risk.
“This is an interesting study looking at risk factors for dementia and suggests that, while some risk factors are more pronounced in men than in women, women may be more at risk of progressing to dementia,” Dr. Snyder said. “The findings outline the importance of understanding how the underlying biology, particularly biology that differs in males and females, may be contributing to risk.”
Data on the country and geographical variations highlighted in the study also point to a potential risk influencer, she said.
“Studying geography-specific risk factors is important because it helps us understand the ‘why’ behind geographic differences in dementia risk,” Dr. Snyder said. “This type of collaboration among countries and researchers is essential for us to understand these puzzle pieces.”
Funding for the study was provided by the U.K. Medical Research Council Skills Development Fellowship, Australian National Health and Medical Research Council Investigator Grant, National Institute on Aging, among others. See the original article for full funding sources. Ms. Gong reported no relevant financial conflicts. Dr. Snyder is employed by the Alzheimer’s Association.
A version of this article originally appeared on Medscape.com.
FROM ALZHEIMER’S & DEMENTIA
Myths about smoking, diet, alcohol, and cancer persist
FRANCE – Conducted every 5 years since 2005, the Cancer Survey documents the knowledge, perceptions, and way of life of the French people in relation to cancer. The researchers analyzed responses to telephone interviews of a representative sample of almost 5,000 individuals aged 15-85 years.
This study shows how thinking has changed over time and how difficult it is to alter preconceived notions.
Is cancer hereditary?
The report shows that 67.7% of respondents believe that cancer is a hereditary disease. Respondents were asked to explain their answer. “Data show that medical practices for cancer treatment substantiate this belief [that cancer is hereditary],” wrote the authors of the report.
“Indeed, health care professionals almost systematically ask questions about family history of breast cancer and, when a family member has been diagnosed with cancer, medical monitoring of other family members is often sought out, thus reinforcing the belief that cancer is hereditary,” they said.
Furthermore, there seems to be confusion regarding the role of genes in the development of cancer. A person can inherit cancer-predisposing genes, not cancer itself. The authors highlighted their concern that this confusion may “lead people to think that prevention measures are unnecessary because cancer is inherited.”
Misconceptions about smoking
About 41% of smokers think that the length of time one has been smoking is the biggest determining factor for developing cancer; 58.1% think the number of cigarettes smoked per day has a bigger impact.
Experts at InCA and SPF put the debate to rest, stating that prolonged exposure to carcinogenic substances is far more toxic. As for the danger threshold concerning the number of cigarettes smoked per day, respondents believed this to be 9.2 cigarettes per day, on average. They believed that the danger threshold for the number of years as an active smoker is 13.4, on average.
“The [survey] respondents clearly understand that smoking carries a risk, but many smokers think that light smoking or smoking for a short period of time doesn’t carry any risks.” Yet it is understood that even occasional tobacco consumption increases mortality.
This was not the only misconception regarding smoking and its relationship with cancer. About 34% of survey respondents agreed with the following statement: “Smoking doesn’t cause cancer unless you’re a heavy smoker and have smoked for a long time.” Furthermore, 43.3% agreed with the statement, “Pollution is more likely to cause cancer than smoking,” 54.6% think that “exercising cleans your lungs of tobacco,” and 61.6% think that “a smoker can prevent developing cancer caused by smoking if they know to quit on time.”
Overweight and obesity
Although diet and excess weight represent the third and fourth biggest avoidable cancer risk factors, after smoking and alcohol, only 30% of survey respondents knew of this link.
“Among the causes of cancer known and cited by respondents without prompting, excessive weight and obesity were mentioned only 100 times out of 12,558 responses,” highlighted the authors of the report. The explanation put forward by the authors is that discourse about diet has been more focused on diet as a protective health factor, especially in preventing cardiovascular diseases. “The link between cancer and diet is less prominent in the public space,” they noted.
Breastfeeding and cancer
About 63% of survey respondents, which for the first time included both women and men, believe that breastfeeding does not affect mothers’ risk of breast cancer, but this is a misconception. And almost 1 in 3 respondents said that breastfeeding provides health benefits for the mother.
Artificial UV rays
Exposure to UV rays, whether of natural or artificial origin, is a major risk factor for skin cancer. However, 1 in 5 people (20.9%) think that a session in a tanning bed is less harmful than sun exposure.
Daily stress
Regarding psychological factors linked to cancer, the authors noted that risk factors not supported by scientific evidence were, ironically, cited more often by respondents than proven risk factors. There is a real knowledge gap between scientific data and the beliefs of the French people. For example, “working at night” is largely not seen as a risk factor, but data show that it presents a clear risk. However, “not being able to express one’s feelings,” “having been weakened by traumatic experiences,” and “being exposed to the stress of modern life” are seen as risk factors of cancer, without any scientific evidence.
Cigarettes and e-cigarettes
About 53% of respondents agreed that “e-cigarettes are just as harmful or more harmful than traditional cigarettes.” Nicotine and the flavors in e-cigarettes are largely perceived as “very” or “extremely” harmful to the health of a person. However, the authors note that “no published study on nicotine substitutes has shown harmful effects on the health of a person, let alone determined it a risk factor for cancer. The nicotine doses in e-cigarettes are similar to traditional nicotine substitutes, and no cytotoxic effect of nicotine in its inhaled form has been found.” There seems to be confusion between dependence and risk of cancer.
Alcohol consumption
Eight of 10 respondents believe that “some people can drink a lot of alcohol all their life without ever getting cancer,” which goes against the scientific literature. The authors of the report state that the negative effects of alcohol on health seem poorly understood. Although alcohol is the second biggest cause of cancer, only a third of survey respondents cited it without having been prompted as one of the main causes of cancer. And 23.5% even think that “in terms of decreasing your risk of cancer, it’s better to drink a little wine than to drink no wine at all.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
FRANCE – Conducted every 5 years since 2005, the Cancer Survey documents the knowledge, perceptions, and way of life of the French people in relation to cancer. The researchers analyzed responses to telephone interviews of a representative sample of almost 5,000 individuals aged 15-85 years.
This study shows how thinking has changed over time and how difficult it is to alter preconceived notions.
Is cancer hereditary?
The report shows that 67.7% of respondents believe that cancer is a hereditary disease. Respondents were asked to explain their answer. “Data show that medical practices for cancer treatment substantiate this belief [that cancer is hereditary],” wrote the authors of the report.
“Indeed, health care professionals almost systematically ask questions about family history of breast cancer and, when a family member has been diagnosed with cancer, medical monitoring of other family members is often sought out, thus reinforcing the belief that cancer is hereditary,” they said.
Furthermore, there seems to be confusion regarding the role of genes in the development of cancer. A person can inherit cancer-predisposing genes, not cancer itself. The authors highlighted their concern that this confusion may “lead people to think that prevention measures are unnecessary because cancer is inherited.”
Misconceptions about smoking
About 41% of smokers think that the length of time one has been smoking is the biggest determining factor for developing cancer; 58.1% think the number of cigarettes smoked per day has a bigger impact.
Experts at InCA and SPF put the debate to rest, stating that prolonged exposure to carcinogenic substances is far more toxic. As for the danger threshold concerning the number of cigarettes smoked per day, respondents believed this to be 9.2 cigarettes per day, on average. They believed that the danger threshold for the number of years as an active smoker is 13.4, on average.
“The [survey] respondents clearly understand that smoking carries a risk, but many smokers think that light smoking or smoking for a short period of time doesn’t carry any risks.” Yet it is understood that even occasional tobacco consumption increases mortality.
This was not the only misconception regarding smoking and its relationship with cancer. About 34% of survey respondents agreed with the following statement: “Smoking doesn’t cause cancer unless you’re a heavy smoker and have smoked for a long time.” Furthermore, 43.3% agreed with the statement, “Pollution is more likely to cause cancer than smoking,” 54.6% think that “exercising cleans your lungs of tobacco,” and 61.6% think that “a smoker can prevent developing cancer caused by smoking if they know to quit on time.”
Overweight and obesity
Although diet and excess weight represent the third and fourth biggest avoidable cancer risk factors, after smoking and alcohol, only 30% of survey respondents knew of this link.
“Among the causes of cancer known and cited by respondents without prompting, excessive weight and obesity were mentioned only 100 times out of 12,558 responses,” highlighted the authors of the report. The explanation put forward by the authors is that discourse about diet has been more focused on diet as a protective health factor, especially in preventing cardiovascular diseases. “The link between cancer and diet is less prominent in the public space,” they noted.
Breastfeeding and cancer
About 63% of survey respondents, which for the first time included both women and men, believe that breastfeeding does not affect mothers’ risk of breast cancer, but this is a misconception. And almost 1 in 3 respondents said that breastfeeding provides health benefits for the mother.
Artificial UV rays
Exposure to UV rays, whether of natural or artificial origin, is a major risk factor for skin cancer. However, 1 in 5 people (20.9%) think that a session in a tanning bed is less harmful than sun exposure.
Daily stress
Regarding psychological factors linked to cancer, the authors noted that risk factors not supported by scientific evidence were, ironically, cited more often by respondents than proven risk factors. There is a real knowledge gap between scientific data and the beliefs of the French people. For example, “working at night” is largely not seen as a risk factor, but data show that it presents a clear risk. However, “not being able to express one’s feelings,” “having been weakened by traumatic experiences,” and “being exposed to the stress of modern life” are seen as risk factors of cancer, without any scientific evidence.
Cigarettes and e-cigarettes
About 53% of respondents agreed that “e-cigarettes are just as harmful or more harmful than traditional cigarettes.” Nicotine and the flavors in e-cigarettes are largely perceived as “very” or “extremely” harmful to the health of a person. However, the authors note that “no published study on nicotine substitutes has shown harmful effects on the health of a person, let alone determined it a risk factor for cancer. The nicotine doses in e-cigarettes are similar to traditional nicotine substitutes, and no cytotoxic effect of nicotine in its inhaled form has been found.” There seems to be confusion between dependence and risk of cancer.
Alcohol consumption
Eight of 10 respondents believe that “some people can drink a lot of alcohol all their life without ever getting cancer,” which goes against the scientific literature. The authors of the report state that the negative effects of alcohol on health seem poorly understood. Although alcohol is the second biggest cause of cancer, only a third of survey respondents cited it without having been prompted as one of the main causes of cancer. And 23.5% even think that “in terms of decreasing your risk of cancer, it’s better to drink a little wine than to drink no wine at all.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
FRANCE – Conducted every 5 years since 2005, the Cancer Survey documents the knowledge, perceptions, and way of life of the French people in relation to cancer. The researchers analyzed responses to telephone interviews of a representative sample of almost 5,000 individuals aged 15-85 years.
This study shows how thinking has changed over time and how difficult it is to alter preconceived notions.
Is cancer hereditary?
The report shows that 67.7% of respondents believe that cancer is a hereditary disease. Respondents were asked to explain their answer. “Data show that medical practices for cancer treatment substantiate this belief [that cancer is hereditary],” wrote the authors of the report.
“Indeed, health care professionals almost systematically ask questions about family history of breast cancer and, when a family member has been diagnosed with cancer, medical monitoring of other family members is often sought out, thus reinforcing the belief that cancer is hereditary,” they said.
Furthermore, there seems to be confusion regarding the role of genes in the development of cancer. A person can inherit cancer-predisposing genes, not cancer itself. The authors highlighted their concern that this confusion may “lead people to think that prevention measures are unnecessary because cancer is inherited.”
Misconceptions about smoking
About 41% of smokers think that the length of time one has been smoking is the biggest determining factor for developing cancer; 58.1% think the number of cigarettes smoked per day has a bigger impact.
Experts at InCA and SPF put the debate to rest, stating that prolonged exposure to carcinogenic substances is far more toxic. As for the danger threshold concerning the number of cigarettes smoked per day, respondents believed this to be 9.2 cigarettes per day, on average. They believed that the danger threshold for the number of years as an active smoker is 13.4, on average.
“The [survey] respondents clearly understand that smoking carries a risk, but many smokers think that light smoking or smoking for a short period of time doesn’t carry any risks.” Yet it is understood that even occasional tobacco consumption increases mortality.
This was not the only misconception regarding smoking and its relationship with cancer. About 34% of survey respondents agreed with the following statement: “Smoking doesn’t cause cancer unless you’re a heavy smoker and have smoked for a long time.” Furthermore, 43.3% agreed with the statement, “Pollution is more likely to cause cancer than smoking,” 54.6% think that “exercising cleans your lungs of tobacco,” and 61.6% think that “a smoker can prevent developing cancer caused by smoking if they know to quit on time.”
Overweight and obesity
Although diet and excess weight represent the third and fourth biggest avoidable cancer risk factors, after smoking and alcohol, only 30% of survey respondents knew of this link.
“Among the causes of cancer known and cited by respondents without prompting, excessive weight and obesity were mentioned only 100 times out of 12,558 responses,” highlighted the authors of the report. The explanation put forward by the authors is that discourse about diet has been more focused on diet as a protective health factor, especially in preventing cardiovascular diseases. “The link between cancer and diet is less prominent in the public space,” they noted.
Breastfeeding and cancer
About 63% of survey respondents, which for the first time included both women and men, believe that breastfeeding does not affect mothers’ risk of breast cancer, but this is a misconception. And almost 1 in 3 respondents said that breastfeeding provides health benefits for the mother.
Artificial UV rays
Exposure to UV rays, whether of natural or artificial origin, is a major risk factor for skin cancer. However, 1 in 5 people (20.9%) think that a session in a tanning bed is less harmful than sun exposure.
Daily stress
Regarding psychological factors linked to cancer, the authors noted that risk factors not supported by scientific evidence were, ironically, cited more often by respondents than proven risk factors. There is a real knowledge gap between scientific data and the beliefs of the French people. For example, “working at night” is largely not seen as a risk factor, but data show that it presents a clear risk. However, “not being able to express one’s feelings,” “having been weakened by traumatic experiences,” and “being exposed to the stress of modern life” are seen as risk factors of cancer, without any scientific evidence.
Cigarettes and e-cigarettes
About 53% of respondents agreed that “e-cigarettes are just as harmful or more harmful than traditional cigarettes.” Nicotine and the flavors in e-cigarettes are largely perceived as “very” or “extremely” harmful to the health of a person. However, the authors note that “no published study on nicotine substitutes has shown harmful effects on the health of a person, let alone determined it a risk factor for cancer. The nicotine doses in e-cigarettes are similar to traditional nicotine substitutes, and no cytotoxic effect of nicotine in its inhaled form has been found.” There seems to be confusion between dependence and risk of cancer.
Alcohol consumption
Eight of 10 respondents believe that “some people can drink a lot of alcohol all their life without ever getting cancer,” which goes against the scientific literature. The authors of the report state that the negative effects of alcohol on health seem poorly understood. Although alcohol is the second biggest cause of cancer, only a third of survey respondents cited it without having been prompted as one of the main causes of cancer. And 23.5% even think that “in terms of decreasing your risk of cancer, it’s better to drink a little wine than to drink no wine at all.”
This article was translated from the Medscape French edition. A version of this article appeared on Medscape.com.
Regular laxative use tied to increased dementia risk
Among more than 500,000 middle-aged or older adults in the UK Biobank, those who reported regular laxative use had a 51% increased risk of dementia due to any cause, compared with their counterparts who did not regularly use laxatives.
Individuals who used only osmotic laxatives had a 64% increased risk, compared with peers who did not use laxatives, while those using one or more types of laxatives, including bulk-forming, stool-softening, or stimulating laxatives, had a 90% increased risk.
“Constipation and laxative use are common among middle-aged and older adults,” study investigator Feng Sha, PhD, with the Chinese Academy of Sciences in Guangdong, China, said in a news release.
“However, regular laxative use may change the microbiome of the gut, possibly affecting nerve signaling from the gut to the brain or increasing the production of intestinal toxins that may affect the brain,” Dr. Sha noted.
The study was published online in Neurology.
Robust link
The findings are based on 502,229 people (54% women; mean age, 57 at baseline) from the UK biobank database. All were dementia-free at baseline.
A total of 18,235 participants (3.6%) said they used over-the-counter laxatives regularly, which was defined as using them most days of the week during the month before the study.
Over an average of 9.8 years, dementia was recorded in 218 (1.3%) of those who regularly used laxatives and in 1,969 (0.4%) of those did not.
After adjusting for factors such as age, sex, education, other illnesses, medication use, and a family history of dementia, regular use of laxatives was significantly associated with increased risk of all-cause dementia (adjusted hazard ratio, 1.51; 95% confidence interval, 1.30-1.75) and vascular dementia (aHR, 1.65; 95% CI, 1.21-2.27), with no significant association observed for Alzheimer’s disease (aHR, 1.05; 95% CI, 0.79-1.40).
The risk of dementia also increased with the number of laxative types used. All-cause dementia risk increased by 28% (aHR, 1.28; 95% CI, 1.03-1.61) for those using a single laxative type and by 90% (aHR, 1.90; 95% CI, 1.20-3.01) for those using two or more types, compared with nonuse.
Among those who reported using only one type of laxative, only those using osmotic laxatives had a statistically significant higher risk of all-cause dementia (aHR, 1.64; 95% CI, 1.20-2.24) and vascular dementia (aHR, 1.97; 95% CI, 1.04-3.75).
“These results remained robust in various subgroup and sensitivity analyses,” the investigators report.
They caution that they had no data on laxative dosage and so they were unable to explore the relationship between various laxative dosages and dementia risk.
Interpret with caution
Commenting on the findings for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the results are “interesting and demonstrate an association between laxative use and later life risk of dementia.”
However, “there is no proven causation, and there are some caveats,” Dr. Snyder said. “It’s unclear what may be driving this association, though other lines of research have suggested a linkage between our overall gut health, our immune system, and our brain health.”
Dr. Snyder said it’s also worth noting that the data came from the UK Biobank, which, “while a wealth of information for research purposes, is not representative of other countries. More research is needed.”
The Alzheimer’s Association is leading a 2-year clinical trial, U.S. Pointer, to examine the impact of behavioral interventions on the gut-brain axis to “better understand how our gut health may affect our brains,” Dr. Snyder told this news organization.
“While we await the results of that study, people should talk to their doctor about the risks and benefits of laxatives for their health, as well as discuss alternative methods of alleviating constipation, such as increasing dietary fiber and drinking more water,” she advised.
The study was funded by the National Natural Science Foundation of China, Shenzhen Science and Technology Program, and the Chinese Academy of Sciences. The authors and Dr. Snyder have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Among more than 500,000 middle-aged or older adults in the UK Biobank, those who reported regular laxative use had a 51% increased risk of dementia due to any cause, compared with their counterparts who did not regularly use laxatives.
Individuals who used only osmotic laxatives had a 64% increased risk, compared with peers who did not use laxatives, while those using one or more types of laxatives, including bulk-forming, stool-softening, or stimulating laxatives, had a 90% increased risk.
“Constipation and laxative use are common among middle-aged and older adults,” study investigator Feng Sha, PhD, with the Chinese Academy of Sciences in Guangdong, China, said in a news release.
“However, regular laxative use may change the microbiome of the gut, possibly affecting nerve signaling from the gut to the brain or increasing the production of intestinal toxins that may affect the brain,” Dr. Sha noted.
The study was published online in Neurology.
Robust link
The findings are based on 502,229 people (54% women; mean age, 57 at baseline) from the UK biobank database. All were dementia-free at baseline.
A total of 18,235 participants (3.6%) said they used over-the-counter laxatives regularly, which was defined as using them most days of the week during the month before the study.
Over an average of 9.8 years, dementia was recorded in 218 (1.3%) of those who regularly used laxatives and in 1,969 (0.4%) of those did not.
After adjusting for factors such as age, sex, education, other illnesses, medication use, and a family history of dementia, regular use of laxatives was significantly associated with increased risk of all-cause dementia (adjusted hazard ratio, 1.51; 95% confidence interval, 1.30-1.75) and vascular dementia (aHR, 1.65; 95% CI, 1.21-2.27), with no significant association observed for Alzheimer’s disease (aHR, 1.05; 95% CI, 0.79-1.40).
The risk of dementia also increased with the number of laxative types used. All-cause dementia risk increased by 28% (aHR, 1.28; 95% CI, 1.03-1.61) for those using a single laxative type and by 90% (aHR, 1.90; 95% CI, 1.20-3.01) for those using two or more types, compared with nonuse.
Among those who reported using only one type of laxative, only those using osmotic laxatives had a statistically significant higher risk of all-cause dementia (aHR, 1.64; 95% CI, 1.20-2.24) and vascular dementia (aHR, 1.97; 95% CI, 1.04-3.75).
“These results remained robust in various subgroup and sensitivity analyses,” the investigators report.
They caution that they had no data on laxative dosage and so they were unable to explore the relationship between various laxative dosages and dementia risk.
Interpret with caution
Commenting on the findings for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the results are “interesting and demonstrate an association between laxative use and later life risk of dementia.”
However, “there is no proven causation, and there are some caveats,” Dr. Snyder said. “It’s unclear what may be driving this association, though other lines of research have suggested a linkage between our overall gut health, our immune system, and our brain health.”
Dr. Snyder said it’s also worth noting that the data came from the UK Biobank, which, “while a wealth of information for research purposes, is not representative of other countries. More research is needed.”
The Alzheimer’s Association is leading a 2-year clinical trial, U.S. Pointer, to examine the impact of behavioral interventions on the gut-brain axis to “better understand how our gut health may affect our brains,” Dr. Snyder told this news organization.
“While we await the results of that study, people should talk to their doctor about the risks and benefits of laxatives for their health, as well as discuss alternative methods of alleviating constipation, such as increasing dietary fiber and drinking more water,” she advised.
The study was funded by the National Natural Science Foundation of China, Shenzhen Science and Technology Program, and the Chinese Academy of Sciences. The authors and Dr. Snyder have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
Among more than 500,000 middle-aged or older adults in the UK Biobank, those who reported regular laxative use had a 51% increased risk of dementia due to any cause, compared with their counterparts who did not regularly use laxatives.
Individuals who used only osmotic laxatives had a 64% increased risk, compared with peers who did not use laxatives, while those using one or more types of laxatives, including bulk-forming, stool-softening, or stimulating laxatives, had a 90% increased risk.
“Constipation and laxative use are common among middle-aged and older adults,” study investigator Feng Sha, PhD, with the Chinese Academy of Sciences in Guangdong, China, said in a news release.
“However, regular laxative use may change the microbiome of the gut, possibly affecting nerve signaling from the gut to the brain or increasing the production of intestinal toxins that may affect the brain,” Dr. Sha noted.
The study was published online in Neurology.
Robust link
The findings are based on 502,229 people (54% women; mean age, 57 at baseline) from the UK biobank database. All were dementia-free at baseline.
A total of 18,235 participants (3.6%) said they used over-the-counter laxatives regularly, which was defined as using them most days of the week during the month before the study.
Over an average of 9.8 years, dementia was recorded in 218 (1.3%) of those who regularly used laxatives and in 1,969 (0.4%) of those did not.
After adjusting for factors such as age, sex, education, other illnesses, medication use, and a family history of dementia, regular use of laxatives was significantly associated with increased risk of all-cause dementia (adjusted hazard ratio, 1.51; 95% confidence interval, 1.30-1.75) and vascular dementia (aHR, 1.65; 95% CI, 1.21-2.27), with no significant association observed for Alzheimer’s disease (aHR, 1.05; 95% CI, 0.79-1.40).
The risk of dementia also increased with the number of laxative types used. All-cause dementia risk increased by 28% (aHR, 1.28; 95% CI, 1.03-1.61) for those using a single laxative type and by 90% (aHR, 1.90; 95% CI, 1.20-3.01) for those using two or more types, compared with nonuse.
Among those who reported using only one type of laxative, only those using osmotic laxatives had a statistically significant higher risk of all-cause dementia (aHR, 1.64; 95% CI, 1.20-2.24) and vascular dementia (aHR, 1.97; 95% CI, 1.04-3.75).
“These results remained robust in various subgroup and sensitivity analyses,” the investigators report.
They caution that they had no data on laxative dosage and so they were unable to explore the relationship between various laxative dosages and dementia risk.
Interpret with caution
Commenting on the findings for this news organization, Heather Snyder, PhD, vice president of medical and scientific relations at the Alzheimer’s Association, said the results are “interesting and demonstrate an association between laxative use and later life risk of dementia.”
However, “there is no proven causation, and there are some caveats,” Dr. Snyder said. “It’s unclear what may be driving this association, though other lines of research have suggested a linkage between our overall gut health, our immune system, and our brain health.”
Dr. Snyder said it’s also worth noting that the data came from the UK Biobank, which, “while a wealth of information for research purposes, is not representative of other countries. More research is needed.”
The Alzheimer’s Association is leading a 2-year clinical trial, U.S. Pointer, to examine the impact of behavioral interventions on the gut-brain axis to “better understand how our gut health may affect our brains,” Dr. Snyder told this news organization.
“While we await the results of that study, people should talk to their doctor about the risks and benefits of laxatives for their health, as well as discuss alternative methods of alleviating constipation, such as increasing dietary fiber and drinking more water,” she advised.
The study was funded by the National Natural Science Foundation of China, Shenzhen Science and Technology Program, and the Chinese Academy of Sciences. The authors and Dr. Snyder have disclosed no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM NEUROLOGY
One in five children at risk for eating disorder: Study
More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.
The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.
The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than 14 pounds in a 3-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”
The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.
In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.
The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.
The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.
“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.
The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.
A version of this article first appeared on WebMD.com.
More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.
The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.
The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than 14 pounds in a 3-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”
The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.
In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.
The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.
The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.
“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.
The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.
A version of this article first appeared on WebMD.com.
More than 1 in 5 children worldwide are at risk of developing an eating disorder such as bulimia, anorexia, or binge eating, a new analysis suggests.
The study was published in the journal JAMA Pediatrics. Researchers analyzed data for 63,181 adolescents 6-18 years old from 16 countries to look for what is called “disordered eating.” None of the children included in the study had diagnosed physical or mental disorders, and data were not included from the COVID-19 time period.
The researchers examined results from a widely used standardized eating disorder questionnaire called the Sick, Control, One, Fat, Food (SCOFF). When someone answers yes to two or more of the questions, the person is considered to have disordered eating, which “denotes a suspicion of an existing eating disorder,” the researchers write. The five questions are:
- Do you make yourself sick because you feel uncomfortably full?
- Do you worry you have lost control over how much you eat?
- Have you recently lost more than 14 pounds in a 3-month period?
- Do you believe yourself to be fat when others say you are too thin?
- Would you say that food dominates your life?
Overall, 22% of children replied yes to two or more of the questions. The proportion of children with disordered eating is likely even higher, the researchers explain, because children may hide symptoms “due to feelings of shame or stigmatization.”
The findings are a dramatic shift from the estimation that 2.7% of people ages 13-18 have an eating disorder during their adolescent years.
In this latest study, disordered eating was more common among girls, older children, and those with a higher body mass index, or BMI, which is a combined measure of height and weight.
The analysis showed that 30% of girls had disordered eating, compared with 17% of boys. When looking at responses by age, the proportion of kids with disordered eating increased by 20 percentage points between the ages of 10 and 18.
The findings regarding children who already have a high BMI confirms previous research that many of those children are already following disordered eating behaviors while trying to lose weight, the authors write.
“Although most adolescents who develop an eating disorder do not report prior excess weight problems, some adolescents could misinterpret what eating healthy consists of and engage in unhealthy behaviors (for instance, skipping meals to generate a caloric deficit), which could then lead to development of an eating disorder,” the researchers explain.
The study points to the need for parents, caregivers, and health care professionals to be on the lookout for disordered eating symptoms in children because they are linked to the risk of developing a clinical eating disorder. The symptoms to watch for include behaviors such as weight loss dieting, binge eating, self-induced vomiting, excessive exercise, and the use of laxatives or diuretics, the researchers write.
A version of this article first appeared on WebMD.com.
FROM JAMA PEDIATRICS
How spirituality guides these three doctors
Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
Tapping into the universe
Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.
“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”
Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.
“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”
Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.
“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”
Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”
When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.
Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
Spirituality supports patients
Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.
“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”
When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”
These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.
Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.
“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”
Dr. Shamie says that he turns to his faith in good times as well as tough ones.
“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”
For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.
“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”
There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.
“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
Doctors without faith
So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.
The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.
A version of this article first appeared on Medscape.com.
Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
Tapping into the universe
Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.
“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”
Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.
“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”
Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.
“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”
Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”
When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.
Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
Spirituality supports patients
Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.
“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”
When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”
These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.
Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.
“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”
Dr. Shamie says that he turns to his faith in good times as well as tough ones.
“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”
For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.
“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”
There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.
“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
Doctors without faith
So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.
The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.
A version of this article first appeared on Medscape.com.
Whether you’re spiritual, religious – or neither – the Medscape Physician Lifestyle & Happiness Report 2023 asked if you have a religious or spiritual belief. Turns out 69% of physicians shared that they have a spiritual or religious practice.
Tapping into the universe
Nick Shamie, MD, an orthopedic surgeon specializing in spine surgery at University of California, Los Angeles, says the constant challenges of making life-and-death decisions offer an opportunity to check in with a higher power.
“Sometimes when I’m going into a tough surgery or have a tough situation, I pause and think about how this isn’t about me and the situation I’m in,” says Dr. Shamie, whose family is Muslim. “It’s about the whole universe. I feel like someone, or some being, is looking over my shoulders, and if my intentions are good, I’ll be fine. The person I’m going to take care of will be fine. That’s how I use my faith.”
Having a belief in something greater than herself also fuels Jill Carnahan, MD, a family medicine physician and functional medicine expert in Boulder, Colo.
“This is key for me as a physician,” says Dr. Carnahan, author of “Unexpected: Finding Resilience Through Functional Medicine, Science, and Faith.” “I urge physicians to think about their source of strength. That’s not necessarily even religious. It could be meditation or being in nature.”
Dr. Carnahan likes to share with patients that there are lessons that can come from being ill – whether treating ill patients or struggling with one’s own illness.
“I like to teach this idea of illness as a teacher,” says Dr. Carnahan, who has Crohn’s disease and is a cancer survivor. “This is tough, but what you’re saying here is that there is meaning or purpose to this experience. It brings awareness to your life that may not have been there before.”
Often illness is our body’s way of getting our attention that our life, relationships, or work needs adjustment. Illness can be a reminder to make changes. “For example, a diagnosis of autoimmunity may be a reminder to take better care of ourselves, or a diagnosis of cancer may cause us to get out of an unhealthy relationship or change jobs to do something more fulfilling, as we have increased awareness of the brevity of life.”
When patients are affected by illness, pain, reduced functionality, and even imminent death, understanding the experience is difficult, and finding any purpose in it may seem impossible. Still, studies show that those who find meaning in the experience cope better with their illness.
Finding that meaning may be a strong driver of survival and may be positively related to hope, belief, and happiness.
Spirituality supports patients
Even if you’re not religious yourself, it can be helpful to support a patient who opts to pray before an arduous procedure, says Sharyar Baradaran, DDS, a periodontist specializing in gum surgery in Beverly Hills, Calif.
“I’ve had patients who go into meditation mode, or they say a prayer before I start surgery,” he says. “I take that opportunity to connect. In that instance, we hold hands. I want them to know that I understand what they’re going through and how they’re trying to find the courage to undergo surgery.”
When Dr. Shamie was a child, his father described religion as embodying the basic tenet of being good to others. “I’ve taken that to heart,” he says. “All religions, all faiths have that as a central premise.”
These doctors agree that when you take the time to stop and hold a patient’s hand, bow your head during their prayer, or acknowledge or speak for a few moments about their faith, especially during a health crisis, surgery, or challenging diagnosis, patients appreciate it and develop an even deeper connection with you.
Dr. Baradaran believes spirituality can play an important role in how health care providers care for patients. Though it may not be widely discussed or reported, and physicians may find little time and space to address patients’ spiritual needs, there is growing sensitivity regarding spirituality in health care. One study found that while physicians understand its importance, nurses are more apt to integrate spirituality into practice.
“No matter the religion, if you’re spiritual, it means you’re listening and being respectful,” says Dr. Baradaran, who is Jewish. “There are times that I’m not familiar with the prayers my patients are saying, but I always take them in, absorb them, and respect them. This allows me to have a deeper connection with them, which is wonderful.”
Dr. Shamie says that he turns to his faith in good times as well as tough ones.
“I see a lot of people who are dealing with very difficult situations, and it’s not their choice to be in this position,” he says. “At those moments, I think to myself how fortunate I am that I’m not experiencing what this individual or family is going through. I do thank God at that time. I appreciate the life I have, and when I witness hardships, it resets my appreciation.”
For Dr. Carnahan, faith is about becoming comfortable with the inevitable uncertainty of life. It’s also about finding ways to tap into the day’s stresses.
“As physicians, we’re workaholics, and one in four of us are burnt out,” she says. “One solution that really works is to step back from the day-to-day grind and find time to pray or meditate or be in nature.”
There are times when a tragedy occurs, and despite your most intense efforts, a patient may die. Those experiences can be crushing to a physician. However, to guide you through the loss of a patient or the daily juggles of managing your practice, Dr. Carnahan suggests finding time every morning to focus on the day ahead and how you connect with the universe.
“I take 15 minutes in the morning and think about how I will bring love to the world,” she says. “If you look for the miracles and the good and the unexpected, that gratitude shift allows your mind to be transformed by what’s happening. It’s often in those moments that you’ll realize again why you went into medicine in the first place.”
Doctors without faith
So, what does this mean if you’re among the 25% of physicians in the Medscape report who do not have a religious or spiritual leaning and aren’t apt to be spiritually minded when it comes to your patients? An article on KevinMD.com points out that atheist physicians are often in the closet about their atheism because they usually bow their heads or keep a respectful silence when a patient or their family offers a prayer request before surgery or a prayer of thanks after a procedure.
The retired atheist physician who wrote the piece reminds us that nonreligious doctors are good people with a high moral compass who may not believe in an afterlife. However, that means they try to make their patients’ quality of life the best they can.
A version of this article first appeared on Medscape.com.
Two cups of coffee increase heart dangers with hypertension
according to researchers at Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo.
What to know
People with severely high blood pressure who drink two or more cups of caffeinated coffee each day could double their risk of dying from a heart attack, stroke, or any type of cardiovascular disease.
Too much coffee may raise blood pressure and lead to anxiety, heart palpitations, and difficulty sleeping.
An 8-ounce cup of coffee has 80-100 mg of caffeine, while an 8-ounce cup of green or black tea has 30-50 mg.
Drinking one cup of coffee a day or any amount of green tea was not associated with risk of death across any blood pressure categories, and drinking green tea was not associated with increased risk of death related to cardiovascular disease at any blood pressure level.
Frequent consumers of coffee were more likely to be younger, current smokers, current drinkers, to eat fewer vegetables, and to have higher total cholesterol levels and lower systolic blood pressure regardless of their blood pressure category.
This is a summary of the article “Coffee and Green Tea Consumption and Cardiovascular Disease Mortality Among People With and Without Hypertension,” published in the Journal of the American Heart Association.
A version of this article first appeared on Medscape.com.
according to researchers at Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo.
What to know
People with severely high blood pressure who drink two or more cups of caffeinated coffee each day could double their risk of dying from a heart attack, stroke, or any type of cardiovascular disease.
Too much coffee may raise blood pressure and lead to anxiety, heart palpitations, and difficulty sleeping.
An 8-ounce cup of coffee has 80-100 mg of caffeine, while an 8-ounce cup of green or black tea has 30-50 mg.
Drinking one cup of coffee a day or any amount of green tea was not associated with risk of death across any blood pressure categories, and drinking green tea was not associated with increased risk of death related to cardiovascular disease at any blood pressure level.
Frequent consumers of coffee were more likely to be younger, current smokers, current drinkers, to eat fewer vegetables, and to have higher total cholesterol levels and lower systolic blood pressure regardless of their blood pressure category.
This is a summary of the article “Coffee and Green Tea Consumption and Cardiovascular Disease Mortality Among People With and Without Hypertension,” published in the Journal of the American Heart Association.
A version of this article first appeared on Medscape.com.
according to researchers at Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo.
What to know
People with severely high blood pressure who drink two or more cups of caffeinated coffee each day could double their risk of dying from a heart attack, stroke, or any type of cardiovascular disease.
Too much coffee may raise blood pressure and lead to anxiety, heart palpitations, and difficulty sleeping.
An 8-ounce cup of coffee has 80-100 mg of caffeine, while an 8-ounce cup of green or black tea has 30-50 mg.
Drinking one cup of coffee a day or any amount of green tea was not associated with risk of death across any blood pressure categories, and drinking green tea was not associated with increased risk of death related to cardiovascular disease at any blood pressure level.
Frequent consumers of coffee were more likely to be younger, current smokers, current drinkers, to eat fewer vegetables, and to have higher total cholesterol levels and lower systolic blood pressure regardless of their blood pressure category.
This is a summary of the article “Coffee and Green Tea Consumption and Cardiovascular Disease Mortality Among People With and Without Hypertension,” published in the Journal of the American Heart Association.
A version of this article first appeared on Medscape.com.
FROM JOURNAL OF AMERICAN HEART ASSOCIATION
Diabetes drug tied to lower dementia risk
new research suggests.
Overall, in a large cohort study from South Korea, patients who took pioglitazone were 16% less likely to develop dementia over an average of 10 years than peers who did not take the drug.
However, the dementia risk reduction was 54% among those with ischemic heart disease and 43% among those with a history of stroke.
“Our study was to see the association between pioglitazone use and incidence of dementia, not how (with what mechanisms) this drug can suppress dementia pathology,” coinvestigator Eosu Kim, MD, PhD, Yonsei University, Seoul, South Korea, said in an interview.
However, “as we found this drug is more effective in diabetic patients who have blood circulation problems in the heart or brain than in those without such problems, we speculate that pioglitazone’s antidementia action may be related to improving blood vessel’s health,” Dr. Kim said.
This finding suggests that pioglitazone could be used as a personalized treatment approach for dementia prevention in this subgroup of patients with diabetes, the researchers noted.
The results were published online in Neurology.
Dose-response relationship
Risk for dementia is doubled in adults with T2DM, the investigators wrote. Prior studies have suggested that pioglitazone may protect against dementia, as well as a first or recurrent stroke, in patients with T2DM.
This led Dr. Kim and colleagues to examine the effects of pioglitazone on dementia risk overall and in relation to stroke and ischemic heart disease.
Using the national Korean health database, the researchers identified 91,218 adults aged 50 and older with new-onset T2DM who did not have dementia. A total of 3,467 were treated with pioglitazone.
Pioglitazone exposure was defined as a total cumulative daily dose of 90 or more calculated from all dispensations during 4 years after T2DM diagnosis, with outcomes assessed after this period.
Over an average of 10 years, 8.3% of pioglitazone users developed dementia, compared with 10.0% of nonusers.
There was a statistically significant 16% lower risk for developing all-cause dementia among pioglitazone users than among nonusers (adjusted hazard ratio, 0.84; 95% confidence interval, 0.75-0.95).
A dose-response relationship was evident; pioglitazone users who received the highest cumulative daily dose were at lower risk for dementia (aHR, 0.72; 95% CI, 0.55-0.94).
Several limitations
The reduced risk for dementia was more pronounced among patients who used pioglitazone for 4 years in comparison with patients who did not use the drug (aHR, 0.63; 95% CI, 0.44-0.90).
The apparent protective effect of pioglitazone with regard to dementia was greater among those with a history of ischemic heart disease (aHR, 0.46; 95% CI, 0.24-0.90) or stroke (aHR, 0.57; 95% CI, 0.38-0.86) before diabetes diagnosis.
The incidence of stroke was also reduced with pioglitazone use (aHR, 0.81; 95% CI, 0.66-1.0).
“These results provide valuable information on who could potentially benefit from pioglitazone use for prevention of dementia,” Dr. Kim said in a news release.
However, “the risk and benefit balance of long-term use of this drug to prevent dementia should be prospectively assessed,” he said in an interview.
The researchers cautioned that the study was observational; hence, the reported associations cannot address causal relationships. Also, because of the use of claims data, drug compliance could not be guaranteed, and exposure may have been overestimated.
There is also the potential for selection bias, and no information on apolipoprotein E was available, they noted.
More data needed
In an accompanying editorial, Colleen J. Maxwell, PhD, University of Waterloo (Ont.), and colleagues wrote that the results “not only support previous studies showing the potential cognitive benefit of pioglitazone but also extend our understanding of this benefit through the mediating effect of reducing ischemic stroke.”
However, because of their associated risks, which include fractures, weight gain, heart failure, and bladder cancer, thiazolidinediones are not currently favored in diabetes management guidelines – and their use has significantly declined since the mid to late 2000s, the editorialists noted.
They agreed that it will be important to reassess the risk-benefit profile of pioglitazone in T2DM as additional findings emerge.
They also noted that sodium-glucose cotransporter-2 inhibitors, which have significant cardiovascular and renal benefits and minimal side effects, may also lower the risk for dementia.
“As both pioglitazone and SGLT-2 inhibitors are second-line options for physicians, the current decision would easily be in favor of SGLT-2 inhibitors given their safety profile,” Dr. Maxwell and colleagues wrote.
For now, pioglitazone “should not be used to prevent dementia in patients with T2DM,” they concluded.
The study was supported by grants from the National Research Foundation of Korea funded by the Korean government and the Ministry of Health and Welfare. The investigators and editorialists report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
new research suggests.
Overall, in a large cohort study from South Korea, patients who took pioglitazone were 16% less likely to develop dementia over an average of 10 years than peers who did not take the drug.
However, the dementia risk reduction was 54% among those with ischemic heart disease and 43% among those with a history of stroke.
“Our study was to see the association between pioglitazone use and incidence of dementia, not how (with what mechanisms) this drug can suppress dementia pathology,” coinvestigator Eosu Kim, MD, PhD, Yonsei University, Seoul, South Korea, said in an interview.
However, “as we found this drug is more effective in diabetic patients who have blood circulation problems in the heart or brain than in those without such problems, we speculate that pioglitazone’s antidementia action may be related to improving blood vessel’s health,” Dr. Kim said.
This finding suggests that pioglitazone could be used as a personalized treatment approach for dementia prevention in this subgroup of patients with diabetes, the researchers noted.
The results were published online in Neurology.
Dose-response relationship
Risk for dementia is doubled in adults with T2DM, the investigators wrote. Prior studies have suggested that pioglitazone may protect against dementia, as well as a first or recurrent stroke, in patients with T2DM.
This led Dr. Kim and colleagues to examine the effects of pioglitazone on dementia risk overall and in relation to stroke and ischemic heart disease.
Using the national Korean health database, the researchers identified 91,218 adults aged 50 and older with new-onset T2DM who did not have dementia. A total of 3,467 were treated with pioglitazone.
Pioglitazone exposure was defined as a total cumulative daily dose of 90 or more calculated from all dispensations during 4 years after T2DM diagnosis, with outcomes assessed after this period.
Over an average of 10 years, 8.3% of pioglitazone users developed dementia, compared with 10.0% of nonusers.
There was a statistically significant 16% lower risk for developing all-cause dementia among pioglitazone users than among nonusers (adjusted hazard ratio, 0.84; 95% confidence interval, 0.75-0.95).
A dose-response relationship was evident; pioglitazone users who received the highest cumulative daily dose were at lower risk for dementia (aHR, 0.72; 95% CI, 0.55-0.94).
Several limitations
The reduced risk for dementia was more pronounced among patients who used pioglitazone for 4 years in comparison with patients who did not use the drug (aHR, 0.63; 95% CI, 0.44-0.90).
The apparent protective effect of pioglitazone with regard to dementia was greater among those with a history of ischemic heart disease (aHR, 0.46; 95% CI, 0.24-0.90) or stroke (aHR, 0.57; 95% CI, 0.38-0.86) before diabetes diagnosis.
The incidence of stroke was also reduced with pioglitazone use (aHR, 0.81; 95% CI, 0.66-1.0).
“These results provide valuable information on who could potentially benefit from pioglitazone use for prevention of dementia,” Dr. Kim said in a news release.
However, “the risk and benefit balance of long-term use of this drug to prevent dementia should be prospectively assessed,” he said in an interview.
The researchers cautioned that the study was observational; hence, the reported associations cannot address causal relationships. Also, because of the use of claims data, drug compliance could not be guaranteed, and exposure may have been overestimated.
There is also the potential for selection bias, and no information on apolipoprotein E was available, they noted.
More data needed
In an accompanying editorial, Colleen J. Maxwell, PhD, University of Waterloo (Ont.), and colleagues wrote that the results “not only support previous studies showing the potential cognitive benefit of pioglitazone but also extend our understanding of this benefit through the mediating effect of reducing ischemic stroke.”
However, because of their associated risks, which include fractures, weight gain, heart failure, and bladder cancer, thiazolidinediones are not currently favored in diabetes management guidelines – and their use has significantly declined since the mid to late 2000s, the editorialists noted.
They agreed that it will be important to reassess the risk-benefit profile of pioglitazone in T2DM as additional findings emerge.
They also noted that sodium-glucose cotransporter-2 inhibitors, which have significant cardiovascular and renal benefits and minimal side effects, may also lower the risk for dementia.
“As both pioglitazone and SGLT-2 inhibitors are second-line options for physicians, the current decision would easily be in favor of SGLT-2 inhibitors given their safety profile,” Dr. Maxwell and colleagues wrote.
For now, pioglitazone “should not be used to prevent dementia in patients with T2DM,” they concluded.
The study was supported by grants from the National Research Foundation of Korea funded by the Korean government and the Ministry of Health and Welfare. The investigators and editorialists report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
new research suggests.
Overall, in a large cohort study from South Korea, patients who took pioglitazone were 16% less likely to develop dementia over an average of 10 years than peers who did not take the drug.
However, the dementia risk reduction was 54% among those with ischemic heart disease and 43% among those with a history of stroke.
“Our study was to see the association between pioglitazone use and incidence of dementia, not how (with what mechanisms) this drug can suppress dementia pathology,” coinvestigator Eosu Kim, MD, PhD, Yonsei University, Seoul, South Korea, said in an interview.
However, “as we found this drug is more effective in diabetic patients who have blood circulation problems in the heart or brain than in those without such problems, we speculate that pioglitazone’s antidementia action may be related to improving blood vessel’s health,” Dr. Kim said.
This finding suggests that pioglitazone could be used as a personalized treatment approach for dementia prevention in this subgroup of patients with diabetes, the researchers noted.
The results were published online in Neurology.
Dose-response relationship
Risk for dementia is doubled in adults with T2DM, the investigators wrote. Prior studies have suggested that pioglitazone may protect against dementia, as well as a first or recurrent stroke, in patients with T2DM.
This led Dr. Kim and colleagues to examine the effects of pioglitazone on dementia risk overall and in relation to stroke and ischemic heart disease.
Using the national Korean health database, the researchers identified 91,218 adults aged 50 and older with new-onset T2DM who did not have dementia. A total of 3,467 were treated with pioglitazone.
Pioglitazone exposure was defined as a total cumulative daily dose of 90 or more calculated from all dispensations during 4 years after T2DM diagnosis, with outcomes assessed after this period.
Over an average of 10 years, 8.3% of pioglitazone users developed dementia, compared with 10.0% of nonusers.
There was a statistically significant 16% lower risk for developing all-cause dementia among pioglitazone users than among nonusers (adjusted hazard ratio, 0.84; 95% confidence interval, 0.75-0.95).
A dose-response relationship was evident; pioglitazone users who received the highest cumulative daily dose were at lower risk for dementia (aHR, 0.72; 95% CI, 0.55-0.94).
Several limitations
The reduced risk for dementia was more pronounced among patients who used pioglitazone for 4 years in comparison with patients who did not use the drug (aHR, 0.63; 95% CI, 0.44-0.90).
The apparent protective effect of pioglitazone with regard to dementia was greater among those with a history of ischemic heart disease (aHR, 0.46; 95% CI, 0.24-0.90) or stroke (aHR, 0.57; 95% CI, 0.38-0.86) before diabetes diagnosis.
The incidence of stroke was also reduced with pioglitazone use (aHR, 0.81; 95% CI, 0.66-1.0).
“These results provide valuable information on who could potentially benefit from pioglitazone use for prevention of dementia,” Dr. Kim said in a news release.
However, “the risk and benefit balance of long-term use of this drug to prevent dementia should be prospectively assessed,” he said in an interview.
The researchers cautioned that the study was observational; hence, the reported associations cannot address causal relationships. Also, because of the use of claims data, drug compliance could not be guaranteed, and exposure may have been overestimated.
There is also the potential for selection bias, and no information on apolipoprotein E was available, they noted.
More data needed
In an accompanying editorial, Colleen J. Maxwell, PhD, University of Waterloo (Ont.), and colleagues wrote that the results “not only support previous studies showing the potential cognitive benefit of pioglitazone but also extend our understanding of this benefit through the mediating effect of reducing ischemic stroke.”
However, because of their associated risks, which include fractures, weight gain, heart failure, and bladder cancer, thiazolidinediones are not currently favored in diabetes management guidelines – and their use has significantly declined since the mid to late 2000s, the editorialists noted.
They agreed that it will be important to reassess the risk-benefit profile of pioglitazone in T2DM as additional findings emerge.
They also noted that sodium-glucose cotransporter-2 inhibitors, which have significant cardiovascular and renal benefits and minimal side effects, may also lower the risk for dementia.
“As both pioglitazone and SGLT-2 inhibitors are second-line options for physicians, the current decision would easily be in favor of SGLT-2 inhibitors given their safety profile,” Dr. Maxwell and colleagues wrote.
For now, pioglitazone “should not be used to prevent dementia in patients with T2DM,” they concluded.
The study was supported by grants from the National Research Foundation of Korea funded by the Korean government and the Ministry of Health and Welfare. The investigators and editorialists report no relevant financial relationships.
A version of this article originally appeared on Medscape.com.
FROM NEUROLOGY