Arrow pointing up

FEATURED

illustation of fatty liver

AASLD PUBLISHES GUIDANCE ON FATTY LIVER DISEASE

The American Association for the Study of Liver Diseases (AASLD) published new guidance on diagnosing and treating fatty liver disease. They recommend providers screen at-risk patients with the FIB-4 score and refer those with a value of 1.3 or more for vibration-controlled transient elastography (Fibroscan) or an enhanced liver fibrosis (ELF) test, a blood assay that measures levels of three direct markers of liver fibrosis. Weight loss and exercise were recommended for treatment, while pioglitazone, vitamin E, and semaglutide were weakly endorsed in select patients.

Using their guidance, a fifty-year-old with an AST of 42, ALT of 30, and platelet count of 280,000 (FIB-4 of 1.37) would be referred for a Fibroscan (typically at a specialist's office) or ELF test. Given our state of rampant obesity, the cost of following these guidelines would add up quickly.

The caveat of fatty liver disease has always been its treatment, weight loss and exercise, two things most patients already know they should be doing. Referring these patients for expensive care so they can be told something they already know doesn't seem productive. For those who progress to cirrhosis (around 6% of all fatty liver patients), biannual hepatocellular screening is indicated.
Healthcare and Currencies by TradingView
coffee cups and coffee beans

STUDY LOOKS AT THE ACUTE EFFECTS OF COFFEE ON ASSORTED HEALTH OUTCOMES

A study published in The New England Journal of Medicine evaluated the effects of coffee on a variety of health-related outcomes. One-hundred healthy participants (mean age 39) were randomly assigned via text message to consume coffee or not in 2-day intervals over 14 days. Subjects wore continuous ECG devices, wrist-worn accelerometers, and continuous glucose monitors. Results for the primary outcome, average number of daily premature atrial contractions, and select secondary endpoints were as follows:
  • Daily premature atrial contractions: Coffee - 58, No coffee - 53 (HR 1.09 [0.98 - 1.20])
  • Daily premature ventricular contractions: Coffee - 154, No coffee - 102 (HR 1.51 [1.18 - 1.94])
  • Minutes of sleep at night: Coffee - 397, No coffee - 432 (Diff 36 [25 - 47])
  • Daily average glucose levels (mg/dl): Coffee - 95, No coffee - 96 (Diff 0.41 [5.42 to 4.60]
  • Daily step count: Coffee - 10646, No coffee - 9665 (Diff 1058 [441 - 1675]
This study is interesting and pertinent, given that 70% of Americans drink coffee every day. Premature atrial contractions were not significantly increased by coffee, but ventricular ones were. Patients also slept an average of 36 minutes longer on days they did not consume coffee, which is a greater effect than what is seen with some prescription sleep aids.
ADA says skip metformin and head straight to SGLT2 inhibitors or GLP-1 analogs
Diabetic checking blood sugar with glucometer
The 2023 American Diabetes Association type 2 diabetes treatment guidelines no longer recommend metformin as first-line therapy. Instead, the guidelines divide patients into categories based on comorbidities (CVD, CKD, CHF) or goals (weight loss, glycemic control) and recommend therapies proven effective in these conditions. In all cases, an SGLT2 inhibitor or GLP-1 analog is preferred.

While GLP-1 analogs and SGLT2 inhibitors are effective drugs that improve comorbid conditions, none have generics, which means they are unaffordable for many patients. Side effects, including gastrointestinal complaints with GLP-1 analogs and urinary issues with SGLT2 inhibitors, are another barrier to patient acceptance. Metformin, sulfonylureas, glitazones, and insulin remain the most cost-effective options.
telemedicien over laptop

DEA BAULKS ON NEW TELEMEDICINE RULES

On May 3rd, the DEA announced that for the time being, it is leaving in place current telemedicine rules that waive the in-person requirement for controlled substances; the waiver was set to expire on May 11th when the Department of Health and Human Services COVID public health emergency ends. In February, the DEA proposed rules for moving forward that essentially reinstated the in-person visit requirement (DEA telemedicine proposal). This prompted a deluge of criticism and a record 38,000 public comments that are giving the agency pause.

UPDATE: The DEA announced on May 9th that the current flexibilities (i.e. no in-person requirement) will remain in effect until November 11, 2023, giving the agency more time to consider future regulations. They went on to state that patients prescribed controlled substances over telemedicine up until November 11, 2023, can continue to be treated over telemedicine until November 11, 2024; this differs from their proposed guidance that only allowed 6 more months of treatment after the current rules expire. See DEA statement on telemedicine.
Study finds hydrochlorothiazide doesn't prevent kidney stone recurrence
Illustration of kidney with a stone
For decades, hydrochlorothiazide (HCTZ) has been recommended to prevent kidney stone recurrence in patients with calcium stones. A recent study published in the New England Journal of Medicine calls this long-standing guidance into question. The NOSTONE trial randomized 416 adults with a history of two or more calcium stones to three doses of once-daily HCTZ (12.5 mg, 25 mg, 50 mg) or placebo. The primary outcome was a composite of symptomatic or radiologic stone recurrence. After a median follow-up of 2.9 years, there was no significant difference between any of the treatment arms (59%, 56%, 49%, 59%, respectively).

The results of this study are surprising given that HCTZ reduces urinary calcium concentrations, and theoretically, this should suppress stone formation. The authors note that supersaturation ratios for calcium oxalate and calcium phosphate - measures associated with stone formation - were unchanged in the HCTZ groups, possibly explaining the overall lack of efficacy.

LATEST NEWS

Postexposure doxycycline prevents STDs

STD with red ribbon
A study (N=501) published in The New England Journal of Medicine found that a one-time dose of doxycycline hyclate 200 mg delayed-release tablet within 72 hours of unprotected intercourse reduced the incidence of STDs (gonorrhea, chlamydia, and syphilis) by 20% in MSM and transgender women.

First ever biologic approved for polymyalgia rheumatica (PMR)

Kevzara (sarilumab) logo
In March, the FDA approved sarilumab (Kevzara®), an antibody to IL-6 receptors, for the treatment of PMR. It is the first and only biologic to receive a PMR indication. Approval was based on results of a 52-week study (N=118) that compared sarilumab 200 mg every 2 weeks to placebo. At the end of the study, 28.3% of sarilumab-treated patients achieved sustained remission compared to 10.3% of placebo-treated patients.

Small study finds as-needed naltrexone helps reduce binge drinking

picture of bartender pouring shots
A small placebo-controlled trial (N=120) published in the American Journal of Psychiatry evaluated the effects of as-needed naltrexone (50 mg during alcohol cravings or when binge drinking was anticipated) on 4 different drinking outcomes in sexual and gender minority men. Naltrexone significantly improved 3 of the outcomes, including number of drinks in past 30 days (31% reduction), any binge drinking in the past week (17% reduction), and number of binge drinking days in the past week (26% reduction).

Benzodiazepines get updated pregnancy labeling

pregnant woman holding ultrasound image
For years, benzodiazepines have carried warnings that they are unsafe in pregnancy, and some have FDA pregnancy category D and X ratings. Recent label updates now state that there is no clear association between benzodiazepines and major birth defects. For women receiving benzodiazepines late in pregnancy, a warning about neonatal sedation and/or withdrawal was added.

Another study shows MRI-targeted prostate biopsies are the way to go

picture of doctor holding prostate cancer ribbon
For years, systematic ultrasound-guided biopsies that randomly sampled different areas of the prostate were the standard workup for an elevated PSA. Recent advances in MRI technology, however, have made MRI-targeted biopsies a reality. Two large studies [PMID 29552975, PMID 34237810] showed that MRI-targeted biopsies reduced the number of biopsy procedures and decreased overdiagnosis with very little loss of significant cancer detection. A third study (see link below) was recently published that validated these findings.

POPULAR PAGES

CHARTS

BASICS

MEDICATIONS

NEW DRUGS

POPULAR BUT UNPROVEN

  • Meniscal surgery - It's one of the most common orthopedic procedures performed, but does it do anything?
  • CPAP for sleep apnea - Sleep doctors are on every corner it seems, but what are the benefits of diagnosing and treating sleep apnea?
  • Knee injections - these treatments are popular among orthopedists and primary care doctors, but are they effective?
  • Pneumonia vaccines in adults - vaccine manufacturers, the CDC, and Medicare want everyone to get a pneumonia vaccine, so they must be highly effective, right?
Another "generic" Lantus becomes available
Woman injecting insulin
Rezvoglar, a new insulin glargine product, is now available at pharmacies. It is the second biosimilar designated as interchangeable with Lantus, which means pharmacists can substitute it for Lantus without the prescriber's permission. Semglee, another insulin glargine approved in 2021, has the same designation. Lantus is the only insulin that currently has FDA-approved alternative products.

Cheaper alternatives to brand-name insulins have been a long time coming, although enthusiasm for biosimilars may now be diminished, as several large manufacturers announced recently that out-of-pocket insulin costs for all patients will be capped at $35 a month.
WEIGHT LOSS DRUGS - Where are we now?
Obese man sitting on curb after exercising
Interest in weight loss medications has been revived with the introduction of the highly-effective GLP-1 drugs. Demand for Novo Nordisk's Wegovy is so high that the manufacturer has been unable to maintain supplies and "bootleg" compounded semaglutide has become a thing. Lilly's Mounjaro, which is currently only approved for diabetes, is more effective than Wegovy and will likely see even higher demand.

So how do the new drugs compare with the old? Which patients qualify, and what are their options if they don't? We break it down for you at the link below.

CLINICAL CHALLENGE

A 55-year-old female with depression comes to see you about her medication. She has been taking Zoloft for five years and has had no depressive episodes in the last three. She is thinking about stopping the Zoloft and wants to know what your advice is.

Should you recommend against it, or tell her it's worth a try? Are there any studies that offer guidance on the issue? See the link below for more.