TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include anemia and aspirin use in older adults, prescription of medications for alcohol use disorder in hospitalized patients, testosterone supplements and cardiovascular disease, and time-restricted eating and weight loss.
Program notes:
0:38 Aspirin and anemia in older adults
1:39 Had a 20% increased incidence of anemia
2:40 Tailor therapy over life course
2:50 Time-restricted eating versus calorie counting
3:50 About the same in both intervention groups
4:53 Testosterone supplements and the heart
5:53 Did not increase risk in men at heightened risk
6:53 An individual decision
7:15 Pharmacologic treatment initiation for alcohol use disorder
8:15 0.7% initiated treatment
9:15 Hospitalized with primary or secondary diagnosis
10:15 Were able to increase prescription in one study
11:20 End
Transcript:
Elizabeth: Does time-restricted eating result in weight loss?
Rick: Is testosterone-replacement therapy safe for your heart?
Elizabeth: How often are effective medications used for alcohol use disorder?
Rick: How does aspirin affect the incidence of anemia in the elderly?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine
Elizabeth: Rick, how about if we start with the oldest one first and that’s this issue of aspirin and anemia in older adults? It’s in Annals of Internal Medicine.
Rick: Since approximately 50% of older persons in the United States take aspirin for preventive uses, this is actually a pretty important topic. Concomitantly, anemia is pretty common as well in the elderly. Sometimes it’s just because they have chronic diseases like kidney disease and an inflammatory condition. Sometimes they’re iron-deficient. Then about a third of the time we just don’t know what causes it. We call it anemia of the elderly.
Because aspirin has dual effects, as an antiplatelet agent and it also is anti-inflammatory, the question is for older individuals taking aspirin, does it increase or decrease the incidence of anemia?
The investigators did a post-hoc analysis of a study. This was in aspirin in reducing events in the elderly. They took older individuals and put them on a low-dose aspirin (100 mg) just to see whether over the long term they would have a better life. They tested blood every year during the 5 years the study went on.
But what they found is that older individuals that took aspirin had a 20% increased incidence of anemia. You think, well, that’s because they had a lot more major bleeding. Actually, that wasn’t the case, but it’s just kind of occult blood loss that probably occurs in these individuals. I think we’re going to hear about using it less commonly in the elderly because of this and other potential complications associated with aspirin use.
Elizabeth: What’s your view on the alternative to that?
Rick: This is a balance between the risk and the harms. For individuals that clearly have heart disease or cerebrovascular disease, it’s beneficial. But let’s take a 70-year-old individual that is at low risk for cardiovascular disease and then you have this harm of anemia, a major bleeding. As this information comes in, I think we are better able to assess the harms versus the benefit in particular patient populations.
Elizabeth: Clearly, we have talked many times and it seems like more frequently about really having to tailor over the life course the implementation of different therapies. This sounds like it’s yet one more.
Rick: It is, because, Elizabeth, the incidence of anemia continues to grow the longer that you’re on aspirin.
Elizabeth: Staying in Annals of Internal Medicine, let’s turn to this issue — and again it’s a recurring one — about time-restricted eating in this population they did without calorie counting for weight loss, and it’s a racially diverse population.
They enrolled 90 adults with obesity. There were 77 who completed this study. Their mean age was 40 years, 33% of whom were Black and 46% were Hispanic. They said we’re going to compare time-restricted eating to calorie restriction to basically a control group. They followed these folks for a year.
The time period during which those folks who were on the time-restricted eating when they could actually consume calories was between noon and 8:00 p.m. Their calorie-reduction group was prescribed a 25% energy restriction from baseline, but were not asked to change that eating window.
They basically saw that at 1 year the weight losses were 3.5 and 4.3 kg in, respectively, the TRE — time-restricted eating — and calorie-restriction groups. The control group gained 1.1 kg, so there was no real statistical significance in the differences between time-restricted eating and calorie restriction in secondary outcomes looking at body composition, self-reported energy intake, steps per day, lipids, blood pressure, insulin, glucose, and hemoglobin A1C. They also provided in this study counseling, so that’s another important factor to be considered here.
Rick: I guess people are motivated differently. To me, time-restricted eating is pretty easy. You just decide you’re going to eat between noon and 8:00 p.m., you don’t worry about the calories, and you’re still able to lose weight. Now, you’re able to drink non-caloric beverages. It’s a pretty simple diet. There are some people that just can’t do that, and for them doing a caloric restriction where they count calories, look at food, is better. Both of them are effective and much more effective than just nutritional counseling.
Elizabeth: Clearly, some assessment of who are you and what’s your approach to things before attempting a diet is probably a good idea.
Rick: Absolutely.
Elizabeth: Let’s turn to this issue of testosterone and the heart.
Rick: This is the New England Journal of Medicine, Elizabeth. This is a very well-done study of over 5,000 men age 45 to 80 who had symptoms of low testosterone, decreased libido, decreased energy, decreased spontaneous erections, low/depressed mood, and hot flashes even.
They were assigned after documenting twice that they had low testosterone to either testosterone or placebo with the intention of determining did testosterone therapy increase the risk of cardiovascular events. These are men that had known cardiovascular disease or had multiple risk factors.
The reason they did this study was because back in 2015, the FDA issued guidance that required manufacturers of approved testosterone products to actually conduct these trials, because there were some conflicting data that testosterone therapy increased cardiovascular events.
They took high-risk men and put them on testosterone or placebo. What they discovered was that the testosterone administered as a gel did not increase the risk of cardiovascular events. However, there were some side effects. It doubled the risk of pulmonary embolism from about 0.5% to 0.9%. It increased the risk of atrial fibrillation from about 2% to about 5%.
Elizabeth: Talk to me about where you think this notion of low testosterone fits into when we talked about lifespan of men. Is it something that just declines anyway?
Rick: Testosterone does decline. There is no question about it. We know what the normal ranges are for age groups, but there are men that even within that have lower testosterone. We know that testosterone in older men improves sexual function. It increases bone mineral density. It can actually treat unexplained anemia.
Elizabeth: What would you say to a guy who says to you, “Look, I have got these symptoms and I’m going to try this gel,” with regard to these other risks?
Rick: I would certainly screen them, but what I would say is that even in men that have known cardiovascular disease or are at high risk of such it can be safely taken with regard to their cardiovascular disease. Again, this is an individual decision.
Now, the other thing I’d mention, Elizabeth, is it’s clear that it increases the risk of prostate cancer as well. This was a short-term study, and they specifically excluded men that had a previous history of prostate cancer.
Elizabeth: More coming, I bet, about this one. Let’s finally turn back to Annals of Internal Medicine and take a look at pharmacologic treatment initiation among Medicare beneficiaries who are hospitalized with alcohol use disorder.
I have a lot of sensitivity to this because on the MICU [medical intensive care unit], we see a lot of people who have acute liver problems as a result of alcohol use disorder. It turns out that there are 29 million adults in the United States who have this, and it contributes to more than 140,000 deaths annually. It turns out that there are treatments for this, pharmacologic treatments, that include naltrexone, acamprosate, disulfiram. They call this MAUD — medication for alcohol use disorder — treatment.
This study took a look at if you’re hospitalized and this is something that’s on your chart, how often is pharmacologic treatment actually initiated. Their cohort included over 20,000 alcohol use disorder hospitalizations representing over 20,000 unique patients. What they found was that MAUD treatment was initiated within 2 days of discharge in 0.7% of folks and in 1.3% within 30 days.
This is pretty pathetic as far as I’m concerned. They looked at what’s associated with initiation, younger age, and those who had access to psychiatry or addiction medicine.
Rick: You think that it would be treated with effective therapy. These therapies do one of two things. Either they decrease the craving for alcohol by changing the neurotransmitters or they actually cause aversive reactions when alcohol is ingested. All three of the agents that you mentioned have been approved by the FDA. They have been around since, I guess, the mid-1990s. They have been shown to be effective. Their safety profile is pretty good. To hear that less than 2% of individuals diagnosed with alcohol use disorder are actually prescribed these medications is very disturbing.
When you say these are individuals that were hospitalized, some of them were hospitalized for the alcohol use disorder. Some of them they were just noted to have it — that was a secondary diagnosis. Nevertheless, these are all individuals that could benefit from pharmacologic therapy, so this was really a sobering finding.
Elizabeth: Then some of the other factors that they were able to look out included regional variation and also significantly higher initiation among white people than among non-Hispanic Black people or Black people, which is just really troubling.
Rick: This is clearly a missed opportunity, because these patients are hospitalized. They are a captive audience. This is a unique opportunity to both make the diagnosis and to initiate therapy. We talked before about the paucity of inpatient addiction healthcare professionals. We need to pay attention to this and make these services and these medicines available.
Elizabeth: I would say that the editorialist notes that medication-assisted treatment of alcohol use disorder increased in one of their studies from 0% to 64% accompanied by a decrease in all-cause 30-day readmission rates and hospitalizations, which is a great thing.
The editorialists also suggest that hospitalists should become involved in the initiation of treatment. I would just note that in my observations of hospitalists in many respects it’s a lot like primary care docs in that there is just such a huge laundry list of things that they take care of. Adding this also just seems like it might be a big lift.
Rick: But how they did that in the study you mentioned was it was a part of the discharge protocol. When you discharge somebody, there are certain orders. You’re right. One of the things they did was they assessed their eligibility and they initiated them. Again, to go from 0% initiation in these drugs to 64% at the time of discharge shows us it can be done.
Elizabeth: On that good news note then, that’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. Y’all listen up and make healthy choices.
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