Latest News

More than one third of patients with cancer visited an emergency department (ED) in the 90 days before their diagnosis, according to a study of medical records from Ontario, Canada.

Researchers examined Institute for Clinical Evaluative Sciences (ICES) data that had been gathered from January 1, 2014, to December 31, 2021. The study focused on patients aged 18 years or older with confirmed primary cancer diagnoses.

Factors associated with an increased likelihood of an ED visit ahead of diagnosis included having certain cancers, living in rural areas, and having less access to primary care, according to study author Keerat Grewal, MD, an emergency physician and clinician scientist at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health in Toronto, Ontario, Canada, and coauthors.

“The ED is a distressing environment for patients to receive a possible cancer diagnosis,” the authors wrote. “Moreover, it is frequently ill equipped to provide ongoing continuity of care, which can lead patients down a poorly defined diagnostic pathway before receiving a confirmed diagnosis based on tissue and a subsequent treatment plan.”

The findings were published online on November 4 in CMAJ).
 

Neurologic Cancers Prominent

In an interview, Grewal said in an interview that the study reflects her desire as an emergency room physician to understand why so many patients with cancer get the initial reports about their disease from clinicians whom they often have just met for the first time.

Among patients with an ED visit before cancer diagnosis, 51.4% were admitted to hospital from the most recent visit.

Compared with patients with a family physician on whom they could rely for routine care, those who had no outpatient visits (odds ratio [OR], 2.09) or fewer than three outpatient visits (OR, 1.41) in the 6-30 months before cancer diagnosis were more likely to have an ED visit before their cancer diagnosis.

Other factors associated with increased odds of ED use before cancer diagnosis included rurality (OR, 1.15), residence in northern Ontario (northeast region: OR, 1.14 and northwest region: OR, 1.27 vs Toronto region), and living in the most marginalized areas (material resource deprivation: OR, 1.37 and housing stability: OR, 1.09 vs least marginalized area).

The researchers also found that patients with certain cancers were more likely to have sought care in the ED. They compared these cancers with breast cancer, which is often detected through screening.

“Patients with neurologic cancers had extremely high odds of ED use before cancer diagnosis,” the authors wrote. “This is likely because of the emergent nature of presentation, with acute neurologic symptoms such as weakness, confusion, or seizures, which require urgent assessment.” On the other hand, pancreatic, liver, or thoracic cancer can trigger nonspecific symptoms that may be ignored until they reach a crisis level that prompts an ED visit.

The limitations of the study included its inability to identify cancer-related ED visits and its narrow focus on patients in Ontario, according to the researchers. But the use of the ICES databases also allowed researchers access to a broader pool of data than are available in many other cases.

The findings in the new paper echo those of previous research, the authors noted. Research in the United Kingdom found that 24%-31% of cancer diagnoses involved the ED. In addition, a study of people enrolled in the US Medicare program, which serves patients aged 65 years or older, found that 23% were seen in the ED in the 30 days before diagnosis.
 

‘Unpacking the Data’

The current findings also are consistent with those of an International Cancer Benchmarking Partnership study that was published in 2022 in The Lancet Oncology, said Erika Nicholson, MHS, vice president of cancer systems and innovation at the Canadian Partnership Against Cancer. The latter study analyzed cancer registration and linked hospital admissions data from 14 jurisdictions in Australia, Canada, Denmark, New Zealand, Norway, and the United Kingdom.

“We see similar trends in terms of people visiting EDs and being diagnosed through EDs internationally,” Nicholson said. “We’re working with partners to put in place different strategies to address the challenges” that this phenomenon presents in terms of improving screening and follow-up care.

“Cancer is not one disease, but many diseases,” she said. “They present differently. We’re focused on really unpacking the data and understanding them.”

All this research highlights the need for more services and personnel to address cancer, including people who are trained to help patients cope after getting concerning news through emergency care, she said.

“That means having a system that fully supports you and helps you navigate through that diagnostic process,” Nicholson said. Addressing the added challenges for patients who don’t have secure housing is a special need, she added.

This study was supported by the Canadian Institutes of Health Research (CIHR). Grewal reported receiving grants from CIHR and the Canadian Association of Emergency Physicians. Nicholson reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

More than one third of patients with cancer visited an emergency department (ED) in the 90 days before their diagnosis, according to a study of medical records from Ontario, Canada.

Researchers examined Institute for Clinical Evaluative Sciences (ICES) data that had been gathered from January 1, 2014, to December 31, 2021. The study focused on patients aged 18 years or older with confirmed primary cancer diagnoses.

Factors associated with an increased likelihood of an ED visit ahead of diagnosis included having certain cancers, living in rural areas, and having less access to primary care, according to study author Keerat Grewal, MD, an emergency physician and clinician scientist at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health in Toronto, Ontario, Canada, and coauthors.

“The ED is a distressing environment for patients to receive a possible cancer diagnosis,” the authors wrote. “Moreover, it is frequently ill equipped to provide ongoing continuity of care, which can lead patients down a poorly defined diagnostic pathway before receiving a confirmed diagnosis based on tissue and a subsequent treatment plan.”

The findings were published online on November 4 in CMAJ).
 

Neurologic Cancers Prominent

In an interview, Grewal said in an interview that the study reflects her desire as an emergency room physician to understand why so many patients with cancer get the initial reports about their disease from clinicians whom they often have just met for the first time.

Among patients with an ED visit before cancer diagnosis, 51.4% were admitted to hospital from the most recent visit.

Compared with patients with a family physician on whom they could rely for routine care, those who had no outpatient visits (odds ratio [OR], 2.09) or fewer than three outpatient visits (OR, 1.41) in the 6-30 months before cancer diagnosis were more likely to have an ED visit before their cancer diagnosis.

Other factors associated with increased odds of ED use before cancer diagnosis included rurality (OR, 1.15), residence in northern Ontario (northeast region: OR, 1.14 and northwest region: OR, 1.27 vs Toronto region), and living in the most marginalized areas (material resource deprivation: OR, 1.37 and housing stability: OR, 1.09 vs least marginalized area).

The researchers also found that patients with certain cancers were more likely to have sought care in the ED. They compared these cancers with breast cancer, which is often detected through screening.

“Patients with neurologic cancers had extremely high odds of ED use before cancer diagnosis,” the authors wrote. “This is likely because of the emergent nature of presentation, with acute neurologic symptoms such as weakness, confusion, or seizures, which require urgent assessment.” On the other hand, pancreatic, liver, or thoracic cancer can trigger nonspecific symptoms that may be ignored until they reach a crisis level that prompts an ED visit.

The limitations of the study included its inability to identify cancer-related ED visits and its narrow focus on patients in Ontario, according to the researchers. But the use of the ICES databases also allowed researchers access to a broader pool of data than are available in many other cases.

The findings in the new paper echo those of previous research, the authors noted. Research in the United Kingdom found that 24%-31% of cancer diagnoses involved the ED. In addition, a study of people enrolled in the US Medicare program, which serves patients aged 65 years or older, found that 23% were seen in the ED in the 30 days before diagnosis.
 

‘Unpacking the Data’

The current findings also are consistent with those of an International Cancer Benchmarking Partnership study that was published in 2022 in The Lancet Oncology, said Erika Nicholson, MHS, vice president of cancer systems and innovation at the Canadian Partnership Against Cancer. The latter study analyzed cancer registration and linked hospital admissions data from 14 jurisdictions in Australia, Canada, Denmark, New Zealand, Norway, and the United Kingdom.

“We see similar trends in terms of people visiting EDs and being diagnosed through EDs internationally,” Nicholson said. “We’re working with partners to put in place different strategies to address the challenges” that this phenomenon presents in terms of improving screening and follow-up care.

“Cancer is not one disease, but many diseases,” she said. “They present differently. We’re focused on really unpacking the data and understanding them.”

All this research highlights the need for more services and personnel to address cancer, including people who are trained to help patients cope after getting concerning news through emergency care, she said.

“That means having a system that fully supports you and helps you navigate through that diagnostic process,” Nicholson said. Addressing the added challenges for patients who don’t have secure housing is a special need, she added.

This study was supported by the Canadian Institutes of Health Research (CIHR). Grewal reported receiving grants from CIHR and the Canadian Association of Emergency Physicians. Nicholson reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

More than one third of patients with cancer visited an emergency department (ED) in the 90 days before their diagnosis, according to a study of medical records from Ontario, Canada.

Researchers examined Institute for Clinical Evaluative Sciences (ICES) data that had been gathered from January 1, 2014, to December 31, 2021. The study focused on patients aged 18 years or older with confirmed primary cancer diagnoses.

Factors associated with an increased likelihood of an ED visit ahead of diagnosis included having certain cancers, living in rural areas, and having less access to primary care, according to study author Keerat Grewal, MD, an emergency physician and clinician scientist at the Schwartz/Reisman Emergency Medicine Institute at Sinai Health in Toronto, Ontario, Canada, and coauthors.

“The ED is a distressing environment for patients to receive a possible cancer diagnosis,” the authors wrote. “Moreover, it is frequently ill equipped to provide ongoing continuity of care, which can lead patients down a poorly defined diagnostic pathway before receiving a confirmed diagnosis based on tissue and a subsequent treatment plan.”

The findings were published online on November 4 in CMAJ).
 

Neurologic Cancers Prominent

In an interview, Grewal said in an interview that the study reflects her desire as an emergency room physician to understand why so many patients with cancer get the initial reports about their disease from clinicians whom they often have just met for the first time.

Among patients with an ED visit before cancer diagnosis, 51.4% were admitted to hospital from the most recent visit.

Compared with patients with a family physician on whom they could rely for routine care, those who had no outpatient visits (odds ratio [OR], 2.09) or fewer than three outpatient visits (OR, 1.41) in the 6-30 months before cancer diagnosis were more likely to have an ED visit before their cancer diagnosis.

Other factors associated with increased odds of ED use before cancer diagnosis included rurality (OR, 1.15), residence in northern Ontario (northeast region: OR, 1.14 and northwest region: OR, 1.27 vs Toronto region), and living in the most marginalized areas (material resource deprivation: OR, 1.37 and housing stability: OR, 1.09 vs least marginalized area).

The researchers also found that patients with certain cancers were more likely to have sought care in the ED. They compared these cancers with breast cancer, which is often detected through screening.

“Patients with neurologic cancers had extremely high odds of ED use before cancer diagnosis,” the authors wrote. “This is likely because of the emergent nature of presentation, with acute neurologic symptoms such as weakness, confusion, or seizures, which require urgent assessment.” On the other hand, pancreatic, liver, or thoracic cancer can trigger nonspecific symptoms that may be ignored until they reach a crisis level that prompts an ED visit.

The limitations of the study included its inability to identify cancer-related ED visits and its narrow focus on patients in Ontario, according to the researchers. But the use of the ICES databases also allowed researchers access to a broader pool of data than are available in many other cases.

The findings in the new paper echo those of previous research, the authors noted. Research in the United Kingdom found that 24%-31% of cancer diagnoses involved the ED. In addition, a study of people enrolled in the US Medicare program, which serves patients aged 65 years or older, found that 23% were seen in the ED in the 30 days before diagnosis.
 

‘Unpacking the Data’

The current findings also are consistent with those of an International Cancer Benchmarking Partnership study that was published in 2022 in The Lancet Oncology, said Erika Nicholson, MHS, vice president of cancer systems and innovation at the Canadian Partnership Against Cancer. The latter study analyzed cancer registration and linked hospital admissions data from 14 jurisdictions in Australia, Canada, Denmark, New Zealand, Norway, and the United Kingdom.

“We see similar trends in terms of people visiting EDs and being diagnosed through EDs internationally,” Nicholson said. “We’re working with partners to put in place different strategies to address the challenges” that this phenomenon presents in terms of improving screening and follow-up care.

“Cancer is not one disease, but many diseases,” she said. “They present differently. We’re focused on really unpacking the data and understanding them.”

All this research highlights the need for more services and personnel to address cancer, including people who are trained to help patients cope after getting concerning news through emergency care, she said.

“That means having a system that fully supports you and helps you navigate through that diagnostic process,” Nicholson said. Addressing the added challenges for patients who don’t have secure housing is a special need, she added.

This study was supported by the Canadian Institutes of Health Research (CIHR). Grewal reported receiving grants from CIHR and the Canadian Association of Emergency Physicians. Nicholson reported no relevant financial relationships.

A version of this article appeared on Medscape.com.

TOPLINE:

COVID-19 infection increases the risk for autoimmune blistering diseases (AIBDs), specifically pemphigus and bullous pemphigoid, according to a study that also found that vaccination against COVID-19 is associated with a reduced risk for these conditions.

METHODOLOGY:

• Researchers conducted a population-based retrospective cohort study using data from the TriNetX Analytics Network, encompassing over 112 million electronic health records in the United States.
• The study compared the risk for AIBD within 3 months among individuals who had COVID-19 infection and no COVID-19 vaccination 6 months prior to the infection (n = 4,787,106), individuals who had COVID-19 vaccination but did not have COVID-19 infection (n = 3,466,536), and individuals who did not have COVID-19 infection or vaccination (n = 5,609,197).
• The mean age of the three groups was 44.9, 52.3, and 49.3 years, respectively.
• Propensity score matching included 4,408,748 individuals each for the comparison between COVID-19 infection and controls, 3,465,420 for COVID-19 vaccination and controls, and 3,362,850 for COVID-19 infection and vaccination. The mean follow-up ranged from 72.2 to 76.3 days.

TAKEAWAY:

• Individuals with COVID-19 infection showed a 50.8% increased risk for AIBD within 3 months (P < .001) compared with those without infection or vaccination. The risk was more pronounced for pemphigus (hazard ratio [HR], 2.432; P < .001) than bullous pemphigoid (HR, 1.376; P = .036).
• On the contrary, individuals who had the COVID-19 vaccination showed almost half the risk for AIBD (HR, 0.514; P < .001). The risk reduction was significant for pemphigus (HR, 0.477; P = .030), but not for bullous pemphigoid (HR, 0.846).
• When the infection and vaccination groups were compared, COVID-19 infection increased AIBD risk by more than threefold (HR, 3.130; P < .001), with a particularly high risk for pemphigus (HR, 5.508; P < .001). A significant risk was also seen for bullous pemphigoid (HR, 1.587; P = .008).

IN PRACTICE:

“The findings underscore the importance of vaccination not only in preventing severe COVID-19 outcomes but also in potentially protecting against autoimmune complications,” the authors wrote, adding that “this potential dual benefit of vaccination should be a key message in public health campaigns and clinical practice to enhance vaccine uptake and ultimately improve health outcomes.”

SOURCE:

The study was led by Philip Curman, MD, PhD, of the Dermato-Venereology Clinic at Karolinska University Hospital, Stockholm, Sweden, and was published online on November 7 in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The retrospective design has inherent biases, there is potential underreporting of COVID-19 cases and vaccinations, and there is misallocation of individuals. Unmeasured confounding factors may be present.

DISCLOSURES:

This study was funded by grant from the State of Schleswig-Holstein. Two authors were employees of TriNetX. Some authors received financial support and travel grants from various sources, including TriNetX. Additional disclosures are noted in the article.
 

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

TOPLINE:

COVID-19 infection increases the risk for autoimmune blistering diseases (AIBDs), specifically pemphigus and bullous pemphigoid, according to a study that also found that vaccination against COVID-19 is associated with a reduced risk for these conditions.

METHODOLOGY:

• Researchers conducted a population-based retrospective cohort study using data from the TriNetX Analytics Network, encompassing over 112 million electronic health records in the United States.
• The study compared the risk for AIBD within 3 months among individuals who had COVID-19 infection and no COVID-19 vaccination 6 months prior to the infection (n = 4,787,106), individuals who had COVID-19 vaccination but did not have COVID-19 infection (n = 3,466,536), and individuals who did not have COVID-19 infection or vaccination (n = 5,609,197).
• The mean age of the three groups was 44.9, 52.3, and 49.3 years, respectively.
• Propensity score matching included 4,408,748 individuals each for the comparison between COVID-19 infection and controls, 3,465,420 for COVID-19 vaccination and controls, and 3,362,850 for COVID-19 infection and vaccination. The mean follow-up ranged from 72.2 to 76.3 days.

TAKEAWAY:

• Individuals with COVID-19 infection showed a 50.8% increased risk for AIBD within 3 months (P < .001) compared with those without infection or vaccination. The risk was more pronounced for pemphigus (hazard ratio [HR], 2.432; P < .001) than bullous pemphigoid (HR, 1.376; P = .036).
• On the contrary, individuals who had the COVID-19 vaccination showed almost half the risk for AIBD (HR, 0.514; P < .001). The risk reduction was significant for pemphigus (HR, 0.477; P = .030), but not for bullous pemphigoid (HR, 0.846).
• When the infection and vaccination groups were compared, COVID-19 infection increased AIBD risk by more than threefold (HR, 3.130; P < .001), with a particularly high risk for pemphigus (HR, 5.508; P < .001). A significant risk was also seen for bullous pemphigoid (HR, 1.587; P = .008).

IN PRACTICE:

“The findings underscore the importance of vaccination not only in preventing severe COVID-19 outcomes but also in potentially protecting against autoimmune complications,” the authors wrote, adding that “this potential dual benefit of vaccination should be a key message in public health campaigns and clinical practice to enhance vaccine uptake and ultimately improve health outcomes.”

SOURCE:

The study was led by Philip Curman, MD, PhD, of the Dermato-Venereology Clinic at Karolinska University Hospital, Stockholm, Sweden, and was published online on November 7 in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The retrospective design has inherent biases, there is potential underreporting of COVID-19 cases and vaccinations, and there is misallocation of individuals. Unmeasured confounding factors may be present.

DISCLOSURES:

This study was funded by grant from the State of Schleswig-Holstein. Two authors were employees of TriNetX. Some authors received financial support and travel grants from various sources, including TriNetX. Additional disclosures are noted in the article.
 

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

TOPLINE:

COVID-19 infection increases the risk for autoimmune blistering diseases (AIBDs), specifically pemphigus and bullous pemphigoid, according to a study that also found that vaccination against COVID-19 is associated with a reduced risk for these conditions.

METHODOLOGY:

• Researchers conducted a population-based retrospective cohort study using data from the TriNetX Analytics Network, encompassing over 112 million electronic health records in the United States.
• The study compared the risk for AIBD within 3 months among individuals who had COVID-19 infection and no COVID-19 vaccination 6 months prior to the infection (n = 4,787,106), individuals who had COVID-19 vaccination but did not have COVID-19 infection (n = 3,466,536), and individuals who did not have COVID-19 infection or vaccination (n = 5,609,197).
• The mean age of the three groups was 44.9, 52.3, and 49.3 years, respectively.
• Propensity score matching included 4,408,748 individuals each for the comparison between COVID-19 infection and controls, 3,465,420 for COVID-19 vaccination and controls, and 3,362,850 for COVID-19 infection and vaccination. The mean follow-up ranged from 72.2 to 76.3 days.

TAKEAWAY:

• Individuals with COVID-19 infection showed a 50.8% increased risk for AIBD within 3 months (P < .001) compared with those without infection or vaccination. The risk was more pronounced for pemphigus (hazard ratio [HR], 2.432; P < .001) than bullous pemphigoid (HR, 1.376; P = .036).
• On the contrary, individuals who had the COVID-19 vaccination showed almost half the risk for AIBD (HR, 0.514; P < .001). The risk reduction was significant for pemphigus (HR, 0.477; P = .030), but not for bullous pemphigoid (HR, 0.846).
• When the infection and vaccination groups were compared, COVID-19 infection increased AIBD risk by more than threefold (HR, 3.130; P < .001), with a particularly high risk for pemphigus (HR, 5.508; P < .001). A significant risk was also seen for bullous pemphigoid (HR, 1.587; P = .008).

IN PRACTICE:

“The findings underscore the importance of vaccination not only in preventing severe COVID-19 outcomes but also in potentially protecting against autoimmune complications,” the authors wrote, adding that “this potential dual benefit of vaccination should be a key message in public health campaigns and clinical practice to enhance vaccine uptake and ultimately improve health outcomes.”

SOURCE:

The study was led by Philip Curman, MD, PhD, of the Dermato-Venereology Clinic at Karolinska University Hospital, Stockholm, Sweden, and was published online on November 7 in the Journal of the American Academy of Dermatology.

LIMITATIONS:

The retrospective design has inherent biases, there is potential underreporting of COVID-19 cases and vaccinations, and there is misallocation of individuals. Unmeasured confounding factors may be present.

DISCLOSURES:

This study was funded by grant from the State of Schleswig-Holstein. Two authors were employees of TriNetX. Some authors received financial support and travel grants from various sources, including TriNetX. Additional disclosures are noted in the article.
 

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

TOPLINE: 

Topical ivermectin treatment was found to increase Staphylococcus epidermidis on the skin of patients with rosacea, in addition to reducing density of Demodex, in a small study. 

METHODOLOGY:

• In this single-center, open label study, 10 adults (mean age, 66.4 years) with papulopustular rosacea were treated with 1% ivermectin cream daily for 12 weeks.
• Skin swabs from lesional and nonlesional sites were collected at baseline and after 3 months of treatment to assess changes in the bacterial microbiome and the density of Demodex mites.
• The average baseline total papule count was 26.9, and the Clinician’s Erythema Assessment (CEA) score was 2 (average value on a scale of 0-4 from five locations on the face).
• For comparison, baseline swabs were taken from 10 healthy age-matched individuals.

TAKEAWAY:

• The density of Demodex mites was significantly reduced on lesional skin (P = .002) with topical ivermectin, which has anthelmintic effects against Demodex and is an effective treatment for rosacea.
• The absolute abundance of S epidermidis increased after ivermectin treatment on lesional skin (P = .039), while no changes were seen in Cutibacterium acnes.
• No changes were noted on nonlesional skin in the patients with rosacea.
• Topical ivermectin also reduced the number of papules and CEA scores (both P = .002) in individuals with rosacea.

IN PRACTICE:

“Treatment with topical ivermectin may improve the symptoms of rosacea through modulation of the skin microbiome beyond decreasing Demodex,” the authors concluded. “The results of this study,” they added, “provide valuable insights into the intricacies of the cutaneous microbiome in the pathophysiology of rosacea and highlight the potential therapeutic interventions targeting the skin microbiome.”

SOURCE:

The study was led by Teruaki Nakatsuji, PhD, of the department of dermatology, University of California, San Diego. It was published online on October 29 in the Journal of Investigative Dermatology.

LIMITATIONS: 

The small sample size of 10 patients with rosacea limits the generalizability of the findings, and the study’s open-label design may introduce bias in the clinical assessments. Further research with larger sample sizes and randomized controlled trials is needed to confirm these findings.

DISCLOSURES:

This work was funded by a grant from the National Rosacea Society. One author disclosed being the cofounder and consultant, with equity interest in MatriSys Bioscience. The other authors reported no competing interests.

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

TOPLINE: 

Topical ivermectin treatment was found to increase Staphylococcus epidermidis on the skin of patients with rosacea, in addition to reducing density of Demodex, in a small study. 

METHODOLOGY:

• In this single-center, open label study, 10 adults (mean age, 66.4 years) with papulopustular rosacea were treated with 1% ivermectin cream daily for 12 weeks.
• Skin swabs from lesional and nonlesional sites were collected at baseline and after 3 months of treatment to assess changes in the bacterial microbiome and the density of Demodex mites.
• The average baseline total papule count was 26.9, and the Clinician’s Erythema Assessment (CEA) score was 2 (average value on a scale of 0-4 from five locations on the face).
• For comparison, baseline swabs were taken from 10 healthy age-matched individuals.

TAKEAWAY:

• The density of Demodex mites was significantly reduced on lesional skin (P = .002) with topical ivermectin, which has anthelmintic effects against Demodex and is an effective treatment for rosacea.
• The absolute abundance of S epidermidis increased after ivermectin treatment on lesional skin (P = .039), while no changes were seen in Cutibacterium acnes.
• No changes were noted on nonlesional skin in the patients with rosacea.
• Topical ivermectin also reduced the number of papules and CEA scores (both P = .002) in individuals with rosacea.

IN PRACTICE:

“Treatment with topical ivermectin may improve the symptoms of rosacea through modulation of the skin microbiome beyond decreasing Demodex,” the authors concluded. “The results of this study,” they added, “provide valuable insights into the intricacies of the cutaneous microbiome in the pathophysiology of rosacea and highlight the potential therapeutic interventions targeting the skin microbiome.”

SOURCE:

The study was led by Teruaki Nakatsuji, PhD, of the department of dermatology, University of California, San Diego. It was published online on October 29 in the Journal of Investigative Dermatology.

LIMITATIONS: 

The small sample size of 10 patients with rosacea limits the generalizability of the findings, and the study’s open-label design may introduce bias in the clinical assessments. Further research with larger sample sizes and randomized controlled trials is needed to confirm these findings.

DISCLOSURES:

This work was funded by a grant from the National Rosacea Society. One author disclosed being the cofounder and consultant, with equity interest in MatriSys Bioscience. The other authors reported no competing interests.

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

TOPLINE: 

Topical ivermectin treatment was found to increase Staphylococcus epidermidis on the skin of patients with rosacea, in addition to reducing density of Demodex, in a small study. 

METHODOLOGY:

• In this single-center, open label study, 10 adults (mean age, 66.4 years) with papulopustular rosacea were treated with 1% ivermectin cream daily for 12 weeks.
• Skin swabs from lesional and nonlesional sites were collected at baseline and after 3 months of treatment to assess changes in the bacterial microbiome and the density of Demodex mites.
• The average baseline total papule count was 26.9, and the Clinician’s Erythema Assessment (CEA) score was 2 (average value on a scale of 0-4 from five locations on the face).
• For comparison, baseline swabs were taken from 10 healthy age-matched individuals.

TAKEAWAY:

• The density of Demodex mites was significantly reduced on lesional skin (P = .002) with topical ivermectin, which has anthelmintic effects against Demodex and is an effective treatment for rosacea.
• The absolute abundance of S epidermidis increased after ivermectin treatment on lesional skin (P = .039), while no changes were seen in Cutibacterium acnes.
• No changes were noted on nonlesional skin in the patients with rosacea.
• Topical ivermectin also reduced the number of papules and CEA scores (both P = .002) in individuals with rosacea.

IN PRACTICE:

“Treatment with topical ivermectin may improve the symptoms of rosacea through modulation of the skin microbiome beyond decreasing Demodex,” the authors concluded. “The results of this study,” they added, “provide valuable insights into the intricacies of the cutaneous microbiome in the pathophysiology of rosacea and highlight the potential therapeutic interventions targeting the skin microbiome.”

SOURCE:

The study was led by Teruaki Nakatsuji, PhD, of the department of dermatology, University of California, San Diego. It was published online on October 29 in the Journal of Investigative Dermatology.

LIMITATIONS: 

The small sample size of 10 patients with rosacea limits the generalizability of the findings, and the study’s open-label design may introduce bias in the clinical assessments. Further research with larger sample sizes and randomized controlled trials is needed to confirm these findings.

DISCLOSURES:

This work was funded by a grant from the National Rosacea Society. One author disclosed being the cofounder and consultant, with equity interest in MatriSys Bioscience. The other authors reported no competing interests.

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

Veterans Health Administration cancer centers are lacking registered dieticians (RDs), and patients are more likely to be diagnosed with malnutrition when they are on staff, according to a new study.

The average number of full-time RDs across 13 cancer centers was just 1 per 1,065 patients, advanced practice oncology dietitian Katherine Petersen, MS, RDN, CSO, of the Phoenix VA Health Care System, reported at the AVAHO annual meeting.

However, patients treated by RDs were more likely to be diagnosed with malnutrition (odds ratio [OR], 2.9, 95% CI, 1.6-5.1). And patients were more likely to maintain weight if their clinic had a higher ratio of RDs to oncologists (OR, 1.6 for each 10% increase in ratio, 95% CI, 2.0-127.5).

Petersen told Federal Practitioner that dieticians came up with the idea for the study after attending AVAHO meetings. “A lot of the questions we were getting from physicians and other providers were: How do we get dietitians in our clinic?”

There is currently no standard staffing model for dieticians in oncology centers, Petersen said, and they are not reimbursed through Medicare or Medicaid. “We thought, ‘What do we add to the cancer center by having adequate staffing levels and seeing cancer patients?’ We designed a study to try and get to the heart of that.”

Petersen and her team focused on malnutrition. Nutrition impairment impacts an estimated 40% to 80% of patients with gastrointestinal, head and neck, pancreas, and colorectal cancer at diagnosis, she said.

Petersen discussed the published evidence that outlines how physicians recognize malnutrition at a lower rate than RDs. Dietary counseling from an RD is linked to better nutritional outcomes, physical function, and quality of life.

The study authors examined 2016 and 2017 VA registry data and reviewed charts of 681 veterans treated by 207 oncologists. Oncology clinics had a mean of 0.5 full-time equivalent (FTE) RD. The mean ratio of full-time RDs to oncologists was 1 per 48.5 and ranged from 1 per 4 to 1 per 850.

“It's almost like somebody randomly assigned [RDs] to cancer centers, and it has nothing to do with how many patients are seen in that particular center,” Petersen said. “Some clinics only have .1 or .2 FTEs assigned, and that may be a larger cancer center where they have maybe 85 cancer oncology providers, which includes surgical, medical, and radiation oncology and trainees.”

Why would a clinic have a .1 FTE RD, which suggests someone may be working 4 hours a week? In this kind of situation, an RD may cover a variety of areas and only work in cancer care when they receive a referral, Petersen said.

“That is just vastly underserving veterans,” she said. “You're missing so many veterans whom you could help with preventative care if you're only getting patients referred based on consults.”

As for the findings regarding higher RD staffing and higher detection of malnutrition, the study text notes “there was not a ‘high enough’ level of RD staffing at which we stopped seeing this trend. This is probably because – at least at the time of this study – no VA cancer center was adequately staffed for nutrition.”

Petersen hopes the findings will convince VA cancer center leadership to boost better patient outcomes by prioritizing the hiring of RDs.

Katherine Petersen, MS, RDN, CSO has no disclosures.

Veterans Health Administration cancer centers are lacking registered dieticians (RDs), and patients are more likely to be diagnosed with malnutrition when they are on staff, according to a new study.

The average number of full-time RDs across 13 cancer centers was just 1 per 1,065 patients, advanced practice oncology dietitian Katherine Petersen, MS, RDN, CSO, of the Phoenix VA Health Care System, reported at the AVAHO annual meeting.

However, patients treated by RDs were more likely to be diagnosed with malnutrition (odds ratio [OR], 2.9, 95% CI, 1.6-5.1). And patients were more likely to maintain weight if their clinic had a higher ratio of RDs to oncologists (OR, 1.6 for each 10% increase in ratio, 95% CI, 2.0-127.5).

Petersen told Federal Practitioner that dieticians came up with the idea for the study after attending AVAHO meetings. “A lot of the questions we were getting from physicians and other providers were: How do we get dietitians in our clinic?”

There is currently no standard staffing model for dieticians in oncology centers, Petersen said, and they are not reimbursed through Medicare or Medicaid. “We thought, ‘What do we add to the cancer center by having adequate staffing levels and seeing cancer patients?’ We designed a study to try and get to the heart of that.”

Petersen and her team focused on malnutrition. Nutrition impairment impacts an estimated 40% to 80% of patients with gastrointestinal, head and neck, pancreas, and colorectal cancer at diagnosis, she said.

Petersen discussed the published evidence that outlines how physicians recognize malnutrition at a lower rate than RDs. Dietary counseling from an RD is linked to better nutritional outcomes, physical function, and quality of life.

The study authors examined 2016 and 2017 VA registry data and reviewed charts of 681 veterans treated by 207 oncologists. Oncology clinics had a mean of 0.5 full-time equivalent (FTE) RD. The mean ratio of full-time RDs to oncologists was 1 per 48.5 and ranged from 1 per 4 to 1 per 850.

“It's almost like somebody randomly assigned [RDs] to cancer centers, and it has nothing to do with how many patients are seen in that particular center,” Petersen said. “Some clinics only have .1 or .2 FTEs assigned, and that may be a larger cancer center where they have maybe 85 cancer oncology providers, which includes surgical, medical, and radiation oncology and trainees.”

Why would a clinic have a .1 FTE RD, which suggests someone may be working 4 hours a week? In this kind of situation, an RD may cover a variety of areas and only work in cancer care when they receive a referral, Petersen said.

“That is just vastly underserving veterans,” she said. “You're missing so many veterans whom you could help with preventative care if you're only getting patients referred based on consults.”

As for the findings regarding higher RD staffing and higher detection of malnutrition, the study text notes “there was not a ‘high enough’ level of RD staffing at which we stopped seeing this trend. This is probably because – at least at the time of this study – no VA cancer center was adequately staffed for nutrition.”

Petersen hopes the findings will convince VA cancer center leadership to boost better patient outcomes by prioritizing the hiring of RDs.

Katherine Petersen, MS, RDN, CSO has no disclosures.

Veterans Health Administration cancer centers are lacking registered dieticians (RDs), and patients are more likely to be diagnosed with malnutrition when they are on staff, according to a new study.

The average number of full-time RDs across 13 cancer centers was just 1 per 1,065 patients, advanced practice oncology dietitian Katherine Petersen, MS, RDN, CSO, of the Phoenix VA Health Care System, reported at the AVAHO annual meeting.

However, patients treated by RDs were more likely to be diagnosed with malnutrition (odds ratio [OR], 2.9, 95% CI, 1.6-5.1). And patients were more likely to maintain weight if their clinic had a higher ratio of RDs to oncologists (OR, 1.6 for each 10% increase in ratio, 95% CI, 2.0-127.5).

Petersen told Federal Practitioner that dieticians came up with the idea for the study after attending AVAHO meetings. “A lot of the questions we were getting from physicians and other providers were: How do we get dietitians in our clinic?”

There is currently no standard staffing model for dieticians in oncology centers, Petersen said, and they are not reimbursed through Medicare or Medicaid. “We thought, ‘What do we add to the cancer center by having adequate staffing levels and seeing cancer patients?’ We designed a study to try and get to the heart of that.”

Petersen and her team focused on malnutrition. Nutrition impairment impacts an estimated 40% to 80% of patients with gastrointestinal, head and neck, pancreas, and colorectal cancer at diagnosis, she said.

Petersen discussed the published evidence that outlines how physicians recognize malnutrition at a lower rate than RDs. Dietary counseling from an RD is linked to better nutritional outcomes, physical function, and quality of life.

The study authors examined 2016 and 2017 VA registry data and reviewed charts of 681 veterans treated by 207 oncologists. Oncology clinics had a mean of 0.5 full-time equivalent (FTE) RD. The mean ratio of full-time RDs to oncologists was 1 per 48.5 and ranged from 1 per 4 to 1 per 850.

“It's almost like somebody randomly assigned [RDs] to cancer centers, and it has nothing to do with how many patients are seen in that particular center,” Petersen said. “Some clinics only have .1 or .2 FTEs assigned, and that may be a larger cancer center where they have maybe 85 cancer oncology providers, which includes surgical, medical, and radiation oncology and trainees.”

Why would a clinic have a .1 FTE RD, which suggests someone may be working 4 hours a week? In this kind of situation, an RD may cover a variety of areas and only work in cancer care when they receive a referral, Petersen said.

“That is just vastly underserving veterans,” she said. “You're missing so many veterans whom you could help with preventative care if you're only getting patients referred based on consults.”

As for the findings regarding higher RD staffing and higher detection of malnutrition, the study text notes “there was not a ‘high enough’ level of RD staffing at which we stopped seeing this trend. This is probably because – at least at the time of this study – no VA cancer center was adequately staffed for nutrition.”

Petersen hopes the findings will convince VA cancer center leadership to boost better patient outcomes by prioritizing the hiring of RDs.

Katherine Petersen, MS, RDN, CSO has no disclosures.

TOPLINE:

Rituximab and cyclophosphamide are equally effective in achieving remission or low disease activity rates in childhood-onset antineutrophil cytoplasmic antibody–associated vasculitis (AAV), and those who received rituximab required a significantly lower steroid dose than those who received cyclophosphamide or a combination therapy.

METHODOLOGY:

• Researchers evaluated the efficacy of rituximab, cyclophosphamide, or a combination of both in pediatric patients diagnosed with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis.
• A total of 104 patients (median age at diagnosis, 14 years; 67% girls) were included from A Registry of Childhood Vasculitis; the majority had a diagnosis of GPA (81%) and renal involvement (87%). Overall, induction therapy involved rituximab for 43%, cyclophosphamide for 46%, and a combination of both for 11% patients.
• The primary endpoint was the rate of achieving remission (Pediatric Vasculitis Activity Score [PVAS] of 0) or low disease activity (PVAS ≤ 2) at the post-induction visit (4-6 months after diagnosis).
• The secondary endpoints were the degree of disease-related damage at 12- and 24-month visits and rates of drug-related hospitalization occurring between the diagnosis and post-induction visits.

TAKEAWAY:

• At the post-induction visit, 63% patients achieved remission or low disease activity, with the rates being similar between patients who received rituximab and those who received cyclophosphamide (64% vs 62%).
• Patients treated with rituximab required a significantly lower median steroid dose (0.13 mg/kg per day) than those treated with cyclophosphamide (0.3 mg/kg per day) or the combination therapy (0.3 mg/kg per day; P < .001) at the post-induction visit.
• Overall, 61% and 56% patients receiving rituximab and cyclophosphamide, respectively, had disease-related damage measure on the Pediatric Vasculitis Damage Index at the 12-month visit; however, the degree of damage was low.
• The percentage of patients requiring hospitalization was higher in the rituximab group than in the cyclophosphamide group (22% vs 10%), primarily stemming from drug- or infection-related causes (11% vs 2%).

IN PRACTICE:

“The results of this study may assist with current clinical decision-making with regard to the choice of induction medications in childhood-onset AAV and will complement the ongoing [Childhood Arthritis and Rheumatology Research Alliance] prospective [consensus treatment plans] study,” the authors wrote.

SOURCE:

This study was led by Samuel J. Gagne, MD, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center in Pennsylvania, and was published online in Arthritis Care & Research.

LIMITATIONS:

Study limitations included the inconsistencies in glucocorticoid dosing, which may have affected remission rates. Moreover, data on the adverse events not requiring hospitalization and long-term adverse events were not captured.

DISCLOSURES:

This study received funding through a Nationwide Children’s Hospital intramural grant award. The authors reported no potential conflicts of interest.

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

TOPLINE:

Rituximab and cyclophosphamide are equally effective in achieving remission or low disease activity rates in childhood-onset antineutrophil cytoplasmic antibody–associated vasculitis (AAV), and those who received rituximab required a significantly lower steroid dose than those who received cyclophosphamide or a combination therapy.

METHODOLOGY:

• Researchers evaluated the efficacy of rituximab, cyclophosphamide, or a combination of both in pediatric patients diagnosed with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis.
• A total of 104 patients (median age at diagnosis, 14 years; 67% girls) were included from A Registry of Childhood Vasculitis; the majority had a diagnosis of GPA (81%) and renal involvement (87%). Overall, induction therapy involved rituximab for 43%, cyclophosphamide for 46%, and a combination of both for 11% patients.
• The primary endpoint was the rate of achieving remission (Pediatric Vasculitis Activity Score [PVAS] of 0) or low disease activity (PVAS ≤ 2) at the post-induction visit (4-6 months after diagnosis).
• The secondary endpoints were the degree of disease-related damage at 12- and 24-month visits and rates of drug-related hospitalization occurring between the diagnosis and post-induction visits.

TAKEAWAY:

• At the post-induction visit, 63% patients achieved remission or low disease activity, with the rates being similar between patients who received rituximab and those who received cyclophosphamide (64% vs 62%).
• Patients treated with rituximab required a significantly lower median steroid dose (0.13 mg/kg per day) than those treated with cyclophosphamide (0.3 mg/kg per day) or the combination therapy (0.3 mg/kg per day; P < .001) at the post-induction visit.
• Overall, 61% and 56% patients receiving rituximab and cyclophosphamide, respectively, had disease-related damage measure on the Pediatric Vasculitis Damage Index at the 12-month visit; however, the degree of damage was low.
• The percentage of patients requiring hospitalization was higher in the rituximab group than in the cyclophosphamide group (22% vs 10%), primarily stemming from drug- or infection-related causes (11% vs 2%).

IN PRACTICE:

“The results of this study may assist with current clinical decision-making with regard to the choice of induction medications in childhood-onset AAV and will complement the ongoing [Childhood Arthritis and Rheumatology Research Alliance] prospective [consensus treatment plans] study,” the authors wrote.

SOURCE:

This study was led by Samuel J. Gagne, MD, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center in Pennsylvania, and was published online in Arthritis Care & Research.

LIMITATIONS:

Study limitations included the inconsistencies in glucocorticoid dosing, which may have affected remission rates. Moreover, data on the adverse events not requiring hospitalization and long-term adverse events were not captured.

DISCLOSURES:

This study received funding through a Nationwide Children’s Hospital intramural grant award. The authors reported no potential conflicts of interest.

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

TOPLINE:

Rituximab and cyclophosphamide are equally effective in achieving remission or low disease activity rates in childhood-onset antineutrophil cytoplasmic antibody–associated vasculitis (AAV), and those who received rituximab required a significantly lower steroid dose than those who received cyclophosphamide or a combination therapy.

METHODOLOGY:

• Researchers evaluated the efficacy of rituximab, cyclophosphamide, or a combination of both in pediatric patients diagnosed with granulomatosis with polyangiitis (GPA) or microscopic polyangiitis.
• A total of 104 patients (median age at diagnosis, 14 years; 67% girls) were included from A Registry of Childhood Vasculitis; the majority had a diagnosis of GPA (81%) and renal involvement (87%). Overall, induction therapy involved rituximab for 43%, cyclophosphamide for 46%, and a combination of both for 11% patients.
• The primary endpoint was the rate of achieving remission (Pediatric Vasculitis Activity Score [PVAS] of 0) or low disease activity (PVAS ≤ 2) at the post-induction visit (4-6 months after diagnosis).
• The secondary endpoints were the degree of disease-related damage at 12- and 24-month visits and rates of drug-related hospitalization occurring between the diagnosis and post-induction visits.

TAKEAWAY:

• At the post-induction visit, 63% patients achieved remission or low disease activity, with the rates being similar between patients who received rituximab and those who received cyclophosphamide (64% vs 62%).
• Patients treated with rituximab required a significantly lower median steroid dose (0.13 mg/kg per day) than those treated with cyclophosphamide (0.3 mg/kg per day) or the combination therapy (0.3 mg/kg per day; P < .001) at the post-induction visit.
• Overall, 61% and 56% patients receiving rituximab and cyclophosphamide, respectively, had disease-related damage measure on the Pediatric Vasculitis Damage Index at the 12-month visit; however, the degree of damage was low.
• The percentage of patients requiring hospitalization was higher in the rituximab group than in the cyclophosphamide group (22% vs 10%), primarily stemming from drug- or infection-related causes (11% vs 2%).

IN PRACTICE:

“The results of this study may assist with current clinical decision-making with regard to the choice of induction medications in childhood-onset AAV and will complement the ongoing [Childhood Arthritis and Rheumatology Research Alliance] prospective [consensus treatment plans] study,” the authors wrote.

SOURCE:

This study was led by Samuel J. Gagne, MD, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center in Pennsylvania, and was published online in Arthritis Care & Research.

LIMITATIONS:

Study limitations included the inconsistencies in glucocorticoid dosing, which may have affected remission rates. Moreover, data on the adverse events not requiring hospitalization and long-term adverse events were not captured.

DISCLOSURES:

This study received funding through a Nationwide Children’s Hospital intramural grant award. The authors reported no potential conflicts of interest.

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

This transcript has been edited for clarity. 

This episode of Medicine Matters reviews highlights from the Advisory Committee on Immunization Practices’ (ACIP’s) October 2024 meeting, with new recommendations for pneumococcal, COVID, and meningococcal B (Men B) vaccines, as well as a safety update for maternal RSV vaccination.

Pneumococcal Vaccination and New Lower Age-Based Recommendations 

New age-based recommendation. ACIP has lowered the age for routine vaccination with the pneumococcal conjugate vaccine (PCV) from age 65 down to age 50, but only with PCV. Review of data revealed that more than half of those in the 50- to 64-year-old age group already had a risk indication to receive a PCV dose. In addition, rates of invasive pneumococcal disease peak at younger ages in Black patients compared with White patients. The rate of invasive pneumococcal disease (IPD) among Black adults aged 50 or older exceeds the average rate of IPD for all adults aged 65 or older. The goal of this age-based change is to reduce disease in demographic groups with the highest burden of disease. 

The new expanded age-based recommendation applies only to vaccination with PCV. Conjugate vaccines trigger memory B-cell production and therefore induce greater long-term immunity. New research is now focusing on higher-valent PCV vaccines. Two 24-valent pneumococcal conjugate vaccines and one 31-valent pneumococcal conjugate vaccine are now in advanced stages of development.

Risk-based recommendation. A risk-based recommendation for ages 19 through 49 years still applies to those with certain medical conditions, including diabetes; chronic heart, lung, liver, or kidney disease; and also for those with immunocompromising conditions. Risk-based recommendations are harder to implement particularly because many vaccines are now administered in pharmacies and pharmacists don’t know the patients as well as their physicians do, so it’s harder for them to know who should get the vaccine if the recommendation is based on risk.

COVID-19 Vaccines With Additional Dose Recommendations 

Everyone 6 months or older is recommended to receive a dose of the updated 2024-2025 COVID vaccine. An additional updated COVID vaccine dose is now recommended for everyone aged 65 or older, and for those aged 6 months or older with immunocompromising (moderate or severe) conditions. Review of data revealed that 1 in 6 patients hospitalized with COVID have an immunocompromising condition, and 70% of COVID hospitalizations are in those aged 65 or older. This older age group also has the highest death rates due to COVID-19. We know that vaccination protection wanes with time. Data from previous studies show that additional vaccine doses provide additional protection. Additional doses are now being recommended for those at highest risk.

Timing of additional doses. This second dose is recommended at 6 months after the last updated COVID-19 vaccine dose. However, the additional dose can be given as early as 2 months after the last dose. Those who recently had COVID-19 can wait 3 months before getting an additional vaccine dose. This flexibility allows patients to maximize additional protection by timing additional doses around travel and life events, such as weddings, family get-togethers, or chemotherapy.

Those with immunocompromising conditions may receive more doses. Patients with immunocompromising conditions can receive even more additional doses, if recommended by their physician, under shared clinical decision-making. 

Meningococcal Vaccines

Meningococcal disease is rare but deadly. The disease can progress rapidly. As many as 10%-15% of people with meningococcal infection die, even with appropriate antibiotic therapy. And for those who survive, about 20% suffer long-term sequalae (cognitive deficits, hearing loss, limb amputations).

Aligning Men B vaccine dosing intervals. The new ACIP vote applies only to Men B vaccines, of which there are two: one by GSK (brand name Bexsero), and the other by Wyeth, a Pfizer subsidiary (brand name Trumenba). The two MenB vaccine products are not interchangeable. The same type of MenB vaccine has to be used to complete the series.

The MenB vaccines initially had different dosing schedules and now they don’t. ACIP voted to harmonize and align the dosing schedule for the two different MenB products to mirror recent FDA (Food and Drug Administration) labeling updates. So now the dosing recommendations for both MenB vaccines are the same: either two doses given 6 months apart to healthy adolescents and young adults, or a three-dose series given at zero, 1-2 months, and 6 months for those at high risk or for those who want to optimize rapid protection (for example, if they are starting the series within 6 months of going off to college). But understand that the current recommendation for MenB vaccination for healthy adolescents and young adults is based on shared clinical decision-making, preferably for those aged 16-18.

MenACWY. Two doses of MenACWY are routinely recommended, with the first dose at age 11-12 and a second dose at age 16. The MenACWY vaccines are interchangeable.

Implementation challenges and new pentavalent vaccines. Having to use the same MenB vaccine product for all doses in a patient’s series is difficult. It’s even more difficult when the patient needs both MenACWY and MenB vaccinations. 

Adding to the complexity is a new pentavalent vaccine from Pfizer (brand name Penbraya) that combines MenACWY with the MenB vaccine. And another pentavalent vaccine version by GSK is up for regulatory decision in February 2025.

The work group did say that they plan to take a fresh look at the meningococcal vaccination schedule. Let’s hope it gets simpler, so more to come on that.
 

Respiratory Syncytial Virus (RSV) Vaccines 

Current RSV vaccine recommendations for older adults. RSV vaccine has both age- and risk-based recommendations. Now, everyone aged 75 or older needs a dose of RSV vaccine. Adults aged 60-75 with risk factors for severe RSV are also recommended to receive a dose of RSV vaccine, but not adults without these risk factors. The conditions associated with increased risk for severe RSV disease include lung disease, heart disease, immune compromise, diabetes, obesity with BMI (body mass index) of 40 or higher, neurologic or neuromuscular conditions, chronic kidney disease, liver disorders, and hematologic disorders. Frailty, as well as living in a nursing home or other long-term care facility, are other risk factors for severe RSV disease. Those aged 60-75 without these risk factors are no longer recommended to receive it. 

Three RSV vaccines. We now have three RSV vaccine to choose from. Two are protein subunit vaccines. One is by Pfizer (brand name Abrysvo) that does not contain an adjuvant. The other protein-based RSV vaccine by GSK (brand name Arexvy) does contain an adjuvant. The third RSV vaccine by Moderna (brand name mRESVIA) uses an mRNA platform, and durability of protection is still unclear. However, recent studies now suggest that the RSV protein subunit vaccines confer 36 months of protection rather than only 24 months. 

All three RSV vaccines are licensed for those aged 60 or older. The age indication for GSK’s RSV vaccine, Arexvy, has already been lowered by the FDA to age 50. FDA recently lowered the age approval for Abrysvo to age 18 for those at high risk. However, ACIP has not yet expanded its age recommendations for getting these vaccines. One of the main hesitations is vaccine safety concerns. FDA›s safety update presented to ACIP still suggests an increased risk for Guillain-Barré syndrome with both protein-based RSV vaccines among those aged 65 or older. Fortunately, the risk is rare: less than 10 cases per million vaccinations. 

RSV immunization for infant protection. RSV season starts in October and goes through March. We now have two new ways to protect babies. One is a maternal RSV vaccine, given at 32-36 weeks of pregnancy to moms who will deliver their babies during RSV season. But only Pfizer’s RSV vaccine (brand name Abrysvo, without an adjuvant) can be given during pregnancy. 

A maternal RSV vaccine safety update, presented at ACIP, was reassuring. Abrysvo was not associated with increased risk for preterm birth or small gestational age at birth. 

Nirsevimab, a long-acting monoclonal antibody, can be given to infants. Nirsevimab is indicated for all babies under 8 months of age entering their first RSV season. 

People who received a maternal RSV vaccine during a previous pregnancy are not recommended to receive additional doses during subsequent pregnancies. However, infants born to women who were vaccinated during a prior pregnancy should receive nirsevimab.

Sandra Adamson Fryhofer, Adjunct Clinical Associate Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia, has disclosed conflicts of interest with the American Medical Association, the Medical Association of Atlanta, ACIP, and Medscape.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity. 

This episode of Medicine Matters reviews highlights from the Advisory Committee on Immunization Practices’ (ACIP’s) October 2024 meeting, with new recommendations for pneumococcal, COVID, and meningococcal B (Men B) vaccines, as well as a safety update for maternal RSV vaccination.

Pneumococcal Vaccination and New Lower Age-Based Recommendations 

New age-based recommendation. ACIP has lowered the age for routine vaccination with the pneumococcal conjugate vaccine (PCV) from age 65 down to age 50, but only with PCV. Review of data revealed that more than half of those in the 50- to 64-year-old age group already had a risk indication to receive a PCV dose. In addition, rates of invasive pneumococcal disease peak at younger ages in Black patients compared with White patients. The rate of invasive pneumococcal disease (IPD) among Black adults aged 50 or older exceeds the average rate of IPD for all adults aged 65 or older. The goal of this age-based change is to reduce disease in demographic groups with the highest burden of disease. 

The new expanded age-based recommendation applies only to vaccination with PCV. Conjugate vaccines trigger memory B-cell production and therefore induce greater long-term immunity. New research is now focusing on higher-valent PCV vaccines. Two 24-valent pneumococcal conjugate vaccines and one 31-valent pneumococcal conjugate vaccine are now in advanced stages of development.

Risk-based recommendation. A risk-based recommendation for ages 19 through 49 years still applies to those with certain medical conditions, including diabetes; chronic heart, lung, liver, or kidney disease; and also for those with immunocompromising conditions. Risk-based recommendations are harder to implement particularly because many vaccines are now administered in pharmacies and pharmacists don’t know the patients as well as their physicians do, so it’s harder for them to know who should get the vaccine if the recommendation is based on risk.

COVID-19 Vaccines With Additional Dose Recommendations 

Everyone 6 months or older is recommended to receive a dose of the updated 2024-2025 COVID vaccine. An additional updated COVID vaccine dose is now recommended for everyone aged 65 or older, and for those aged 6 months or older with immunocompromising (moderate or severe) conditions. Review of data revealed that 1 in 6 patients hospitalized with COVID have an immunocompromising condition, and 70% of COVID hospitalizations are in those aged 65 or older. This older age group also has the highest death rates due to COVID-19. We know that vaccination protection wanes with time. Data from previous studies show that additional vaccine doses provide additional protection. Additional doses are now being recommended for those at highest risk.

Timing of additional doses. This second dose is recommended at 6 months after the last updated COVID-19 vaccine dose. However, the additional dose can be given as early as 2 months after the last dose. Those who recently had COVID-19 can wait 3 months before getting an additional vaccine dose. This flexibility allows patients to maximize additional protection by timing additional doses around travel and life events, such as weddings, family get-togethers, or chemotherapy.

Those with immunocompromising conditions may receive more doses. Patients with immunocompromising conditions can receive even more additional doses, if recommended by their physician, under shared clinical decision-making. 

Meningococcal Vaccines

Meningococcal disease is rare but deadly. The disease can progress rapidly. As many as 10%-15% of people with meningococcal infection die, even with appropriate antibiotic therapy. And for those who survive, about 20% suffer long-term sequalae (cognitive deficits, hearing loss, limb amputations).

Aligning Men B vaccine dosing intervals. The new ACIP vote applies only to Men B vaccines, of which there are two: one by GSK (brand name Bexsero), and the other by Wyeth, a Pfizer subsidiary (brand name Trumenba). The two MenB vaccine products are not interchangeable. The same type of MenB vaccine has to be used to complete the series.

The MenB vaccines initially had different dosing schedules and now they don’t. ACIP voted to harmonize and align the dosing schedule for the two different MenB products to mirror recent FDA (Food and Drug Administration) labeling updates. So now the dosing recommendations for both MenB vaccines are the same: either two doses given 6 months apart to healthy adolescents and young adults, or a three-dose series given at zero, 1-2 months, and 6 months for those at high risk or for those who want to optimize rapid protection (for example, if they are starting the series within 6 months of going off to college). But understand that the current recommendation for MenB vaccination for healthy adolescents and young adults is based on shared clinical decision-making, preferably for those aged 16-18.

MenACWY. Two doses of MenACWY are routinely recommended, with the first dose at age 11-12 and a second dose at age 16. The MenACWY vaccines are interchangeable.

Implementation challenges and new pentavalent vaccines. Having to use the same MenB vaccine product for all doses in a patient’s series is difficult. It’s even more difficult when the patient needs both MenACWY and MenB vaccinations. 

Adding to the complexity is a new pentavalent vaccine from Pfizer (brand name Penbraya) that combines MenACWY with the MenB vaccine. And another pentavalent vaccine version by GSK is up for regulatory decision in February 2025.

The work group did say that they plan to take a fresh look at the meningococcal vaccination schedule. Let’s hope it gets simpler, so more to come on that.
 

Respiratory Syncytial Virus (RSV) Vaccines 

Current RSV vaccine recommendations for older adults. RSV vaccine has both age- and risk-based recommendations. Now, everyone aged 75 or older needs a dose of RSV vaccine. Adults aged 60-75 with risk factors for severe RSV are also recommended to receive a dose of RSV vaccine, but not adults without these risk factors. The conditions associated with increased risk for severe RSV disease include lung disease, heart disease, immune compromise, diabetes, obesity with BMI (body mass index) of 40 or higher, neurologic or neuromuscular conditions, chronic kidney disease, liver disorders, and hematologic disorders. Frailty, as well as living in a nursing home or other long-term care facility, are other risk factors for severe RSV disease. Those aged 60-75 without these risk factors are no longer recommended to receive it. 

Three RSV vaccines. We now have three RSV vaccine to choose from. Two are protein subunit vaccines. One is by Pfizer (brand name Abrysvo) that does not contain an adjuvant. The other protein-based RSV vaccine by GSK (brand name Arexvy) does contain an adjuvant. The third RSV vaccine by Moderna (brand name mRESVIA) uses an mRNA platform, and durability of protection is still unclear. However, recent studies now suggest that the RSV protein subunit vaccines confer 36 months of protection rather than only 24 months. 

All three RSV vaccines are licensed for those aged 60 or older. The age indication for GSK’s RSV vaccine, Arexvy, has already been lowered by the FDA to age 50. FDA recently lowered the age approval for Abrysvo to age 18 for those at high risk. However, ACIP has not yet expanded its age recommendations for getting these vaccines. One of the main hesitations is vaccine safety concerns. FDA›s safety update presented to ACIP still suggests an increased risk for Guillain-Barré syndrome with both protein-based RSV vaccines among those aged 65 or older. Fortunately, the risk is rare: less than 10 cases per million vaccinations. 

RSV immunization for infant protection. RSV season starts in October and goes through March. We now have two new ways to protect babies. One is a maternal RSV vaccine, given at 32-36 weeks of pregnancy to moms who will deliver their babies during RSV season. But only Pfizer’s RSV vaccine (brand name Abrysvo, without an adjuvant) can be given during pregnancy. 

A maternal RSV vaccine safety update, presented at ACIP, was reassuring. Abrysvo was not associated with increased risk for preterm birth or small gestational age at birth. 

Nirsevimab, a long-acting monoclonal antibody, can be given to infants. Nirsevimab is indicated for all babies under 8 months of age entering their first RSV season. 

People who received a maternal RSV vaccine during a previous pregnancy are not recommended to receive additional doses during subsequent pregnancies. However, infants born to women who were vaccinated during a prior pregnancy should receive nirsevimab.

Sandra Adamson Fryhofer, Adjunct Clinical Associate Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia, has disclosed conflicts of interest with the American Medical Association, the Medical Association of Atlanta, ACIP, and Medscape.

A version of this article first appeared on Medscape.com.

This transcript has been edited for clarity. 

This episode of Medicine Matters reviews highlights from the Advisory Committee on Immunization Practices’ (ACIP’s) October 2024 meeting, with new recommendations for pneumococcal, COVID, and meningococcal B (Men B) vaccines, as well as a safety update for maternal RSV vaccination.

Pneumococcal Vaccination and New Lower Age-Based Recommendations 

New age-based recommendation. ACIP has lowered the age for routine vaccination with the pneumococcal conjugate vaccine (PCV) from age 65 down to age 50, but only with PCV. Review of data revealed that more than half of those in the 50- to 64-year-old age group already had a risk indication to receive a PCV dose. In addition, rates of invasive pneumococcal disease peak at younger ages in Black patients compared with White patients. The rate of invasive pneumococcal disease (IPD) among Black adults aged 50 or older exceeds the average rate of IPD for all adults aged 65 or older. The goal of this age-based change is to reduce disease in demographic groups with the highest burden of disease. 

The new expanded age-based recommendation applies only to vaccination with PCV. Conjugate vaccines trigger memory B-cell production and therefore induce greater long-term immunity. New research is now focusing on higher-valent PCV vaccines. Two 24-valent pneumococcal conjugate vaccines and one 31-valent pneumococcal conjugate vaccine are now in advanced stages of development.

Risk-based recommendation. A risk-based recommendation for ages 19 through 49 years still applies to those with certain medical conditions, including diabetes; chronic heart, lung, liver, or kidney disease; and also for those with immunocompromising conditions. Risk-based recommendations are harder to implement particularly because many vaccines are now administered in pharmacies and pharmacists don’t know the patients as well as their physicians do, so it’s harder for them to know who should get the vaccine if the recommendation is based on risk.

COVID-19 Vaccines With Additional Dose Recommendations 

Everyone 6 months or older is recommended to receive a dose of the updated 2024-2025 COVID vaccine. An additional updated COVID vaccine dose is now recommended for everyone aged 65 or older, and for those aged 6 months or older with immunocompromising (moderate or severe) conditions. Review of data revealed that 1 in 6 patients hospitalized with COVID have an immunocompromising condition, and 70% of COVID hospitalizations are in those aged 65 or older. This older age group also has the highest death rates due to COVID-19. We know that vaccination protection wanes with time. Data from previous studies show that additional vaccine doses provide additional protection. Additional doses are now being recommended for those at highest risk.

Timing of additional doses. This second dose is recommended at 6 months after the last updated COVID-19 vaccine dose. However, the additional dose can be given as early as 2 months after the last dose. Those who recently had COVID-19 can wait 3 months before getting an additional vaccine dose. This flexibility allows patients to maximize additional protection by timing additional doses around travel and life events, such as weddings, family get-togethers, or chemotherapy.

Those with immunocompromising conditions may receive more doses. Patients with immunocompromising conditions can receive even more additional doses, if recommended by their physician, under shared clinical decision-making. 

Meningococcal Vaccines

Meningococcal disease is rare but deadly. The disease can progress rapidly. As many as 10%-15% of people with meningococcal infection die, even with appropriate antibiotic therapy. And for those who survive, about 20% suffer long-term sequalae (cognitive deficits, hearing loss, limb amputations).

Aligning Men B vaccine dosing intervals. The new ACIP vote applies only to Men B vaccines, of which there are two: one by GSK (brand name Bexsero), and the other by Wyeth, a Pfizer subsidiary (brand name Trumenba). The two MenB vaccine products are not interchangeable. The same type of MenB vaccine has to be used to complete the series.

The MenB vaccines initially had different dosing schedules and now they don’t. ACIP voted to harmonize and align the dosing schedule for the two different MenB products to mirror recent FDA (Food and Drug Administration) labeling updates. So now the dosing recommendations for both MenB vaccines are the same: either two doses given 6 months apart to healthy adolescents and young adults, or a three-dose series given at zero, 1-2 months, and 6 months for those at high risk or for those who want to optimize rapid protection (for example, if they are starting the series within 6 months of going off to college). But understand that the current recommendation for MenB vaccination for healthy adolescents and young adults is based on shared clinical decision-making, preferably for those aged 16-18.

MenACWY. Two doses of MenACWY are routinely recommended, with the first dose at age 11-12 and a second dose at age 16. The MenACWY vaccines are interchangeable.

Implementation challenges and new pentavalent vaccines. Having to use the same MenB vaccine product for all doses in a patient’s series is difficult. It’s even more difficult when the patient needs both MenACWY and MenB vaccinations. 

Adding to the complexity is a new pentavalent vaccine from Pfizer (brand name Penbraya) that combines MenACWY with the MenB vaccine. And another pentavalent vaccine version by GSK is up for regulatory decision in February 2025.

The work group did say that they plan to take a fresh look at the meningococcal vaccination schedule. Let’s hope it gets simpler, so more to come on that.
 

Respiratory Syncytial Virus (RSV) Vaccines 

Current RSV vaccine recommendations for older adults. RSV vaccine has both age- and risk-based recommendations. Now, everyone aged 75 or older needs a dose of RSV vaccine. Adults aged 60-75 with risk factors for severe RSV are also recommended to receive a dose of RSV vaccine, but not adults without these risk factors. The conditions associated with increased risk for severe RSV disease include lung disease, heart disease, immune compromise, diabetes, obesity with BMI (body mass index) of 40 or higher, neurologic or neuromuscular conditions, chronic kidney disease, liver disorders, and hematologic disorders. Frailty, as well as living in a nursing home or other long-term care facility, are other risk factors for severe RSV disease. Those aged 60-75 without these risk factors are no longer recommended to receive it. 

Three RSV vaccines. We now have three RSV vaccine to choose from. Two are protein subunit vaccines. One is by Pfizer (brand name Abrysvo) that does not contain an adjuvant. The other protein-based RSV vaccine by GSK (brand name Arexvy) does contain an adjuvant. The third RSV vaccine by Moderna (brand name mRESVIA) uses an mRNA platform, and durability of protection is still unclear. However, recent studies now suggest that the RSV protein subunit vaccines confer 36 months of protection rather than only 24 months. 

All three RSV vaccines are licensed for those aged 60 or older. The age indication for GSK’s RSV vaccine, Arexvy, has already been lowered by the FDA to age 50. FDA recently lowered the age approval for Abrysvo to age 18 for those at high risk. However, ACIP has not yet expanded its age recommendations for getting these vaccines. One of the main hesitations is vaccine safety concerns. FDA›s safety update presented to ACIP still suggests an increased risk for Guillain-Barré syndrome with both protein-based RSV vaccines among those aged 65 or older. Fortunately, the risk is rare: less than 10 cases per million vaccinations. 

RSV immunization for infant protection. RSV season starts in October and goes through March. We now have two new ways to protect babies. One is a maternal RSV vaccine, given at 32-36 weeks of pregnancy to moms who will deliver their babies during RSV season. But only Pfizer’s RSV vaccine (brand name Abrysvo, without an adjuvant) can be given during pregnancy. 

A maternal RSV vaccine safety update, presented at ACIP, was reassuring. Abrysvo was not associated with increased risk for preterm birth or small gestational age at birth. 

Nirsevimab, a long-acting monoclonal antibody, can be given to infants. Nirsevimab is indicated for all babies under 8 months of age entering their first RSV season. 

People who received a maternal RSV vaccine during a previous pregnancy are not recommended to receive additional doses during subsequent pregnancies. However, infants born to women who were vaccinated during a prior pregnancy should receive nirsevimab.

Sandra Adamson Fryhofer, Adjunct Clinical Associate Professor of Medicine, Emory University School of Medicine, Atlanta, Georgia, has disclosed conflicts of interest with the American Medical Association, the Medical Association of Atlanta, ACIP, and Medscape.

A version of this article first appeared on Medscape.com.

TOPLINE:

Individuals at an increased risk of developing rheumatoid arthritis (RA) have a unique gut microbial composition, characterized by a notable increase in certain strains of Prevotella bacteria. These changes begin approximately 10 months prior to the onset of RA.

METHODOLOGY:

• In this cross-sectional and longitudinal observational study, researchers aimed to identify microbial associations in the early stages of RA, focusing specifically on Prevotellaceae strains.
• The cross-sectional analysis assessed the gut microbiome profiles of 124 individuals at risk of developing RA, 7 patients with newly diagnosed RA, and 22 healthy control individuals free of musculoskeletal symptoms at five different time points over a period of 15 months; 30 patients progressed to RA during the study period.
• The longitudinal analysis was performed in 19 individuals at risk of developing RA, of whom 5 progressed to the condition.
• The risk of developing RA was identified by the presence of anti–cyclic citrullinated protein (anti-CCP) antibodies and the onset of musculoskeletal pain in the preceding 3 months.
• Gut microbiome taxonomic alterations were investigated using 16S rRNA amplicon sequencing and confirmed with shotgun metagenomic DNA sequencing of 49 samples.

TAKEAWAY:

• Gut microbial diversity, particularly alpha diversity, was notably reduced in CCP+ individuals at risk of developing RA vs healthy control individuals (P = .012). Recognized risk factors for RA development such as the presence of rheumatoid factor antibodies and the human leukocyte antigen shared epitope, were significantly linked to diminished gut microbial diversity, in addition to steroid use.
• A specific Prevotellaceae strain (ASV2058) was found to be overabundant in CCP+ individuals at risk of developing RA and in those newly diagnosed with the condition but not in healthy control individuals. Further analysis showed that enrichment and depletion of three and five strains of Prevotellaceae, respectively, were associated with the progression to RA in CCP+ individuals.
• CCP+ individuals who progressed to RA were found to have substantial fluctuations in gut microbiome profiles around 10 months before clinical diagnosis; however, these profiles were relatively stable 10-15 months before the onset of RA, suggesting that changes in the microbiome occur at a later stage.
• Patients with new-onset RA were found to have distinct metabolic shifts, particularly in pathways related to amino acid and energy metabolism.

IN PRACTICE:

“Individuals at risk of RA harbor a distinctive gut microbial composition, including but not limited to an overabundance of Prevotellaceae species. This microbial signature is consistent and correlates with traditional RA risk factors,” the authors wrote.

SOURCE:

The study was led by Christopher M. Rooney, MD, PhD, University of Leeds in England. It was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small longitudinal sample size and lack of a 1:1 longitudinal comparison between CCP+ individuals at risk for RA and healthy control individuals were major limitations of this study. The new-onset RA cohort was heterogeneous, reflecting the practical constraints of recruitment from standard care clinics. Integrated transcriptomic or metabolomic data were unavailable, restricting interpretation to potential rather than confirmed metabolic activity.

DISCLOSURES:

This study was funded by personal fellowships received by the lead author from Versus Arthritis, Leeds Cares, and a National Institute for Health Research Clinical Lectureship. Some authors disclosed receiving grants, funding, consulting fees, or honoraria from various pharmaceutical companies.

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

TOPLINE:

Individuals at an increased risk of developing rheumatoid arthritis (RA) have a unique gut microbial composition, characterized by a notable increase in certain strains of Prevotella bacteria. These changes begin approximately 10 months prior to the onset of RA.

METHODOLOGY:

• In this cross-sectional and longitudinal observational study, researchers aimed to identify microbial associations in the early stages of RA, focusing specifically on Prevotellaceae strains.
• The cross-sectional analysis assessed the gut microbiome profiles of 124 individuals at risk of developing RA, 7 patients with newly diagnosed RA, and 22 healthy control individuals free of musculoskeletal symptoms at five different time points over a period of 15 months; 30 patients progressed to RA during the study period.
• The longitudinal analysis was performed in 19 individuals at risk of developing RA, of whom 5 progressed to the condition.
• The risk of developing RA was identified by the presence of anti–cyclic citrullinated protein (anti-CCP) antibodies and the onset of musculoskeletal pain in the preceding 3 months.
• Gut microbiome taxonomic alterations were investigated using 16S rRNA amplicon sequencing and confirmed with shotgun metagenomic DNA sequencing of 49 samples.

TAKEAWAY:

• Gut microbial diversity, particularly alpha diversity, was notably reduced in CCP+ individuals at risk of developing RA vs healthy control individuals (P = .012). Recognized risk factors for RA development such as the presence of rheumatoid factor antibodies and the human leukocyte antigen shared epitope, were significantly linked to diminished gut microbial diversity, in addition to steroid use.
• A specific Prevotellaceae strain (ASV2058) was found to be overabundant in CCP+ individuals at risk of developing RA and in those newly diagnosed with the condition but not in healthy control individuals. Further analysis showed that enrichment and depletion of three and five strains of Prevotellaceae, respectively, were associated with the progression to RA in CCP+ individuals.
• CCP+ individuals who progressed to RA were found to have substantial fluctuations in gut microbiome profiles around 10 months before clinical diagnosis; however, these profiles were relatively stable 10-15 months before the onset of RA, suggesting that changes in the microbiome occur at a later stage.
• Patients with new-onset RA were found to have distinct metabolic shifts, particularly in pathways related to amino acid and energy metabolism.

IN PRACTICE:

“Individuals at risk of RA harbor a distinctive gut microbial composition, including but not limited to an overabundance of Prevotellaceae species. This microbial signature is consistent and correlates with traditional RA risk factors,” the authors wrote.

SOURCE:

The study was led by Christopher M. Rooney, MD, PhD, University of Leeds in England. It was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small longitudinal sample size and lack of a 1:1 longitudinal comparison between CCP+ individuals at risk for RA and healthy control individuals were major limitations of this study. The new-onset RA cohort was heterogeneous, reflecting the practical constraints of recruitment from standard care clinics. Integrated transcriptomic or metabolomic data were unavailable, restricting interpretation to potential rather than confirmed metabolic activity.

DISCLOSURES:

This study was funded by personal fellowships received by the lead author from Versus Arthritis, Leeds Cares, and a National Institute for Health Research Clinical Lectureship. Some authors disclosed receiving grants, funding, consulting fees, or honoraria from various pharmaceutical companies.

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

TOPLINE:

Individuals at an increased risk of developing rheumatoid arthritis (RA) have a unique gut microbial composition, characterized by a notable increase in certain strains of Prevotella bacteria. These changes begin approximately 10 months prior to the onset of RA.

METHODOLOGY:

• In this cross-sectional and longitudinal observational study, researchers aimed to identify microbial associations in the early stages of RA, focusing specifically on Prevotellaceae strains.
• The cross-sectional analysis assessed the gut microbiome profiles of 124 individuals at risk of developing RA, 7 patients with newly diagnosed RA, and 22 healthy control individuals free of musculoskeletal symptoms at five different time points over a period of 15 months; 30 patients progressed to RA during the study period.
• The longitudinal analysis was performed in 19 individuals at risk of developing RA, of whom 5 progressed to the condition.
• The risk of developing RA was identified by the presence of anti–cyclic citrullinated protein (anti-CCP) antibodies and the onset of musculoskeletal pain in the preceding 3 months.
• Gut microbiome taxonomic alterations were investigated using 16S rRNA amplicon sequencing and confirmed with shotgun metagenomic DNA sequencing of 49 samples.

TAKEAWAY:

• Gut microbial diversity, particularly alpha diversity, was notably reduced in CCP+ individuals at risk of developing RA vs healthy control individuals (P = .012). Recognized risk factors for RA development such as the presence of rheumatoid factor antibodies and the human leukocyte antigen shared epitope, were significantly linked to diminished gut microbial diversity, in addition to steroid use.
• A specific Prevotellaceae strain (ASV2058) was found to be overabundant in CCP+ individuals at risk of developing RA and in those newly diagnosed with the condition but not in healthy control individuals. Further analysis showed that enrichment and depletion of three and five strains of Prevotellaceae, respectively, were associated with the progression to RA in CCP+ individuals.
• CCP+ individuals who progressed to RA were found to have substantial fluctuations in gut microbiome profiles around 10 months before clinical diagnosis; however, these profiles were relatively stable 10-15 months before the onset of RA, suggesting that changes in the microbiome occur at a later stage.
• Patients with new-onset RA were found to have distinct metabolic shifts, particularly in pathways related to amino acid and energy metabolism.

IN PRACTICE:

“Individuals at risk of RA harbor a distinctive gut microbial composition, including but not limited to an overabundance of Prevotellaceae species. This microbial signature is consistent and correlates with traditional RA risk factors,” the authors wrote.

SOURCE:

The study was led by Christopher M. Rooney, MD, PhD, University of Leeds in England. It was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small longitudinal sample size and lack of a 1:1 longitudinal comparison between CCP+ individuals at risk for RA and healthy control individuals were major limitations of this study. The new-onset RA cohort was heterogeneous, reflecting the practical constraints of recruitment from standard care clinics. Integrated transcriptomic or metabolomic data were unavailable, restricting interpretation to potential rather than confirmed metabolic activity.

DISCLOSURES:

This study was funded by personal fellowships received by the lead author from Versus Arthritis, Leeds Cares, and a National Institute for Health Research Clinical Lectureship. Some authors disclosed receiving grants, funding, consulting fees, or honoraria from various pharmaceutical companies.

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

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

First, there were “Ozempic babies.” Now, there is also Ozempic-before-baby.

Unplanned pregnancies are still regularly being reported among people using glucagon-like peptide 1 receptor agonist (GLP-1 RA) drugs, and now fertility specialists are increasingly incorporating the medicines into preconception care plans.

The specialists say their colleagues in other areas of medicine may have an opportunity, too, to talk about weight loss using these new drugs in terms of reproductive health. Motivation and compliance can transform when the goal isn’t simply weight loss but having children.

“We have this really special moment to help patients be healthier, in order to be healthier for their kids,” said Christina Boots, MD, MSci, an associate professor of reproductive endocrinology and infertility at Northwestern University’s Feinberg School of Medicine, Chicago. “And I think that’s also a very motivating moment. It may be hard to get up and go for a run to make my jeans fit better, but when I think about it in terms of, ‘this might someday help my future daughter,’ that is a whole different level of motivation.”

Discussing obesity treatment can be a delicate conversation, but one that would be beneficial to have with any patient of reproductive age. Here’s why, what to know about the current lengthy list of unknowns and risks, and some options for approaching the topic with patients.
 

What Fertility Docs Are Doing

While overweight and obesity are consistently linked to fertility and pregnancy outcomes, Boots predicts the biggest impact of GLP-1 weight loss for fertility among women will be a specific subset: Those who are not cycling regularly, such as those with polycystic ovary syndrome (PCOS).

“The women who are cycling regularly who have very unexplained infertility and no other comorbidities like high blood pressure or something else going on, I don’t think it’s going to help their fertility very much at all,” she said “It might, but I think there’s probably something else going on in her tubes or with her eggs or his sperm, but it has nothing to do with her metabolic health.

Women who aren’t cycling regularly will benefit, but those with truly unexplained fertility probably won’t, she said.

In their recent narrative review on treating obesity and fertility with GLP-1 RAs that appeared in Fertility and Sterility, Boots and co-author Alyse S. Goldberg, MD, an endocrinologist with the University of Toronto, Ontario, Canada, advocate for the use of GLP-1s as a go-to treatment for obesity as part of preconception care by reproductive endocrinologists, calling the drugs “the most effective, least invasive means of weight loss.”

The paper is timely and necessary because use of GLP-1s is only going to increase, Patricia Jimenez, MD, an associate professor of obstetrics and gynecology at Washington University School of Medicine in St. Louis, Missouri, said in an email to this news organization.

“GLP-1 RAs are becoming a larger part of my practice. More patients are either using them already or interested in using them,” said Jimenez, who is board certified in reproductive endocrinology, obstetrics and gynecology, and obesity medicine. “I specifically see patients to discuss this and do prescribe antiobesity medications, not only GLP-1 RAs. Often this is with people with PCOS who are not planning to conceive soon or patients willing to delay fertility treatment [by] 3-6 months.”

Treating obesity is also important for women who are seeking in vitro fertilization, Boots said, because many IVF clinics have a body mass index cutoff of 40 kg/m².

Like Jimenez’s approach, Boots and Goldberg call for comprehensive obesity care beyond the use of medication, including nutritional counseling and mental health support. Those supports are important during the transition off of GLP-1 medications, which poses a risk for rapid weight regain. That’s even with the potential support of taking metformin, which Boots often prescribes as a bridge.

Semaglutide should be stopped at least 2 months prior to conception, and tirzepatide should be stopped 1 month prior to conception, according to the manufacturers. (Boots and Goldberg listed the Canadian label recommendation for stopping tirzepatide, noting there is no suggested timeline for stopping prior to conception on the US label.)

Numerous studies have shown rapid weight regain is common when stopping GLP-1s, which presents a unique set of risks for pregnant women including early pregnancy loss, gestational diabetes, preeclampsia, and nonelective cesarean delivery.
 

Weighing Risks, Benefits, and Unknowns

Early looks at small human data sets, mostly involving semaglutide and earlier short-acting GLP-1s, and their impact on the risk for birth defects are “reassuring,” Boots said.

“But birth defects are just one small aspect. There’s also metabolic health and things like that long-term. Understanding what it does to the growing baby and the proximity of that medication to that growing baby is really important to see, and can’t be answered with animal studies, not perfectly anyway,” Boots said.

There are no published reports, from clinical trials nor case collections, examining the use of tirzepatide among pregnant people.

“One of the most important questions we need to answer is the preconception safety of these medications, and that includes safety for men,” Joshua Halpern, MD, MS, an adjunct assistant professor of urology at Northwestern University’s Feinberg School of Medicine, and chief scientific officer for Posterity Health, said in an email to this news organization.

“For example, a recent study found that men who were taking metformin, another popular medication for diabetes, were more likely to have children with birth defects, compared with those who were not taking the medication,” Halpern said. “Further studies are needed to determine whether a similar effect might hold true for the GLP-1 agonists.”

Small early studies on sperm are encouraging, Halpern said, suggesting that GLP-1 use may be beneficial, but a better understanding of direct effects is needed.

Among women, there may be cases where continuing use of a GLP-1 during pregnancy may offer benefits that outweigh risks, Boots suggested. Manufacturers have also created pregnancy exposure registries to measure the safety of their therapies during pregnancy.

“I have a group of patients whose sugars are so well controlled on these medications, but as soon as they come off, they get weight regain and their glucose is just so poorly controlled,” she said. “There may be a group of women where the benefits of glucose control outweigh the risks of being on the medication the whole pregnancy.”

The list of important unknowns also includes a need to examine how rapid weight loss may impact ovulation rates and spontaneous conception, as well as miscarriage rates, birth weight, and metabolic health of the child.

More detailed rebound weight gain data is coming next year, with additional analysis expected as well on birth weight and pregnancy outcomes, said Jacqueline Maya, MD, first author of the research abstract presented at this year’s American Diabetes Association conference that examined gestational weight gain among people with preexisting type 2 diabetes who were exposed to GLP-1s during pregnancy. The study included 47 exposed pregnancies (based on prescription records and electronic chart information) and compared gestational weight gain to 141 unexposed matched pregnancies. Among the exposed group, 62% exceeded recommended weight gain, compared with 41% in the unexposed group. On average, gestational weight gain in exposed pregnancies exceeded that among matched unexposed pregnancies by about 6 pounds.

The team is now working with an additional data set to examine exposed pregnancies among people with obesity, said Maya, an instructor of pediatrics at Mass General Hospital and Harvard School of Medicine. She is particularly interested in examining weight trajectories during pregnancy to see how they may affect fetal outcomes. Her team’s current project also will likely include analysis to examine other variables like postpartum weight gain and adiposity characteristics of the baby.

Maya said the team hopes to have more to report at the American Diabetes Association conference in June next year.
 

Offer the Conversation

Using a GLP-1 for weight loss takes time, usually around 1 year to reach a plateau. Boots encouraged nonfertility providers to ask patients of reproductive age about their family plans as an opening.

“I hope for all primary care doctors and gynecologists, that with any patient of reproductive age, you should be bringing this up, asking, ‘Have you thought about having kids? Are you thinking about it soon?’ And if they say they are sometime in the near future, then you can say, ‘Is it OK if I bring up your weight?’ And you should ask permission.”

If the patient declines, it’s OK to bring it up again at a future visit.

“People with obesity have often experienced negative weight bias that impacts their care,” Jimenez said. “Treat obesity as a disease, not a personal failing. Ask permission to discuss weight with the patient beforehand. If they say no, respect that answer. This goes a long way in developing a positive relationship, so they return for care and may be willing to discuss later.” 

When patients are open to the conversation, Boots suggests not focusing on the potential for poor outcomes, and instead perhaps saying, “If you’re thinking about having a baby in 5 years, optimizing your health now will not only make your pregnancy healthier, but your child healthier long-term.”

Discussing contraception plans remains important. People starting semaglutide or tirzepatide should use contraception other than oral birth control for 4 weeks while starting the medicine and for 4 weeks after each dose increase.

Boots said that the contraception conversation is particularly important because many people have come to deeply believe that they are infertile and, thus, may perhaps think contraception advice doesn’t apply to them. Maya hypothesized that behavioral changes following weight loss may also be a pathway toward pregnancy.

“Pregnancy while on GLP-1 RAs does happen. I always have a discussion about this possibility and contraception. This can sometimes be challenging for people with infertility to consider,” Jimenez said. “Explaining the risks, benefits, and unknowns can help. As the [Fertility and Sterility] paper describes, the limited data available has not shown increased fetal or maternal complications. We need more high quality data to better understand the impact of exposure or use around the time of conception and during pregnancy.”

It’s also important to introduce the idea to patients that they may someday need to come off the medications, such as when they are ready to have children, and how important lifestyle and behavioral changes will be at that time, Maya said.

“We do know what the alternative is, and we do know what the risks of obesity are,” she said. “So, it’s a tug and pull. We’re not starting off with healthy. We’re starting off with a disease that is physically and emotionally very difficult for the patient, especially when it starts in childhood.”
 

A version of this article appeared on Medscape.com.

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

SAN ANTONIO — Several types of anti-obesity medications (AOMs), including glucagon-like peptide 1s (GLP-1s), are associated with decreased alcohol use, new research suggests.

The findings, from surveys of more than 14,000 participants in WeightWatchers’ telehealth weight management program, were presented on November 6 at the Obesity Society’s Obesity Week 2024 meeting by the company’s Chief Nutrition Officer, Michelle I. Cardel, PhD, RD, based in Gainesville, Florida.

Similar reductions in alcohol consumption were seen in people taking different classes of AOMs, suggesting “an additional mechanism by which AOMs reduce energy intake, and also signal a potential role for these medications to reduce alcohol use,” Cardel said, adding “Clinicians treating individuals for obesity may consider anti-obesity medications particularly among those who report higher alcohol intake.”

Asked to comment, session moderator and obesity researcher Joseph A. Skelton, MD, professor of pediatrics at Wake Forest University School of Medicine, Winston-Salem, North Carolina, said, “I think there are some overlapping pathways there, possibly a reward system or something like that in the brain. I don’t think we know exactly what the end result will be as a potential use of the medications. But there’s a signal that needs to be investigated more.”

Cardel noted that there was one previous large cohort study finding that semaglutide was associated with a lower risk for alcohol use disorder, and another study that analyzed social media threads of people saying they’d quit drinking after starting a GLP-1 drug. But this new study is the first to examine the relationship with different classes of AOMs and to quantify the amount of alcohol consumed.
 

About Half Reported Reduced Alcohol Consumption, Regardless the AOM Class

The study included 14,053 WeightWatchers’ telehealth program participants who initiated an AOM between January 2022 and August 2023 and refilled the same AOM between October and November 2023. Those who had previously used AOMs before coming to the program or who had undergone bariatric surgery were excluded.

Participants had a mean age of 43 years, were 86% women, were 60% White, and had a mean body mass index of 36. They were surveyed about their weekly alcohol use prior to AOM initiation and again at the time of AOM refill.

At baseline, they were divided into categories of 0 (no alcohol use; n = 6562), category 1 (one to three drinks for women and one to six for men; n = 5948), category 2 (4-6 for women and 7-14 for men; n = 1216), and category 3 (≥ 7 for women and ≥ 15 for men; n = 327).

At the second survey, 24% reported decreased drinking after starting an AOM, 71% reported no change, and 4% reported increased drinking (P < .0001). But when just the 7491 individuals who reported any alcohol use at baseline were included, 45% reported decreased drinking after starting an AOM, 52% reported no change, and only 2% reported increased drinking.

The decrease in drinking with AOM use rose with greater alcohol use at baseline, from 37% for category 1, 76% for category 2, and 91% for category 3. The proportions reporting increased drinking were just 3%, 1%, and 0%, respectively. The adjusted odds ratios (ORs) for decreasing drinking were 5.97 for category 2 (P < .0001) and 19.18 for category 3 (P < .0001) vs category 1.

The proportions reporting reduced drinking were similar across AOM classes: 51% for metformin, 46% for bupropion/naltrexone, 46% for first-generation GLP-1s (Saxenda, Trulicity, and Victoza), and 45% for the second-generation GLP-1 drugs (Mounjaro, Ozempic, Rybelsus, Wegovy, and Zepbound). All were statistically significant at P < .0001.

The highest proportion reporting increased drinking was 4% for bupropion/naltrexone. Compared with women, men were significantly more likely to report decreased drinking with AOM use (adjusted OR, 0.74; P < .001), but there were no differences by race/ethnicity or age.

Compared with those who had overweight, those in obesity classes I, II, and III were all more likely to decrease drinking with AOM use, with adjusted ORs of 1.26 (P = .0045), 1.49 (P < .001), and 1.63 (P < .001), respectively.
 

Mechanisms Appear Both Biological and Behavioral

During the discussion, Cardel said that qualitative assessments with participants suggest that there are at least two mechanisms behind this phenomenon: One biological and the other intentional.

“What we hear from them is twofold, one, particularly amongst those folks on GLP-1 medications, we’re hearing that physiologically, they feel different with the medications, that their cravings for alcohol are decreased, and that when they do choose to drink that there’s often a very much a negative reinforcement ... I’ve had a patient tell me, ‘I used to be able to have two or three margaritas, and maybe I didn’t feel like the best I’d ever felt in the morning, but I was okay. And now if I have two or three drinks, I will be throwing up for 5 hours, and it’s the worst hangover I’ve ever had in my life.’ And so it very much creates that negative reinforcement loop.”

But at the same time, “folks who are coming to us and seeking these medications are very much on a on a health-based journey. That’s what they tell us. The majority of our patients are there to improve their health. We rarely hear about the vanity or aesthetic part of it. So perhaps it’s that, in terms of trying to improve their health, they’re also trying to reduce their alcohol consumption, either just for their overall health or also as a means of trying to decrease their overall calorie consumption.”

In future research, Cardel said, “we want to examine whether the anti-obesity medications are more successful at reducing alcohol use compared to non-pharmacological weight management interventions, as we know that people often reduce their alcohol consumption on a weight management journey as a means of prioritizing their calories for food and decreasing the calories from alcohol.”

Cardel and all the study coauthors were employees and shareholders at WeightWatchers at the time the research was conducted. Skelton is editor in chief of the journal Childhood Obesity.
 

A version of this article appeared on Medscape.com.

TOPLINE:

Both infliximab and adalimumab are safe and effective in achieving remission in patients with severe mucocutaneous Behçet syndrome, with adalimumab demonstrating a quicker response time; both drugs also improve quality of life and disease activity scores.

METHODOLOGY:

• Researchers conducted a phase 3 prospective study to evaluate the efficacy and safety of the anti–tumor necrosis factor–alpha agents infliximab and adalimumab in patients with Behçet syndrome presenting with mucocutaneous manifestations and inadequate response to prior treatments who were recruited from four Italian tertiary referral centers specializing in Behçet syndrome.
• Patients were randomly assigned to receive either 5 mg/kg intravenous infliximab at weeks 0, 2, and 6 and then every 6-8 weeks (n = 22; mean age, 46 years; 32% women) or 40 mg subcutaneous adalimumab every 2 weeks (n = 18; mean age, 48 years; 28% women) for 24 weeks.
• Patients were followed-up for an additional 12 weeks after the treatment period, with regular assessments of disease activity, safety, and adherence to treatment.
• The primary outcome was the time to response of mucocutaneous manifestations over 6 months; the secondary outcomes included relapse rates; quality of life, assessed using the Short-Form Health Survey 36; and disease activity, assessed using the Behçet Disease Current Activity Form.
• The safety and tolerability of the drugs were evaluated as the frequency of treatment-emergent adverse events (AEs) and serious AEs, monitored every 2 weeks.

TAKEAWAY:

• The resolution of mucocutaneous manifestations was achieved significantly more quickly with adalimumab than with infliximab, with a median time to response of 42 vs 152 days (P = .001); the proportion of responders was also higher in the adalimumab group than in the infliximab group (94% vs 64%; P = .023).
• Patients in the infliximab group had a higher risk for nonresponse (adjusted hazard ratio [HR], 3.33; P = .012) and relapse (adjusted HR, 7.57; P = .036) than those in the adalimumab group.
• Both infliximab and adalimumab significantly improved the quality of life in all dimensions (P < .05 for all) and disease activity scores (P < .001 for both) from baseline to the end of the study period, with no significant differences found between the groups.
• Two AEs were reported in the adalimumab group, one of which was serious (myocardial infarction); three nonserious AEs were reported in the infliximab group.

IN PRACTICE:

“ADA [adalimumab] and IFX [infliximab] were generally well tolerated and efficacious in patients with BS [Behçet syndrome] who showed an inadequate response to prior treatments with at least AZA [azathioprine] or CyA [cyclosporine],” the authors wrote. “Although a more detailed treat-to-target profile is yet to be better defined, [the study] results are also crucial in terms of prescriptiveness (currently off label), not only in Italy but also beyond national borders, as the evidence coming from real life still needs to be confirmed by growing data from clinical trials.”

SOURCE:

The study was led by Rosaria Talarico, MD, PhD, University of Pisa in Italy, and was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small sample size and the distinctive study design may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded through a grant from the Italian Medicines Agency. The authors declared no conflicts of interest.

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

TOPLINE:

Both infliximab and adalimumab are safe and effective in achieving remission in patients with severe mucocutaneous Behçet syndrome, with adalimumab demonstrating a quicker response time; both drugs also improve quality of life and disease activity scores.

METHODOLOGY:

• Researchers conducted a phase 3 prospective study to evaluate the efficacy and safety of the anti–tumor necrosis factor–alpha agents infliximab and adalimumab in patients with Behçet syndrome presenting with mucocutaneous manifestations and inadequate response to prior treatments who were recruited from four Italian tertiary referral centers specializing in Behçet syndrome.
• Patients were randomly assigned to receive either 5 mg/kg intravenous infliximab at weeks 0, 2, and 6 and then every 6-8 weeks (n = 22; mean age, 46 years; 32% women) or 40 mg subcutaneous adalimumab every 2 weeks (n = 18; mean age, 48 years; 28% women) for 24 weeks.
• Patients were followed-up for an additional 12 weeks after the treatment period, with regular assessments of disease activity, safety, and adherence to treatment.
• The primary outcome was the time to response of mucocutaneous manifestations over 6 months; the secondary outcomes included relapse rates; quality of life, assessed using the Short-Form Health Survey 36; and disease activity, assessed using the Behçet Disease Current Activity Form.
• The safety and tolerability of the drugs were evaluated as the frequency of treatment-emergent adverse events (AEs) and serious AEs, monitored every 2 weeks.

TAKEAWAY:

• The resolution of mucocutaneous manifestations was achieved significantly more quickly with adalimumab than with infliximab, with a median time to response of 42 vs 152 days (P = .001); the proportion of responders was also higher in the adalimumab group than in the infliximab group (94% vs 64%; P = .023).
• Patients in the infliximab group had a higher risk for nonresponse (adjusted hazard ratio [HR], 3.33; P = .012) and relapse (adjusted HR, 7.57; P = .036) than those in the adalimumab group.
• Both infliximab and adalimumab significantly improved the quality of life in all dimensions (P < .05 for all) and disease activity scores (P < .001 for both) from baseline to the end of the study period, with no significant differences found between the groups.
• Two AEs were reported in the adalimumab group, one of which was serious (myocardial infarction); three nonserious AEs were reported in the infliximab group.

IN PRACTICE:

“ADA [adalimumab] and IFX [infliximab] were generally well tolerated and efficacious in patients with BS [Behçet syndrome] who showed an inadequate response to prior treatments with at least AZA [azathioprine] or CyA [cyclosporine],” the authors wrote. “Although a more detailed treat-to-target profile is yet to be better defined, [the study] results are also crucial in terms of prescriptiveness (currently off label), not only in Italy but also beyond national borders, as the evidence coming from real life still needs to be confirmed by growing data from clinical trials.”

SOURCE:

The study was led by Rosaria Talarico, MD, PhD, University of Pisa in Italy, and was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small sample size and the distinctive study design may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded through a grant from the Italian Medicines Agency. The authors declared no conflicts of interest.

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

TOPLINE:

Both infliximab and adalimumab are safe and effective in achieving remission in patients with severe mucocutaneous Behçet syndrome, with adalimumab demonstrating a quicker response time; both drugs also improve quality of life and disease activity scores.

METHODOLOGY:

• Researchers conducted a phase 3 prospective study to evaluate the efficacy and safety of the anti–tumor necrosis factor–alpha agents infliximab and adalimumab in patients with Behçet syndrome presenting with mucocutaneous manifestations and inadequate response to prior treatments who were recruited from four Italian tertiary referral centers specializing in Behçet syndrome.
• Patients were randomly assigned to receive either 5 mg/kg intravenous infliximab at weeks 0, 2, and 6 and then every 6-8 weeks (n = 22; mean age, 46 years; 32% women) or 40 mg subcutaneous adalimumab every 2 weeks (n = 18; mean age, 48 years; 28% women) for 24 weeks.
• Patients were followed-up for an additional 12 weeks after the treatment period, with regular assessments of disease activity, safety, and adherence to treatment.
• The primary outcome was the time to response of mucocutaneous manifestations over 6 months; the secondary outcomes included relapse rates; quality of life, assessed using the Short-Form Health Survey 36; and disease activity, assessed using the Behçet Disease Current Activity Form.
• The safety and tolerability of the drugs were evaluated as the frequency of treatment-emergent adverse events (AEs) and serious AEs, monitored every 2 weeks.

TAKEAWAY:

• The resolution of mucocutaneous manifestations was achieved significantly more quickly with adalimumab than with infliximab, with a median time to response of 42 vs 152 days (P = .001); the proportion of responders was also higher in the adalimumab group than in the infliximab group (94% vs 64%; P = .023).
• Patients in the infliximab group had a higher risk for nonresponse (adjusted hazard ratio [HR], 3.33; P = .012) and relapse (adjusted HR, 7.57; P = .036) than those in the adalimumab group.
• Both infliximab and adalimumab significantly improved the quality of life in all dimensions (P < .05 for all) and disease activity scores (P < .001 for both) from baseline to the end of the study period, with no significant differences found between the groups.
• Two AEs were reported in the adalimumab group, one of which was serious (myocardial infarction); three nonserious AEs were reported in the infliximab group.

IN PRACTICE:

“ADA [adalimumab] and IFX [infliximab] were generally well tolerated and efficacious in patients with BS [Behçet syndrome] who showed an inadequate response to prior treatments with at least AZA [azathioprine] or CyA [cyclosporine],” the authors wrote. “Although a more detailed treat-to-target profile is yet to be better defined, [the study] results are also crucial in terms of prescriptiveness (currently off label), not only in Italy but also beyond national borders, as the evidence coming from real life still needs to be confirmed by growing data from clinical trials.”

SOURCE:

The study was led by Rosaria Talarico, MD, PhD, University of Pisa in Italy, and was published online in Annals of the Rheumatic Diseases.

LIMITATIONS:

The small sample size and the distinctive study design may have limited the generalizability of the findings.

DISCLOSURES:

This study was funded through a grant from the Italian Medicines Agency. The authors declared no conflicts of interest.

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