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GLP-1s Hold Promise for Addiction but Questions Remain
Glucagon-like peptide 1 receptor agonist (GLP-1) prescriptions for diabetes and obesity treatment are soaring, as is the interest in their potential for treating an array of other conditions. One area in particular is addiction, which, like obesity and diabetes, has been increasing, both in terms of case numbers and deaths from drug overdose, excessive alcohol use, and tobacco/e-cigarettes.
“The evidence is very preliminary and very exciting,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The studies have been going on for more than a decade looking at the effects of GLP medications, mostly first generation and predominantly in rodents,” she said.
GLP “drugs like exenatide and liraglutide all reduced consumption of nicotine, of alcohol, of cocaine, and response to opioids,” Volkow said.
Clinical, Real-World Data Promising
Second-generation agents like semaglutide appear to hold greater promise than their first-generation counterparts. Volkow noted that not only is semaglutide a “much more potent drug,” but pointed to recent findings that saw significant declines in heavy drinking days among patients with alcohol use disorder (AUD).
At the Research Society on Alcohol’s annual meeting in June, researchers from the University of North Carolina at Chapel Hill presented findings of a 2-month, phase 2, randomized clinical trial comparing two low doses (0.25 mg/wk, 0.5 mg/wk) of semaglutide with placebo in 48 participants reporting symptoms of AUD. Though preliminary and unpublished, the data showed a reduction in drinking quantity and heavy drinking in the semaglutide vs placebo groups.
Real-world evidence from electronic health records has also underscored the potential benefit of semaglutide in AUD. In a 12-month retrospective cohort analysis of the records of patients with obesity and no prior AUD diagnosis prescribed semaglutide (n = 45,797) or non-GLP-1 anti-obesity medications (naltrexone, topiramate, n = 38,028), semaglutide was associated with a 50% lower risk for a recurrent AUD diagnosis and a 56% significantly lower risk for incidence AUD diagnosis across gender, age group, and race, and in patients with/without type 2 diabetes.
Likewise, findings from another cohort analysis assigned 1306 treatment-naive patients with type 2 diabetes and no prior AUD diagnosis to semaglutide or non-GLP-1 anti-diabetes medications and followed them for 12 months. Compared with people prescribed non-GLP-1 diabetes medications, those who took semaglutide had a 42% lower risk for recurrent alcohol use diagnosis, consistent across gender, age group, and race, whether the person had been diagnosed with obesity.
However, AUD is not the only addiction where semaglutide appears to have potential benefit. Cohort studies conducted by Volkow and her colleagues have suggested as much as a 78% reduced risk or opioid overdose in patients with comorbid obesity and type 2 diabetes) and a 44% reduction in cannabis use disorder in type 2 diabetes patients without a prior cannabis use disorder history.
Unclear Mechanisms, Multiple Theories
It’s not entirely clear how semaglutide provides a path for addicts to reduce their cravings or which patients might benefit most.
Preclinical studies have suggested that GLP-1 receptors are expressed throughout the mesolimbic dopamine system and transmit dopamine directly to reward centers in the forebrain, for example, the nucleus accumbens. The drugs appear to reduce dopamine release and transmission to these reward centers, as well as to areas that are responsible for impulse control.
“What we’re seeing is counteracting mechanisms that allow you to self-regulate are also involved in addiction, but I don’t know to what extent these medications could help strengthen that,” said Volkow.
Henry Kranzler, MD, professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, has a paper in press looking at genetic correlation between body mass index (BMI) and AUD. “Genetic analysis showed that many of the same genes are working in both disorders but in opposite directions,” he said.
The bottom line is that “they share genetics, but by no means are they the same; this gives us reason to believe that the GLP-1s could be beneficial in obesity but not nearly as beneficial for treating addiction,” said Kranzler.
Behind Closed Doors
Like many people with overweight or obesity who are on semaglutide, Bridget Pilloud, a writer who divides her time between Washington State and Arizona, no longer has any desire to drink.
“I used to really enjoy sitting and slowly sipping an Old Fashioned. I used to really enjoy specific whiskeys. Now, I don’t even like the flavor; the pleasure of drinking is gone,” she said.
Inexplicably, Pilloud said that she’s also given up compulsive shopping; “The hunt and acquisition of it was always really delicious to me,” she said.
Pilloud’s experience is not unique. Angela Fitch, MD, an obesity medicine specialist, co-founder and CMO of knownwell health, and former president of the Obesity Medicine Association, has had patients on semaglutide tell her that they’re not shopping as much.
But self-reports about alcohol consumption are far more common.
A 2023 analysis of social media posts reinforced that the experience is quite common, albeit self-reported.
Researchers used machine learning attribution mapping of 68,250 posts related to GLP-1 or GLP-1/glucose-dependent insulinotropic polypeptide agonists on the Reddit platform. Among the 1580 alcohol-related posts, 71% (1134/1580) of users of either drug said they had reduced cravings and decreased desire to drink. In a remote companion study of 153 people with obesity taking semaglutide (n = 56), tirzepatide (n = 50), or neither (n = 47), there appeared to be a reduced suppression of the desire to consume alcohol, with users reporting fewer drinks and binge episodes than control individuals.
Self-reports also underscored the association between either of the medications and less stimulating/sedative effects of alcohol compared with before starting the medications and to controls.
Behind closed doors, there appears to be as much chatter about the potential of these agents for AUD and other addiction disorders as there are questions about factors like treatment duration, safety of long-term, chronic use, and dosage.
“We don’t have data around people with normal weight and how much risk that is to them if they start taking these medications for addiction and reduce their BMI as low as 18,” said Fitch.
There’s also the question of when and how to wean patients off the medications, a consideration that is quite important for patients with addiction problems, said Volkow.
“What happens when you become addicted to drugs is that you start to degrade social support systems needed for well-being,” she explained. “The big difference with drugs versus foods is that you can live happily with no drugs at all, whereas you die if you don’t eat. So, there are greater challenges in the ability to change the environment (eg, help stabilize everyday life so people have alternative reinforcers) when you remove the reward.”
Additional considerations range from overuse and the development of treatment-resistant obesity to the need to ensure that patients on these drugs receive ongoing management and, of course, access, noted Fitch.
Still, the NIDA coffers are open. “We’re waiting for proposals,” said Volkow.
Fitch is cofounder and CMO of knownwell health. Volkow reported no relevant financial relationships. Kranzler is a member of advisory boards for Altimmune, Clearmind Medicine, Dicerna Pharmaceuticals, Enthion Pharmaceuticals, Eli Lilly and Company, and Sophrosyne Pharmaceuticals; a consultant to Sobrera Pharma and Altimmune; the recipient of research funding and medication supplies for an investigator-initiated study from Alkermes; a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trials Initiative, which was supported in the past 3 years by Alkermes, Dicerna Pharmaceuticals, Ethypharm, Imbrium, Indivior, Kinnov, Eli Lilly, Otsuka, and Pear; and a holder of US patent 10,900,082 titled: “Genotype-guided dosing of opioid agonists,” issued on January 26, 2021.
A version of this article appeared on Medscape.com.
Glucagon-like peptide 1 receptor agonist (GLP-1) prescriptions for diabetes and obesity treatment are soaring, as is the interest in their potential for treating an array of other conditions. One area in particular is addiction, which, like obesity and diabetes, has been increasing, both in terms of case numbers and deaths from drug overdose, excessive alcohol use, and tobacco/e-cigarettes.
“The evidence is very preliminary and very exciting,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The studies have been going on for more than a decade looking at the effects of GLP medications, mostly first generation and predominantly in rodents,” she said.
GLP “drugs like exenatide and liraglutide all reduced consumption of nicotine, of alcohol, of cocaine, and response to opioids,” Volkow said.
Clinical, Real-World Data Promising
Second-generation agents like semaglutide appear to hold greater promise than their first-generation counterparts. Volkow noted that not only is semaglutide a “much more potent drug,” but pointed to recent findings that saw significant declines in heavy drinking days among patients with alcohol use disorder (AUD).
At the Research Society on Alcohol’s annual meeting in June, researchers from the University of North Carolina at Chapel Hill presented findings of a 2-month, phase 2, randomized clinical trial comparing two low doses (0.25 mg/wk, 0.5 mg/wk) of semaglutide with placebo in 48 participants reporting symptoms of AUD. Though preliminary and unpublished, the data showed a reduction in drinking quantity and heavy drinking in the semaglutide vs placebo groups.
Real-world evidence from electronic health records has also underscored the potential benefit of semaglutide in AUD. In a 12-month retrospective cohort analysis of the records of patients with obesity and no prior AUD diagnosis prescribed semaglutide (n = 45,797) or non-GLP-1 anti-obesity medications (naltrexone, topiramate, n = 38,028), semaglutide was associated with a 50% lower risk for a recurrent AUD diagnosis and a 56% significantly lower risk for incidence AUD diagnosis across gender, age group, and race, and in patients with/without type 2 diabetes.
Likewise, findings from another cohort analysis assigned 1306 treatment-naive patients with type 2 diabetes and no prior AUD diagnosis to semaglutide or non-GLP-1 anti-diabetes medications and followed them for 12 months. Compared with people prescribed non-GLP-1 diabetes medications, those who took semaglutide had a 42% lower risk for recurrent alcohol use diagnosis, consistent across gender, age group, and race, whether the person had been diagnosed with obesity.
However, AUD is not the only addiction where semaglutide appears to have potential benefit. Cohort studies conducted by Volkow and her colleagues have suggested as much as a 78% reduced risk or opioid overdose in patients with comorbid obesity and type 2 diabetes) and a 44% reduction in cannabis use disorder in type 2 diabetes patients without a prior cannabis use disorder history.
Unclear Mechanisms, Multiple Theories
It’s not entirely clear how semaglutide provides a path for addicts to reduce their cravings or which patients might benefit most.
Preclinical studies have suggested that GLP-1 receptors are expressed throughout the mesolimbic dopamine system and transmit dopamine directly to reward centers in the forebrain, for example, the nucleus accumbens. The drugs appear to reduce dopamine release and transmission to these reward centers, as well as to areas that are responsible for impulse control.
“What we’re seeing is counteracting mechanisms that allow you to self-regulate are also involved in addiction, but I don’t know to what extent these medications could help strengthen that,” said Volkow.
Henry Kranzler, MD, professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, has a paper in press looking at genetic correlation between body mass index (BMI) and AUD. “Genetic analysis showed that many of the same genes are working in both disorders but in opposite directions,” he said.
The bottom line is that “they share genetics, but by no means are they the same; this gives us reason to believe that the GLP-1s could be beneficial in obesity but not nearly as beneficial for treating addiction,” said Kranzler.
Behind Closed Doors
Like many people with overweight or obesity who are on semaglutide, Bridget Pilloud, a writer who divides her time between Washington State and Arizona, no longer has any desire to drink.
“I used to really enjoy sitting and slowly sipping an Old Fashioned. I used to really enjoy specific whiskeys. Now, I don’t even like the flavor; the pleasure of drinking is gone,” she said.
Inexplicably, Pilloud said that she’s also given up compulsive shopping; “The hunt and acquisition of it was always really delicious to me,” she said.
Pilloud’s experience is not unique. Angela Fitch, MD, an obesity medicine specialist, co-founder and CMO of knownwell health, and former president of the Obesity Medicine Association, has had patients on semaglutide tell her that they’re not shopping as much.
But self-reports about alcohol consumption are far more common.
A 2023 analysis of social media posts reinforced that the experience is quite common, albeit self-reported.
Researchers used machine learning attribution mapping of 68,250 posts related to GLP-1 or GLP-1/glucose-dependent insulinotropic polypeptide agonists on the Reddit platform. Among the 1580 alcohol-related posts, 71% (1134/1580) of users of either drug said they had reduced cravings and decreased desire to drink. In a remote companion study of 153 people with obesity taking semaglutide (n = 56), tirzepatide (n = 50), or neither (n = 47), there appeared to be a reduced suppression of the desire to consume alcohol, with users reporting fewer drinks and binge episodes than control individuals.
Self-reports also underscored the association between either of the medications and less stimulating/sedative effects of alcohol compared with before starting the medications and to controls.
Behind closed doors, there appears to be as much chatter about the potential of these agents for AUD and other addiction disorders as there are questions about factors like treatment duration, safety of long-term, chronic use, and dosage.
“We don’t have data around people with normal weight and how much risk that is to them if they start taking these medications for addiction and reduce their BMI as low as 18,” said Fitch.
There’s also the question of when and how to wean patients off the medications, a consideration that is quite important for patients with addiction problems, said Volkow.
“What happens when you become addicted to drugs is that you start to degrade social support systems needed for well-being,” she explained. “The big difference with drugs versus foods is that you can live happily with no drugs at all, whereas you die if you don’t eat. So, there are greater challenges in the ability to change the environment (eg, help stabilize everyday life so people have alternative reinforcers) when you remove the reward.”
Additional considerations range from overuse and the development of treatment-resistant obesity to the need to ensure that patients on these drugs receive ongoing management and, of course, access, noted Fitch.
Still, the NIDA coffers are open. “We’re waiting for proposals,” said Volkow.
Fitch is cofounder and CMO of knownwell health. Volkow reported no relevant financial relationships. Kranzler is a member of advisory boards for Altimmune, Clearmind Medicine, Dicerna Pharmaceuticals, Enthion Pharmaceuticals, Eli Lilly and Company, and Sophrosyne Pharmaceuticals; a consultant to Sobrera Pharma and Altimmune; the recipient of research funding and medication supplies for an investigator-initiated study from Alkermes; a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trials Initiative, which was supported in the past 3 years by Alkermes, Dicerna Pharmaceuticals, Ethypharm, Imbrium, Indivior, Kinnov, Eli Lilly, Otsuka, and Pear; and a holder of US patent 10,900,082 titled: “Genotype-guided dosing of opioid agonists,” issued on January 26, 2021.
A version of this article appeared on Medscape.com.
Glucagon-like peptide 1 receptor agonist (GLP-1) prescriptions for diabetes and obesity treatment are soaring, as is the interest in their potential for treating an array of other conditions. One area in particular is addiction, which, like obesity and diabetes, has been increasing, both in terms of case numbers and deaths from drug overdose, excessive alcohol use, and tobacco/e-cigarettes.
“The evidence is very preliminary and very exciting,” said Nora D. Volkow, MD, director of the National Institute on Drug Abuse (NIDA). “The studies have been going on for more than a decade looking at the effects of GLP medications, mostly first generation and predominantly in rodents,” she said.
GLP “drugs like exenatide and liraglutide all reduced consumption of nicotine, of alcohol, of cocaine, and response to opioids,” Volkow said.
Clinical, Real-World Data Promising
Second-generation agents like semaglutide appear to hold greater promise than their first-generation counterparts. Volkow noted that not only is semaglutide a “much more potent drug,” but pointed to recent findings that saw significant declines in heavy drinking days among patients with alcohol use disorder (AUD).
At the Research Society on Alcohol’s annual meeting in June, researchers from the University of North Carolina at Chapel Hill presented findings of a 2-month, phase 2, randomized clinical trial comparing two low doses (0.25 mg/wk, 0.5 mg/wk) of semaglutide with placebo in 48 participants reporting symptoms of AUD. Though preliminary and unpublished, the data showed a reduction in drinking quantity and heavy drinking in the semaglutide vs placebo groups.
Real-world evidence from electronic health records has also underscored the potential benefit of semaglutide in AUD. In a 12-month retrospective cohort analysis of the records of patients with obesity and no prior AUD diagnosis prescribed semaglutide (n = 45,797) or non-GLP-1 anti-obesity medications (naltrexone, topiramate, n = 38,028), semaglutide was associated with a 50% lower risk for a recurrent AUD diagnosis and a 56% significantly lower risk for incidence AUD diagnosis across gender, age group, and race, and in patients with/without type 2 diabetes.
Likewise, findings from another cohort analysis assigned 1306 treatment-naive patients with type 2 diabetes and no prior AUD diagnosis to semaglutide or non-GLP-1 anti-diabetes medications and followed them for 12 months. Compared with people prescribed non-GLP-1 diabetes medications, those who took semaglutide had a 42% lower risk for recurrent alcohol use diagnosis, consistent across gender, age group, and race, whether the person had been diagnosed with obesity.
However, AUD is not the only addiction where semaglutide appears to have potential benefit. Cohort studies conducted by Volkow and her colleagues have suggested as much as a 78% reduced risk or opioid overdose in patients with comorbid obesity and type 2 diabetes) and a 44% reduction in cannabis use disorder in type 2 diabetes patients without a prior cannabis use disorder history.
Unclear Mechanisms, Multiple Theories
It’s not entirely clear how semaglutide provides a path for addicts to reduce their cravings or which patients might benefit most.
Preclinical studies have suggested that GLP-1 receptors are expressed throughout the mesolimbic dopamine system and transmit dopamine directly to reward centers in the forebrain, for example, the nucleus accumbens. The drugs appear to reduce dopamine release and transmission to these reward centers, as well as to areas that are responsible for impulse control.
“What we’re seeing is counteracting mechanisms that allow you to self-regulate are also involved in addiction, but I don’t know to what extent these medications could help strengthen that,” said Volkow.
Henry Kranzler, MD, professor of psychiatry and director of the Center for Studies of Addiction at the University of Pennsylvania’s Perelman School of Medicine in Philadelphia, has a paper in press looking at genetic correlation between body mass index (BMI) and AUD. “Genetic analysis showed that many of the same genes are working in both disorders but in opposite directions,” he said.
The bottom line is that “they share genetics, but by no means are they the same; this gives us reason to believe that the GLP-1s could be beneficial in obesity but not nearly as beneficial for treating addiction,” said Kranzler.
Behind Closed Doors
Like many people with overweight or obesity who are on semaglutide, Bridget Pilloud, a writer who divides her time between Washington State and Arizona, no longer has any desire to drink.
“I used to really enjoy sitting and slowly sipping an Old Fashioned. I used to really enjoy specific whiskeys. Now, I don’t even like the flavor; the pleasure of drinking is gone,” she said.
Inexplicably, Pilloud said that she’s also given up compulsive shopping; “The hunt and acquisition of it was always really delicious to me,” she said.
Pilloud’s experience is not unique. Angela Fitch, MD, an obesity medicine specialist, co-founder and CMO of knownwell health, and former president of the Obesity Medicine Association, has had patients on semaglutide tell her that they’re not shopping as much.
But self-reports about alcohol consumption are far more common.
A 2023 analysis of social media posts reinforced that the experience is quite common, albeit self-reported.
Researchers used machine learning attribution mapping of 68,250 posts related to GLP-1 or GLP-1/glucose-dependent insulinotropic polypeptide agonists on the Reddit platform. Among the 1580 alcohol-related posts, 71% (1134/1580) of users of either drug said they had reduced cravings and decreased desire to drink. In a remote companion study of 153 people with obesity taking semaglutide (n = 56), tirzepatide (n = 50), or neither (n = 47), there appeared to be a reduced suppression of the desire to consume alcohol, with users reporting fewer drinks and binge episodes than control individuals.
Self-reports also underscored the association between either of the medications and less stimulating/sedative effects of alcohol compared with before starting the medications and to controls.
Behind closed doors, there appears to be as much chatter about the potential of these agents for AUD and other addiction disorders as there are questions about factors like treatment duration, safety of long-term, chronic use, and dosage.
“We don’t have data around people with normal weight and how much risk that is to them if they start taking these medications for addiction and reduce their BMI as low as 18,” said Fitch.
There’s also the question of when and how to wean patients off the medications, a consideration that is quite important for patients with addiction problems, said Volkow.
“What happens when you become addicted to drugs is that you start to degrade social support systems needed for well-being,” she explained. “The big difference with drugs versus foods is that you can live happily with no drugs at all, whereas you die if you don’t eat. So, there are greater challenges in the ability to change the environment (eg, help stabilize everyday life so people have alternative reinforcers) when you remove the reward.”
Additional considerations range from overuse and the development of treatment-resistant obesity to the need to ensure that patients on these drugs receive ongoing management and, of course, access, noted Fitch.
Still, the NIDA coffers are open. “We’re waiting for proposals,” said Volkow.
Fitch is cofounder and CMO of knownwell health. Volkow reported no relevant financial relationships. Kranzler is a member of advisory boards for Altimmune, Clearmind Medicine, Dicerna Pharmaceuticals, Enthion Pharmaceuticals, Eli Lilly and Company, and Sophrosyne Pharmaceuticals; a consultant to Sobrera Pharma and Altimmune; the recipient of research funding and medication supplies for an investigator-initiated study from Alkermes; a member of the American Society of Clinical Psychopharmacology’s Alcohol Clinical Trials Initiative, which was supported in the past 3 years by Alkermes, Dicerna Pharmaceuticals, Ethypharm, Imbrium, Indivior, Kinnov, Eli Lilly, Otsuka, and Pear; and a holder of US patent 10,900,082 titled: “Genotype-guided dosing of opioid agonists,” issued on January 26, 2021.
A version of this article appeared on Medscape.com.
Are Endocrine Disruptors Really a Threat to Health?
Endocrine disruptors (EDs) — chemicals in the environment that could affect human endocrine function — are increasingly becoming a prominent concern for the public as well as professionals. At its 40th congress, the French Society of Endocrinology hosted a public lecture on the subject, given by Nicolas Chevalier, MD, PhD, professor of endocrinology at the University Hospital of Nice in France.
Environmental EDs
Chevalier began by asking the audience to remember one number: 906. This is the number of substances identified by the French Agency for Food, Environmental and Occupational Health & Safety for which there are sufficient scientific data to confirm or at least suspect endocrine-disrupting activity. In reality, the number is likely closer to 10,000, he said.
These chemicals include bisphenol A and its substitutes, parabens, phthalates, and pesticides. Additionally, lithium (mainly found in batteries), polychlorinated biphenyls, per- and polyfluoroalkyl substances, and polybromodiphenyl ethers, or brominated flame retardants, are included. These products are found throughout our environment, so much so that Chevalier said: “We are swimming in a soup of endocrine disruptors.”
The main source of human contamination is food, responsible for an estimated 80%-90% of those encountered. They may enter the food supply during production or preservation, and pesticides are not the only culprits. For example, fatty fish contain heavy metals. Water is also a significant source of contamination. It is worth noting that tap water is the cleanest and most monitored type when it comes to EDs. However, plastic bottles leach not only EDs but also microplastics, which are a major environmental pollution source.
Many other features in our daily environment contain EDs: Clothing (especially shoes), nonstick cookware, plastic containers (especially those heated in the microwave), plastic toys (which young children often put in their mouths), and cosmetic products (makeup, which is increasingly used by young girls). The placenta is not the barrier it was once thought to be: Amniotic fluid has been found to contain about 35 molecules that are toxic for the fetus, with at least 11 or 12 exceeding safety thresholds.
Multiple Linked Diseases
An incomplete list of ED-related diseases would include cancer, infertility, obesity, and diabetes, Chevalier said. Are these data alarmist? he asked. After all, life expectancy has increased globally by more than 10 years since the 1970s, and this has occurred alongside the increased use of EDs. However, he suggested remembering a second number: 157. This represents the billions of euros in European healthcare costs primarily caused by neurologic disorders linked to pesticides. They have a half-life estimated at least 10 years, and banning them will not stop them from persisting in the environment for up to 40 years. US studies have shown that their presence in the environment contributes to cognitive delays in young children.
Another area of concern is the rising infertility rates among couples, now affecting around one in five in France. This trend has been linked to the toxicity of EDs on the genital tract, especially in men, and is not only related to increased use of birth control. For example, in sub-Saharan Africa, rates of contraceptive use have increased only marginally, but birth rates have significantly decreased in areas contaminated by waste that is inadequately managed by Western standards.
EDs have also been implicated in the rising incidence of several cancers, including breast cancer in women and prostate cancer in men, and may have contributed to increases in both childhood obesity and adult diabetes.
A Difficult Battle
Chevalier asked: Is the increase in ED contamination inevitable? No, he said, but it is extremely difficult to counter. Governments are reluctant to legislate, particularly when jobs are at stake, even though certain workers are particularly exposed. The ideal situation would be for the public to take matters into their own hands by eliminating EDs from their environment through daily actions that pressure policymakers to act. For example:
- Eliminate plastics (especially for food products) and nonstick coatings
- Reject most cleaning products in favor of traditional solutions (eg, white vinegar and baking soda)
- Avoid imported toys (as producer countries often fail to comply with European health standards)
Environmental charters have been created by several local authorities and regional health agencies. Chevalier urged the public to rely on their recommendations and resources to help drive change.
This story was translated from Univadis France 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.
Endocrine disruptors (EDs) — chemicals in the environment that could affect human endocrine function — are increasingly becoming a prominent concern for the public as well as professionals. At its 40th congress, the French Society of Endocrinology hosted a public lecture on the subject, given by Nicolas Chevalier, MD, PhD, professor of endocrinology at the University Hospital of Nice in France.
Environmental EDs
Chevalier began by asking the audience to remember one number: 906. This is the number of substances identified by the French Agency for Food, Environmental and Occupational Health & Safety for which there are sufficient scientific data to confirm or at least suspect endocrine-disrupting activity. In reality, the number is likely closer to 10,000, he said.
These chemicals include bisphenol A and its substitutes, parabens, phthalates, and pesticides. Additionally, lithium (mainly found in batteries), polychlorinated biphenyls, per- and polyfluoroalkyl substances, and polybromodiphenyl ethers, or brominated flame retardants, are included. These products are found throughout our environment, so much so that Chevalier said: “We are swimming in a soup of endocrine disruptors.”
The main source of human contamination is food, responsible for an estimated 80%-90% of those encountered. They may enter the food supply during production or preservation, and pesticides are not the only culprits. For example, fatty fish contain heavy metals. Water is also a significant source of contamination. It is worth noting that tap water is the cleanest and most monitored type when it comes to EDs. However, plastic bottles leach not only EDs but also microplastics, which are a major environmental pollution source.
Many other features in our daily environment contain EDs: Clothing (especially shoes), nonstick cookware, plastic containers (especially those heated in the microwave), plastic toys (which young children often put in their mouths), and cosmetic products (makeup, which is increasingly used by young girls). The placenta is not the barrier it was once thought to be: Amniotic fluid has been found to contain about 35 molecules that are toxic for the fetus, with at least 11 or 12 exceeding safety thresholds.
Multiple Linked Diseases
An incomplete list of ED-related diseases would include cancer, infertility, obesity, and diabetes, Chevalier said. Are these data alarmist? he asked. After all, life expectancy has increased globally by more than 10 years since the 1970s, and this has occurred alongside the increased use of EDs. However, he suggested remembering a second number: 157. This represents the billions of euros in European healthcare costs primarily caused by neurologic disorders linked to pesticides. They have a half-life estimated at least 10 years, and banning them will not stop them from persisting in the environment for up to 40 years. US studies have shown that their presence in the environment contributes to cognitive delays in young children.
Another area of concern is the rising infertility rates among couples, now affecting around one in five in France. This trend has been linked to the toxicity of EDs on the genital tract, especially in men, and is not only related to increased use of birth control. For example, in sub-Saharan Africa, rates of contraceptive use have increased only marginally, but birth rates have significantly decreased in areas contaminated by waste that is inadequately managed by Western standards.
EDs have also been implicated in the rising incidence of several cancers, including breast cancer in women and prostate cancer in men, and may have contributed to increases in both childhood obesity and adult diabetes.
A Difficult Battle
Chevalier asked: Is the increase in ED contamination inevitable? No, he said, but it is extremely difficult to counter. Governments are reluctant to legislate, particularly when jobs are at stake, even though certain workers are particularly exposed. The ideal situation would be for the public to take matters into their own hands by eliminating EDs from their environment through daily actions that pressure policymakers to act. For example:
- Eliminate plastics (especially for food products) and nonstick coatings
- Reject most cleaning products in favor of traditional solutions (eg, white vinegar and baking soda)
- Avoid imported toys (as producer countries often fail to comply with European health standards)
Environmental charters have been created by several local authorities and regional health agencies. Chevalier urged the public to rely on their recommendations and resources to help drive change.
This story was translated from Univadis France 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.
Endocrine disruptors (EDs) — chemicals in the environment that could affect human endocrine function — are increasingly becoming a prominent concern for the public as well as professionals. At its 40th congress, the French Society of Endocrinology hosted a public lecture on the subject, given by Nicolas Chevalier, MD, PhD, professor of endocrinology at the University Hospital of Nice in France.
Environmental EDs
Chevalier began by asking the audience to remember one number: 906. This is the number of substances identified by the French Agency for Food, Environmental and Occupational Health & Safety for which there are sufficient scientific data to confirm or at least suspect endocrine-disrupting activity. In reality, the number is likely closer to 10,000, he said.
These chemicals include bisphenol A and its substitutes, parabens, phthalates, and pesticides. Additionally, lithium (mainly found in batteries), polychlorinated biphenyls, per- and polyfluoroalkyl substances, and polybromodiphenyl ethers, or brominated flame retardants, are included. These products are found throughout our environment, so much so that Chevalier said: “We are swimming in a soup of endocrine disruptors.”
The main source of human contamination is food, responsible for an estimated 80%-90% of those encountered. They may enter the food supply during production or preservation, and pesticides are not the only culprits. For example, fatty fish contain heavy metals. Water is also a significant source of contamination. It is worth noting that tap water is the cleanest and most monitored type when it comes to EDs. However, plastic bottles leach not only EDs but also microplastics, which are a major environmental pollution source.
Many other features in our daily environment contain EDs: Clothing (especially shoes), nonstick cookware, plastic containers (especially those heated in the microwave), plastic toys (which young children often put in their mouths), and cosmetic products (makeup, which is increasingly used by young girls). The placenta is not the barrier it was once thought to be: Amniotic fluid has been found to contain about 35 molecules that are toxic for the fetus, with at least 11 or 12 exceeding safety thresholds.
Multiple Linked Diseases
An incomplete list of ED-related diseases would include cancer, infertility, obesity, and diabetes, Chevalier said. Are these data alarmist? he asked. After all, life expectancy has increased globally by more than 10 years since the 1970s, and this has occurred alongside the increased use of EDs. However, he suggested remembering a second number: 157. This represents the billions of euros in European healthcare costs primarily caused by neurologic disorders linked to pesticides. They have a half-life estimated at least 10 years, and banning them will not stop them from persisting in the environment for up to 40 years. US studies have shown that their presence in the environment contributes to cognitive delays in young children.
Another area of concern is the rising infertility rates among couples, now affecting around one in five in France. This trend has been linked to the toxicity of EDs on the genital tract, especially in men, and is not only related to increased use of birth control. For example, in sub-Saharan Africa, rates of contraceptive use have increased only marginally, but birth rates have significantly decreased in areas contaminated by waste that is inadequately managed by Western standards.
EDs have also been implicated in the rising incidence of several cancers, including breast cancer in women and prostate cancer in men, and may have contributed to increases in both childhood obesity and adult diabetes.
A Difficult Battle
Chevalier asked: Is the increase in ED contamination inevitable? No, he said, but it is extremely difficult to counter. Governments are reluctant to legislate, particularly when jobs are at stake, even though certain workers are particularly exposed. The ideal situation would be for the public to take matters into their own hands by eliminating EDs from their environment through daily actions that pressure policymakers to act. For example:
- Eliminate plastics (especially for food products) and nonstick coatings
- Reject most cleaning products in favor of traditional solutions (eg, white vinegar and baking soda)
- Avoid imported toys (as producer countries often fail to comply with European health standards)
Environmental charters have been created by several local authorities and regional health agencies. Chevalier urged the public to rely on their recommendations and resources to help drive change.
This story was translated from Univadis France 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.
As-Needed Blood Pressure Medication Linked to Higher Risk for Acute Kidney Injury
TOPLINE:
Veterans receiving blood pressure (BP) medication as needed while hospitalized were at a 23% higher risk for acute kidney injury (AKI) and a 1.5-fold greater risk for potentially dangerous rapid reductions in BP.
METHODOLOGY:
- Researchers analyzed the records of 133,760 veterans (90% men; mean age, 71.2 years) hospitalized in Veterans Affairs hospitals between 2015 and 2020.
- The study analyzed as-needed administration of BP drugs to patients who had an elevated BP but were asymptomatic.
- Patients who had at least one systolic BP reading above 140 mm Hg and received scheduled BP medication in the first 24 hours of hospitalization were included; those admitted to intensive care units or those who required surgery were excluded.
- The analysis compared outcomes between 28,526 patients who received as-needed drugs and 105,234 who did not; the primary outcome was time to the first AKI occurrence while hospitalized.
- Secondary outcomes included a reduction of more than 25% in systolic BP within 3 hours of as-needed BP medication, as well as a composite outcome of myocardial infarction, stroke, or death during hospitalization.
TAKEAWAY:
- Researchers found that an AKI was 23% more likely to occur in veterans who received at least one as-needed BP medication (hazard ratio [HR], 1.23; 95% CI, 1.18-1.29).
- Veterans who received BP medication as needed were 50% more likely to experience a rapid drop in BP within 3 hours (HR, 1.50; 95% CI, 1.39-1.62) and more than twice as likely after 1 hour (HR, 2.11; 95% CI, 1.81-2.46) than those who did not receive medication.
- The risk of experiencing the composite outcome was 69% times higher in the as-needed group (rate ratio [RR], 1.69; 95% CI, 1.49-1.92), with individual increased risks for myocardial infarction (RR, 2.92; 95% CI, 2.09-4.07), stroke (RR, 1.99; 95% CI, 1.30-3.03), and death (RR, 1.52; 95% CI, 1.32-1.75).
IN PRACTICE:
“The practical implication of our findings is that there is at least equipoise regarding the utility of as-needed BP medication use for asymptomatic BP elevations in hospitals ... future prospective trials should evaluate the risks and benefits of this common practice,” the study authors wrote.
SOURCE:
The study was led by Muna Thalji Canales, MD, MS, of the North Florida/South Georgia Veterans Health System in Gainesville, Florida. It was published online on November 25 in JAMA Internal Medicine.
LIMITATIONS:
The analysis may have included confounding factors that could have influenced results. The focus on veterans who had not undergone surgery limits generalizability to women, surgical patients, and nonveteran populations. The researchers noted limited data on factors that might influence BP readings in the hospital such as pain, stress, and faulty machinery.
DISCLOSURES:
Study authors reported grants and consulting fees from Merck Sharp & Dohme and BMS, and Teva Pharmaceuticals, among others.
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:
Veterans receiving blood pressure (BP) medication as needed while hospitalized were at a 23% higher risk for acute kidney injury (AKI) and a 1.5-fold greater risk for potentially dangerous rapid reductions in BP.
METHODOLOGY:
- Researchers analyzed the records of 133,760 veterans (90% men; mean age, 71.2 years) hospitalized in Veterans Affairs hospitals between 2015 and 2020.
- The study analyzed as-needed administration of BP drugs to patients who had an elevated BP but were asymptomatic.
- Patients who had at least one systolic BP reading above 140 mm Hg and received scheduled BP medication in the first 24 hours of hospitalization were included; those admitted to intensive care units or those who required surgery were excluded.
- The analysis compared outcomes between 28,526 patients who received as-needed drugs and 105,234 who did not; the primary outcome was time to the first AKI occurrence while hospitalized.
- Secondary outcomes included a reduction of more than 25% in systolic BP within 3 hours of as-needed BP medication, as well as a composite outcome of myocardial infarction, stroke, or death during hospitalization.
TAKEAWAY:
- Researchers found that an AKI was 23% more likely to occur in veterans who received at least one as-needed BP medication (hazard ratio [HR], 1.23; 95% CI, 1.18-1.29).
- Veterans who received BP medication as needed were 50% more likely to experience a rapid drop in BP within 3 hours (HR, 1.50; 95% CI, 1.39-1.62) and more than twice as likely after 1 hour (HR, 2.11; 95% CI, 1.81-2.46) than those who did not receive medication.
- The risk of experiencing the composite outcome was 69% times higher in the as-needed group (rate ratio [RR], 1.69; 95% CI, 1.49-1.92), with individual increased risks for myocardial infarction (RR, 2.92; 95% CI, 2.09-4.07), stroke (RR, 1.99; 95% CI, 1.30-3.03), and death (RR, 1.52; 95% CI, 1.32-1.75).
IN PRACTICE:
“The practical implication of our findings is that there is at least equipoise regarding the utility of as-needed BP medication use for asymptomatic BP elevations in hospitals ... future prospective trials should evaluate the risks and benefits of this common practice,” the study authors wrote.
SOURCE:
The study was led by Muna Thalji Canales, MD, MS, of the North Florida/South Georgia Veterans Health System in Gainesville, Florida. It was published online on November 25 in JAMA Internal Medicine.
LIMITATIONS:
The analysis may have included confounding factors that could have influenced results. The focus on veterans who had not undergone surgery limits generalizability to women, surgical patients, and nonveteran populations. The researchers noted limited data on factors that might influence BP readings in the hospital such as pain, stress, and faulty machinery.
DISCLOSURES:
Study authors reported grants and consulting fees from Merck Sharp & Dohme and BMS, and Teva Pharmaceuticals, among others.
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:
Veterans receiving blood pressure (BP) medication as needed while hospitalized were at a 23% higher risk for acute kidney injury (AKI) and a 1.5-fold greater risk for potentially dangerous rapid reductions in BP.
METHODOLOGY:
- Researchers analyzed the records of 133,760 veterans (90% men; mean age, 71.2 years) hospitalized in Veterans Affairs hospitals between 2015 and 2020.
- The study analyzed as-needed administration of BP drugs to patients who had an elevated BP but were asymptomatic.
- Patients who had at least one systolic BP reading above 140 mm Hg and received scheduled BP medication in the first 24 hours of hospitalization were included; those admitted to intensive care units or those who required surgery were excluded.
- The analysis compared outcomes between 28,526 patients who received as-needed drugs and 105,234 who did not; the primary outcome was time to the first AKI occurrence while hospitalized.
- Secondary outcomes included a reduction of more than 25% in systolic BP within 3 hours of as-needed BP medication, as well as a composite outcome of myocardial infarction, stroke, or death during hospitalization.
TAKEAWAY:
- Researchers found that an AKI was 23% more likely to occur in veterans who received at least one as-needed BP medication (hazard ratio [HR], 1.23; 95% CI, 1.18-1.29).
- Veterans who received BP medication as needed were 50% more likely to experience a rapid drop in BP within 3 hours (HR, 1.50; 95% CI, 1.39-1.62) and more than twice as likely after 1 hour (HR, 2.11; 95% CI, 1.81-2.46) than those who did not receive medication.
- The risk of experiencing the composite outcome was 69% times higher in the as-needed group (rate ratio [RR], 1.69; 95% CI, 1.49-1.92), with individual increased risks for myocardial infarction (RR, 2.92; 95% CI, 2.09-4.07), stroke (RR, 1.99; 95% CI, 1.30-3.03), and death (RR, 1.52; 95% CI, 1.32-1.75).
IN PRACTICE:
“The practical implication of our findings is that there is at least equipoise regarding the utility of as-needed BP medication use for asymptomatic BP elevations in hospitals ... future prospective trials should evaluate the risks and benefits of this common practice,” the study authors wrote.
SOURCE:
The study was led by Muna Thalji Canales, MD, MS, of the North Florida/South Georgia Veterans Health System in Gainesville, Florida. It was published online on November 25 in JAMA Internal Medicine.
LIMITATIONS:
The analysis may have included confounding factors that could have influenced results. The focus on veterans who had not undergone surgery limits generalizability to women, surgical patients, and nonveteran populations. The researchers noted limited data on factors that might influence BP readings in the hospital such as pain, stress, and faulty machinery.
DISCLOSURES:
Study authors reported grants and consulting fees from Merck Sharp & Dohme and BMS, and Teva Pharmaceuticals, among others.
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.
ADA Advises Against Using Compounded GLP-1 RA Medications
In a new statement, the American Diabetes Association (ADA) has advised against the use of compounded glucagon-like peptide 1 receptor agonist (GLP-1 RA) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA medication classes.
The ADA recommends GLP-1 RA and GIP/GLP-1 RA medications approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes, cardiovascular and kidney disease risk reduction, and weight management. The new ADA statement pertains to the unapproved, unregulated versions that have emerged as the demand for these medications for weight loss increases. These are often marketed directly to consumers.
“Compounded GLP-1 RA and dual GIP/GLP-1 RA products have been associated with clinically important dosing errors and adverse events. More concerning to individuals’ safety are counterfeit products that have made their way into the US drug supply chain and those advertised online and by unregulated sources,” the ADA said in the statement, published online on December 2, 2024, in Diabetes Care.
The statement, authored by Joshua J. Neumiller, PharmD, CDCES, of the Department of Pharmacotherapy, Washington State University, Spokane, and colleagues, states the following:
- Non–FDA-approved compounded incretin products are not recommended for use due to uncertainty about their content and resulting concerns about safety, quality, and effectiveness.
- If an incretin medication is unavailable (eg, in shortage), switching to a different FDA-approved medication is recommended as clinically appropriate to achieve and maintain individualized glucose-lowering, weight management, and/or cardiovascular and kidney risk reduction goals.
- Upon resolution of incretin product unavailability, reassess the appropriateness of resuming the original FDA-approved incretin medication.
The document points out that compounded products are not identical to the FDA-approved versions, may be distributed in nonstandard dosing devices, and may not provide sufficient user instructions.
However, “the ADA also recognizes that individuals and clinicians may still elect to use or recommend compounded products for financial or other reasons,” and therefore offers additional advice for the public, including the following:
- Discuss product use with their usual healthcare providers.
- Only use products that include dosing guidance.
- Verify that the compounding pharmacy is registered with FDA.
In addition, report any adverse events or medication errors to the FDA’s Medwatch.
A version of this article appeared on Medscape.com.
In a new statement, the American Diabetes Association (ADA) has advised against the use of compounded glucagon-like peptide 1 receptor agonist (GLP-1 RA) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA medication classes.
The ADA recommends GLP-1 RA and GIP/GLP-1 RA medications approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes, cardiovascular and kidney disease risk reduction, and weight management. The new ADA statement pertains to the unapproved, unregulated versions that have emerged as the demand for these medications for weight loss increases. These are often marketed directly to consumers.
“Compounded GLP-1 RA and dual GIP/GLP-1 RA products have been associated with clinically important dosing errors and adverse events. More concerning to individuals’ safety are counterfeit products that have made their way into the US drug supply chain and those advertised online and by unregulated sources,” the ADA said in the statement, published online on December 2, 2024, in Diabetes Care.
The statement, authored by Joshua J. Neumiller, PharmD, CDCES, of the Department of Pharmacotherapy, Washington State University, Spokane, and colleagues, states the following:
- Non–FDA-approved compounded incretin products are not recommended for use due to uncertainty about their content and resulting concerns about safety, quality, and effectiveness.
- If an incretin medication is unavailable (eg, in shortage), switching to a different FDA-approved medication is recommended as clinically appropriate to achieve and maintain individualized glucose-lowering, weight management, and/or cardiovascular and kidney risk reduction goals.
- Upon resolution of incretin product unavailability, reassess the appropriateness of resuming the original FDA-approved incretin medication.
The document points out that compounded products are not identical to the FDA-approved versions, may be distributed in nonstandard dosing devices, and may not provide sufficient user instructions.
However, “the ADA also recognizes that individuals and clinicians may still elect to use or recommend compounded products for financial or other reasons,” and therefore offers additional advice for the public, including the following:
- Discuss product use with their usual healthcare providers.
- Only use products that include dosing guidance.
- Verify that the compounding pharmacy is registered with FDA.
In addition, report any adverse events or medication errors to the FDA’s Medwatch.
A version of this article appeared on Medscape.com.
In a new statement, the American Diabetes Association (ADA) has advised against the use of compounded glucagon-like peptide 1 receptor agonist (GLP-1 RA) and dual glucose-dependent insulinotropic polypeptide (GIP)/GLP-1 RA medication classes.
The ADA recommends GLP-1 RA and GIP/GLP-1 RA medications approved by the Food and Drug Administration (FDA) for the treatment of type 2 diabetes, cardiovascular and kidney disease risk reduction, and weight management. The new ADA statement pertains to the unapproved, unregulated versions that have emerged as the demand for these medications for weight loss increases. These are often marketed directly to consumers.
“Compounded GLP-1 RA and dual GIP/GLP-1 RA products have been associated with clinically important dosing errors and adverse events. More concerning to individuals’ safety are counterfeit products that have made their way into the US drug supply chain and those advertised online and by unregulated sources,” the ADA said in the statement, published online on December 2, 2024, in Diabetes Care.
The statement, authored by Joshua J. Neumiller, PharmD, CDCES, of the Department of Pharmacotherapy, Washington State University, Spokane, and colleagues, states the following:
- Non–FDA-approved compounded incretin products are not recommended for use due to uncertainty about their content and resulting concerns about safety, quality, and effectiveness.
- If an incretin medication is unavailable (eg, in shortage), switching to a different FDA-approved medication is recommended as clinically appropriate to achieve and maintain individualized glucose-lowering, weight management, and/or cardiovascular and kidney risk reduction goals.
- Upon resolution of incretin product unavailability, reassess the appropriateness of resuming the original FDA-approved incretin medication.
The document points out that compounded products are not identical to the FDA-approved versions, may be distributed in nonstandard dosing devices, and may not provide sufficient user instructions.
However, “the ADA also recognizes that individuals and clinicians may still elect to use or recommend compounded products for financial or other reasons,” and therefore offers additional advice for the public, including the following:
- Discuss product use with their usual healthcare providers.
- Only use products that include dosing guidance.
- Verify that the compounding pharmacy is registered with FDA.
In addition, report any adverse events or medication errors to the FDA’s Medwatch.
A version of this article appeared on Medscape.com.
National Noncompete Ban Unlikely to Survive Under Trump, Experts Say
Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts.
Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.
But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban.
“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.
What’s in a Noncompete Clause?
Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor.
But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed.
At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years.
“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya.
Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”
Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies.
Texas Federal Judge Intervenes to Halt Ban
The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.
“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet.
In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said.
Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”
She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said.
Trump Isn’t Seen as Likely to Support Ban
While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”
In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.”
But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.
And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.
“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”
Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians.
Noncompete Ban Advocates Turn to States
Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court.
“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.
So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said.
According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota.
The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually.
Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause.
“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said.
Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.
A version of this article appeared on Medscape.com.
Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts.
Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.
But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban.
“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.
What’s in a Noncompete Clause?
Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor.
But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed.
At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years.
“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya.
Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”
Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies.
Texas Federal Judge Intervenes to Halt Ban
The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.
“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet.
In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said.
Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”
She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said.
Trump Isn’t Seen as Likely to Support Ban
While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”
In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.”
But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.
And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.
“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”
Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians.
Noncompete Ban Advocates Turn to States
Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court.
“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.
So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said.
According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota.
The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually.
Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause.
“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said.
Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.
A version of this article appeared on Medscape.com.
Even before the presidential election, the Federal Trade Commission’s (FTC) national ban on noncompete clauses faced a tough battle for survival in the courts.
Now, legal specialists forecast a grim prognosis for the ban under Donald Trump’s return to the White House.
But a federal district’s court ruling put the ban on hold, and the Trump administration isn’t expected to support lifting the ban.
“It is likely that the Trump administration will decline to defend the rule and may not even appeal the district court’s ruling, which means that the ban on noncompetes will not go into effect,” Steven Lubet, JD, a professor emeritus at Northwestern University Pritzker School of Law, Chicago, Illinois, said in an interview.
What’s in a Noncompete Clause?
Noncompete clauses in employee contracts typically restrict when and where workers can take future jobs. In medicine, supporters argue that the clauses are fair. Hospitals and practices provide a base of patients to physicians, they say, in return for their agreement not to go work for a competitor.
But those opposed to these clauses argue that the restrictions harm careers and hurt patients by unfairly preventing physicians from moving to new jobs where they’re needed.
At an April meeting, the FTC board voted 3 to 2 to ban noncompete clauses; some nonprofit organizations and senior executives were expected to be exempt. The FTC estimated that the move would save the healthcare system alone as much as $194 billion over 10 years.
“A pandemic killed a million people in this country, and there are doctors who cannot work because of a noncompete,” declared FTC Commissioner Alvaro Bedoya.
Hospitals protested the move. In a statement, the general counsel for the American Hospital Association called it “bad law, bad policy, and a clear sign of an agency run amok” and said the FTC ignored “mountains of contrary legal precedent and evidence about its adverse impacts on the health care markets.”
Although the American Medical Association does not support a total ban, its House of Delegates adopted policies in 2023 to support the prohibition of noncompete contracts for physicians employed by for-profit and nonprofit hospitals, hospital systems, or staffing companies.
Texas Federal Judge Intervenes to Halt Ban
The ban was supposed to take effect on Sept. 4, 2024. But Texas federal judge Ada E. Brown struck down the ban in an Aug. 20 decision. She ruled that the FTC went beyond its authority.
“The district court based its ruling on a very dubious distinction between ‘unfair practices,’ which the FTC may prohibit, and ‘unfair competition,’ which, according to the court, it may not,” said Lubet.
In fact, the ban should stand, he said. “This is a classic case of the government intervening on behalf of consumers/patients by prohibiting an unfair and harmful employment practice,” Lubet said.
Amanda Hill, an attorney in Austin, Texas, who trains physicians about how to negotiate contracts, has a different take. “The Federal Trade Commission came down hard, and honestly, it really overstepped,” she said in an interview. “Congress needs to write laws, not regulatory bodies. I think all the lawyers went: ‘Good try, but you’re not going to get anywhere with that.’ ”
She noted that physicians themselves are divided over the value of noncompete clauses. “I would say 80% of my clients can’t stand noncompetes.” But another 20% own their own practices and hate the idea of losing their physicians to competitors, she said.
Trump Isn’t Seen as Likely to Support Ban
While the Biden administration firmly supported a ban on noncompete clauses, there isn’t a strict Democratic-Republican divide over whether the agreements are a good idea. Some red states have embraced bans, and Hill said this can make sense from a Republican point of view: “We don’t want to run doctors out of town and out of the state because they think they’re going to be bound by big hospitals and corporate interests.”
In fact, former Florida congressman Matt Gaetz, a Republican briefly tapped as President-elect Trump’s nominee for attorney general, supports noncompete clauses. He filed a friend-of-the-court brief with the Texas judge that supported the FTC’s ruling, saying it is a “vindication of economic freedom and free enterprise.”
But Republicans generally “believe that federal agencies are going too far and beyond the power granted to them by Congress,” Atlanta, Georgia, attorney Benjamin Fink, Esq., said in an interview.
And Trump is no fan of the FTC and its chair, Lina Khan, who may step down. Observers don’t expect that the Trump administration or a newly constituted FTC board will support an appeal of the Texas judge’s ruling.
“I don’t think anybody else — another agency or a private party — could step in place of the FTC if the FTC declines to defend the ban,” Atlanta attorney Neal F. Weinrich, Esq., said in an interview. In that case, “I think it ends.”
Attorneys Weinrich and Fink work at the same firm, which handles noncompete agreements for physicians.
Noncompete Ban Advocates Turn to States
Even if Kamala Harris had won the presidency, a national ban on noncompete clauses would have faced an uphill battle at the Supreme Court.
“The Supreme Court majority has been unsympathetic to administrative agencies, interpreting their authority very narrowly,” said Lubet.
So what happens to noncompete clauses now? While bipartisan bills in Congress have tried to ban them, legislation is unlikely to pass now that Republicans will control both the House and Senate, Fink said.
According to a recent article, 12 states prohibit noncompete clauses for physicians: Alabama, California, Colorado, Delaware, Massachusetts, Montana, New Hampshire, New Mexico, North Dakota, Oklahoma, Rhode Island, and South Dakota.
The remaining states allow noncompetes in some form, often excluding them for employees earning below a certain threshold. For example, in Oregon, noncompete agreements may apply to employees earning more than $113,241. Most states have provisions to adjust the threshold annually. The District of Columbia permits 2-year noncompetes for “medical specialists” earning over $250,000 annually.
Indiana employers can no longer enter into noncompete agreements with primary care providers. Other specialties may be subject to the clauses, except when the physician terminates the contract for cause or when an employer terminates the contract without cause.
“I definitely think states are going to continue to restrict the use of noncompetes,” Fink said.
Lubet has no disclosures. Hill, Fink, and Weinrich represent physicians in contract negotiations.
A version of this article appeared on Medscape.com.
Council of Networks: Reflecting on the success of 2024
I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.
Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.
One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring.
For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.
I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.
Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.
One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring.
For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.
I have had the privilege of being the Chair of the Council of Networks this past year, and the engagement of the Chairs, Vice-Chairs, and steering committee members has contributed to a very successful CHEST 2024. Highlights from the meeting include the depth and breadth of 22 Experience CHEST sessions, which were held in the Exhibit Hall and gave trainees and early career faculty the opportunity to submit and present concise teaching on a topic. This year, many of these presentations were devoted to topics of diversity and inclusion.
Our program this year also honored Network Rising Stars at the Network Open Forums. These individuals were early career members who were nominated for their active engagement within CHEST and the Networks. The Networks also hosted a fun and engaging mixer, where members came together and had the opportunity to meet Network leadership, catch up with old friends, and sample a variety of Boston cuisine. I personally had the opportunity to meet several junior faculty who were excited to become involved in the Networks.
One of the initiatives we are working on is developing a robust mentoring program for fellows who are involved in the Networks and Sections. The pieces were put in place over the summer, and we will be gauging success of the program in the spring.
For those of you who have yet to join a Network, we would love for you to be involved. To see the current leadership of each Network, check out their pages on chesnet.org. You can log in to your CHEST account and join as many Networks as you want.
A visible impact
In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.
It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?
Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going.
Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially.
Let’s talk about an example of impact you’ve seen in the past year.
De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website.
We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees.
Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025.
What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician® readers?
De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you!
Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.
To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication.
Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season.
MAKE A GIFT TODAY
In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.
It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?
Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going.
Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially.
Let’s talk about an example of impact you’ve seen in the past year.
De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website.
We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees.
Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025.
What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician® readers?
De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you!
Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.
To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication.
Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season.
MAKE A GIFT TODAY
In 2023, CHEST’s philanthropic approach evolved to align with the organizational mission and elevate the value placed on giving. This was a pivotal transformation allowing CHEST to broaden its scope and deepen its impact, ensuring that every contribution continues to make a meaningful difference. 2024 was the first full year since the transition, and Bob Musacchio, PhD, CEO of CHEST, and Bob De Marco, MD, FCCP, Chair of the CHEST Board of Advisors, sat down to reflect on the year of CHEST philanthropy.
It’s been a full year since the transition to CHEST philanthropy; from your perspective, how has that transition gone so far?
Bob De Marco, MD, FCCP: It’s been a real pleasure to watch the evolution over the past year. The pillars that we defined to support our giving strategy resonated with a lot of past donors and also helped to engage new donors. Through clinical research, community impact, and dedication to education, we know exactly where our focus should be, allowing us to have the strongest impact while ensuring that donors know exactly where their gifts are going.
Bob Musacchio, PhD: Another benefit to the redefined strategy was its clear integration with the CHEST organization. In the past year, CHEST added social responsibility as one of the organizational pillars, which clarified the commitment to both philanthropy and advocacy. By aligning every element of philanthropy with the existing CHEST mission, we are able to expand our reach exponentially.
Let’s talk about an example of impact you’ve seen in the past year.
De Marco: When the original CHEST Foundation merged with CHEST, we established a new priority that continues to drive our mission: bridging gaps, breaking barriers, and improving health care interactions to enhance patient outcomes and overall health. This commitment is reflected in initiatives like Bridging Specialties® and the First 5 Minutes®—both of which you can learn more about on the CHEST website.
We’ve also entered into the second year of our partnership grant with the Association of Pulmonary and Critical Care Medicine Program Directors, which supports a fellow pursuing pulmonary and critical care medicine. This award recognizes the value of a diverse community in advancing medical education in pulmonary and critical care medicine. It provides an Accreditation Council for Graduate Medical Education fellow-in-training with the support, training, and mentorship needed to pursue a career in medical education and eventually serve as a mentor to future trainees.
Musacchio: I’d like to highlight the growth we’ve seen in our Community Impact grants. Following the shift, the impact grants now follow a participatory grantmaking model that empowers local organizations embedded within their communities to solve problems with the unique insights and solutions that only they can provide. This new strategy includes supporting our Community Connections partners, which are highlighted during the annual meeting. In Boston for CHEST 2024, we partnered with three local organizations—Boston Health Care for the Homeless Program, We Got Us, and the Tufts Community Health Workers Engaging in Integrated Care and Community Action Programs Inter-City collaboration—as our Community Connections to financially support their causes and to highlight their work throughout our meeting. Through partnership, we can strengthen our impact and empower communities to prioritize and improve respiratory well-being, and I look forward to continuing to grow this program in Chicago for CHEST 2025.
What’s next for CHEST philanthropy? Any closing thoughts for CHEST Physician® readers?
De Marco: The future is limitless for CHEST philanthropy. The more funding we receive, the more we can distribute to deserving projects. This includes expanding support to additional disease states, funding the next wave of travel grants, and giving more to support the research and clinical innovations that will shape the future of chest medicine . What I’d love to see is more CHEST members engaging with CHEST philanthropy. We invite you to connect with us—CHEST’s philanthropy team—to discuss how your continued investment can drive even greater impact or ask any questions you may have about the program. We’d welcome the opportunity to talk with you!
Also, if you’re thinking about giving before the end of the year, please know that every gift, new or increased, will be matched dollar for dollar through December 31.
To each and every one of you: Thank you for being a part of the CHEST community—and for your generosity and dedication.
Musacchio: I echo Dr. De Marco’s sentiment and want to reiterate that whether you’re a seasoned donor or considering your first gift, you can play a vital role in shaping the future of our field. Every gift—large or small—moves us forward and strengthens the community we all value. Thank you, and have a happy and healthy holiday season.
MAKE A GIFT TODAY
White ribbons around CHEST HQ raise awareness for lung cancer screening and early detection
During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.
According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide.
“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”
To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:
- 50 to 80 years of age;
- have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
- currently smoke or have quit within the last 15 years.
To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.
“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”
During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.
According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide.
“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”
To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:
- 50 to 80 years of age;
- have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
- currently smoke or have quit within the last 15 years.
To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.
“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”
During the month of November, CHEST displayed white ribbons around its headquarters in Glenview, Illinois, to raise awareness for lung cancer screening and early detection.
According to the World Health Organization, lung cancer kills more people yearly than breast, colon, and prostate cancers combined, and there are 2.1 million lung cancer cases worldwide.
“Lung Cancer Awareness Month was an opportunity for us to shine the spotlight on a disease that is impacting the lives of so many,” said Robert Musacchio, PhD, CEO of CHEST. “As a society of 22,000 respiratory professionals, we continuously provide the latest resources to our members, including the latest guidelines for lung cancer screening. Leveraging the awareness month, we wanted to spread the message throughout our local community that the best way to combat lung cancer is through early screening and detection.”
To identify and diagnose lung cancer in its earlier stages, it is recommended to seek lung cancer screening with a low-dose tomography scan (also known as low-dose CT or LDCT scan). Individuals who meet the below criteria are considered to be at high risk for developing lung cancer and should be screened:
- 50 to 80 years of age;
- have a 20 pack-year history of smoking (one pack a day for 20 years, two packs a day for 10 years, etc.); or
- currently smoke or have quit within the last 15 years.
To secure the ribbons, CHEST worked with an organization called the White Ribbon Project, which promotes awareness about lung cancer by changing public perception of the disease. Started by lung cancer survivor Heidi Onda and her husband, Pierre Onda, MD, the white ribbon initiative has spurred a movement to build community, reframe education, increase awareness, and remove the stigma against lung cancer.
“We are grateful for the advocacy and support of the American College of Chest Physicians in raising awareness for lung cancer,” Ms. Onda said. “We believe as a team of survivors, caregivers, those who have lost loved ones, advocates, the medical and science communities, industry representatives, advocacy organizations, legislators, and cancer centers that we can change the public perception of lung cancer. Anyone with lungs can get lung cancer, no one deserves it, and awareness and early detection of the disease are crucial.”
Get to know Incoming CHEST President, John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
Starting January 1, 2025, current President-Elect, John A. Howington, MD, MBA, FCCP, will become the new President of CHEST.
Before Dr. Howington steps into the role of President, he spoke with CHEST for a glimpse into his aspirations for 2025.
What would you like to accomplish as President of CHEST?
First, I want to express my gratitude for the honor and privilege of serving as the 87th President of CHEST. The organization is well-served by a high functioning Board of Regents and an incredible staff. My primary goal is to build on the success and momentum of the presidential years of Dr. Buckley and Dr. Addrizzo-Harris. Their annual meetings were a huge success, and the energy and enthusiasm of our members are palpable.
I feel very strongly that great things are ahead of us in the fields of pulmonary medicine and critical care. The CHEST organization will continue to focus on our mission to crush lung disease and stay true to our values of community, inclusivity, innovation, advocacy, and integrity. With 2025 marking the 90th anniversary of the college, I very much look forward to sharing the impact of the organization and showcasing what is yet to come.
We will continue to collaborate with sister societies and like-minded industry partners to improve the quality of patient care and support clinicians in our field. Specifically, I look forward to continuing the momentum we’ve seen in early identification of lung cancer and increasing cure rates. Working as a team of interventional pulmonologists, respiratory therapists, advanced practice providers, thoracic surgeons, and more, we can make a real impact on what it means to be diagnosed with lung cancer.
What do you consider to be CHEST’s greatest strength, and how will you build upon this during your presidency?
CHEST’s greatest strength is the people involved with the organization. There is such a wonderful culture of inclusivity and innovation cultivated by the outstanding staff, committed volunteers, and expert faculty leaders. We have focused on continuous board development for the last eight years and are seeing the benefits in the strategic and innovative steps the Board of Regents have taken to better serve our members and patients. It’s an honor to step into the role of leading such an extraordinary group.
What are some of the challenges facing CHEST, and how will you address them?
While not unique to CHEST, stress and burnout remain an issue in the field of health care. Clinicians are asked to do more with limited resources to provide high-quality care to an increasing number of patients with widely varying needs. We will continue to focus on providing guidance on best practices in the field of chest medicine and sharing innovations that reduce the burdens of health care delivery. To help alleviate the stress put on clinicians, we want to do our part to help remove anything that stands between a clinician and their ability to provide the best care for patients.
What do you ask of members to support you during your presidency?
What I would ask of our members is that they reach out to connect. I want to both celebrate your wins in the field and work with your suggestions to improve CHEST. Making the organization stronger is a collaborative effort, and every voice matters. My email starting January 1 is [email protected], and if you need some writing inspiration, I’ve got some suggested prompts:
- Share with me a recent personal success or that of a colleague; we want to help spread the word.
- What do you find most rewarding in your practice?
- What’s a recurring challenge you face in practice?
- What is CHEST getting right? Where can we improve?
I look forward to hearing from you.
Warmest regards,
John A. Howington, MD, MBA, FCCP
RBC transfusion guidelines in critical care: Making the case for a restrictive approach
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE
In the high-stakes environment of the intensive care unit (ICU), red blood cell (RBC) transfusions are a common intervention. With approximately 25% of critically ill patients in the US receiving RBC transfusions, optimizing the approach to transfusion is vital not only for patient safety but also for resource management. For the bedside clinician and health care systems, this presents both an opportunity and a challenge: to recalibrate transfusion practices while maintaining the highest standards of patient care.
Why a restrictive strategy?
Historically, transfusions were administered to optimize oxygen delivery to organs in the presence of anemia. However, studies have highlighted the risks associated with transfusions, such as transfusion-related lung injury, circulatory overload, and increased nosocomial infections. These risks are particularly pronounced in critically ill patients, who are often more vulnerable to complications from any additional physiological burden.
The restrictive approach—typically recommended at a hemoglobin threshold of 7 to 8 g/dL—has been shown to be the safer alternative for most ICU patients, as highlighted in recently published clinical guidelines. The data supporting this approach suggest that a restrictive transfusion strategy not only spares patients unnecessary transfusions but also aligns with cost-effective and resource-efficient health care practices.
Key recommendations
For ICU providers, this guideline presents specific recommendations based on a patient’s condition:
• General critical illness: The restrictive approach is preferred over a permissive one, with no adverse effect on ICU mortality, one-year survival, or adverse events. In other words, lower Hgb thresholds do not correlate with poorer outcomes in most critically ill patients.
• Acute gastrointestinal bleeding: Evidence favors a restrictive approach, associated with reduced rebleeding risk and short-term mortality. Studies show a significantly lower incidence of transfusion reactions and costs without compromising patient safety.
• Acute coronary syndrome (ACS): A more cautious approach is advised here. In cases of ACS, a restrictive RBC transfusion strategy could potentially increase the risk of cardiac death. It is recommended to avoid a restrictive approach, as it remains unclear whether there is a gradient effect—where risk progressively increases below a hemoglobin level of 10 g/dL—or a threshold effect at 10 g/dL. In other words, the data does not clarify if a hemoglobin level of 9 g/dL is as safe as 10 g/dL. An individualized transfusion approach, considering patient symptoms and other physiological markers, is recommended.
• Post-cardiac surgery: For postoperative patients, a restrictive strategy is suggested, as it conserves RBCs without impacting outcomes such as mortality or length of hospital stay.
• Isolated troponin elevation: In cases of elevated troponin without evidence of cardiac ischemia, transfusion decisions should consider additional patient-specific variables, with a restrictive approach as the baseline.
• Septic shock: RBC transfusions as part of a resuscitation bundle were not analyzed, as isolating the impact of RBC transfusions from other bundle elements was not feasible. However, with no clear benefit and similar adverse effects, neither strategy proved clinically superior. Nonetheless, a restrictive approach conserves RBC units, thereby saving resources and reducing costs.
The economics of restriction
Beyond clinical benefits, a restrictive approach conserves precious health care resources. With the cost of a single RBC unit hovering around $200—and significantly higher once administrative and logistic expenses are accounted for—reducing unnecessary transfusions translates into substantial savings. For a health care system already strained by limited blood supply and rising demand, a 40% reduction in transfusions across ICUs could alleviate supply pressures and contribute to more equitable resource distribution.
Easier said than done
Adopting a restrictive transfusion policy is not without challenges. Clinicians are trained to act decisively in critical situations, and, often, the instinct is to do more rather than less. However, studies indicate that with proper education, awareness, and decision-support systems, a restrictive policy is both feasible and effective. Institutions may consider behavior modification strategies, such as standardized transfusion order sets and decision-support tools within electronic medical records, to aid in adjusting transfusion practices.
Call to action
The message is clear: For most critically ill patients, a restrictive RBC transfusion strategy is not only safe but optimal. For ICU teams, this calls for a proactive shift in approach. It is a call to scrutinize transfusion triggers and lean toward a judicious, evidence-based approach.
While cases like ACS may require a different approach, the evidence strongly supports that, under most circumstances, less is more. Embracing this approach requires careful consideration, yet the potential benefits for patient safety and health care sustainability are compelling.
As critical care professionals, let us lead the way in refining transfusion practices to uphold patient safety, optimize resources, and adapt to evidence-based guidelines.
ACCESS THE FULL GUIDELINE