Randy Dotinga

LOS ANGELES – On the male fertility front, obesity seems to hurt semen quality. So does weight-loss surgery reverse the trend? A new review of existing research suggests that there may be an effect, but the findings aren’t conclusive.

“We found something,” said Sikarin Upala, MD, a second-year endocrinology fellow at the University of Chicago, who pointed out that three of the four reports he and his colleagues reviewed suggested improvement in semen motility. “But we still need to study more about whether bariatric surgery will affect infertility,” he continued.

Dr. Upala, who led the systematic review and meta-analysis of research into bariatric surgery and semen quality, spoke in an interview after his presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Researchers have linked obesity to infertility in men, but it’s not entirely clear how excess weight and sperm deficiencies are connected. As researchers explained in a 2018 report, “conflicting results have been observed in studies evaluating the correlation between [body mass index] and sperm parameters, such as sperm concentration and total sperm count.” However, they noted that it is “generally accepted” that men with obesity seem to be at higher risk of having a low sperm count or having azoospermia, which is the total lack of sperm in semen.

It’s also not clear whether weight loss directly improves male fertility. “We do know that androgen levels improve after weight-loss surgery, and that might be one factor among several that may contribute to improved male fertility,” Edward Lin, DO, MBA, FACS, professor of surgery and chief of gastrointestinal and general surgery at Emory University, Atlanta, said in an interview.

In their review, Dr. Upala and his colleagues analyzed four studies published between 2012 and 2018 that evaluated the effect of bariatric surgery on semen quality. All of the studies examined semen volume and sperm morphology and motility, and three examined sperm concentration.

A meta-analysis found that motility and volume improved after surgery; however, some of the studies (two for volume, one for motility) failed to show a statistically significant change.

There was no statistically significant difference in sperm morphology or concentration overall, although one study showed a statistically significant improvement in both categories.

Overall, “there might be a little bit of positive effect, but we couldn’t reach a good conclusion because there were too few studies,” Dr. Upala said.

Dr. Lin, director of the Emory Bariatrics Center, agreed that the review findings are limited. He said that although the findings hint at a positive effect on semen quality, “the jury is still out” when it comes to a link between bariatric surgery and male infertility.

“Multiple factors contribute to semen quality,” he added, pointing to vitamin deficiencies, micronutrient levels in the body, enzyme signaling pathways, and sperm chromatin integrity. “In fact, surgically or diet-induced weight loss may be associated with permissive malnutrition, which further exacerbates these deficiencies. Deficiencies in these areas can sometimes take months, if not years, to correct by taking vitamin D or copper or zinc, for example.”

Dr. Lin referred to a small study in which reporters observed semen abnormalities and subfertility after weight-loss surgery despite improvements in androgenic and quality of life levels.

Dr. Upala reported having no relevant disclosures.

LOS ANGELES – On the male fertility front, obesity seems to hurt semen quality. So does weight-loss surgery reverse the trend? A new review of existing research suggests that there may be an effect, but the findings aren’t conclusive.

“We found something,” said Sikarin Upala, MD, a second-year endocrinology fellow at the University of Chicago, who pointed out that three of the four reports he and his colleagues reviewed suggested improvement in semen motility. “But we still need to study more about whether bariatric surgery will affect infertility,” he continued.

Dr. Upala, who led the systematic review and meta-analysis of research into bariatric surgery and semen quality, spoke in an interview after his presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Researchers have linked obesity to infertility in men, but it’s not entirely clear how excess weight and sperm deficiencies are connected. As researchers explained in a 2018 report, “conflicting results have been observed in studies evaluating the correlation between [body mass index] and sperm parameters, such as sperm concentration and total sperm count.” However, they noted that it is “generally accepted” that men with obesity seem to be at higher risk of having a low sperm count or having azoospermia, which is the total lack of sperm in semen.

It’s also not clear whether weight loss directly improves male fertility. “We do know that androgen levels improve after weight-loss surgery, and that might be one factor among several that may contribute to improved male fertility,” Edward Lin, DO, MBA, FACS, professor of surgery and chief of gastrointestinal and general surgery at Emory University, Atlanta, said in an interview.

In their review, Dr. Upala and his colleagues analyzed four studies published between 2012 and 2018 that evaluated the effect of bariatric surgery on semen quality. All of the studies examined semen volume and sperm morphology and motility, and three examined sperm concentration.

A meta-analysis found that motility and volume improved after surgery; however, some of the studies (two for volume, one for motility) failed to show a statistically significant change.

There was no statistically significant difference in sperm morphology or concentration overall, although one study showed a statistically significant improvement in both categories.

Overall, “there might be a little bit of positive effect, but we couldn’t reach a good conclusion because there were too few studies,” Dr. Upala said.

Dr. Lin, director of the Emory Bariatrics Center, agreed that the review findings are limited. He said that although the findings hint at a positive effect on semen quality, “the jury is still out” when it comes to a link between bariatric surgery and male infertility.

“Multiple factors contribute to semen quality,” he added, pointing to vitamin deficiencies, micronutrient levels in the body, enzyme signaling pathways, and sperm chromatin integrity. “In fact, surgically or diet-induced weight loss may be associated with permissive malnutrition, which further exacerbates these deficiencies. Deficiencies in these areas can sometimes take months, if not years, to correct by taking vitamin D or copper or zinc, for example.”

Dr. Lin referred to a small study in which reporters observed semen abnormalities and subfertility after weight-loss surgery despite improvements in androgenic and quality of life levels.

Dr. Upala reported having no relevant disclosures.

LOS ANGELES – On the male fertility front, obesity seems to hurt semen quality. So does weight-loss surgery reverse the trend? A new review of existing research suggests that there may be an effect, but the findings aren’t conclusive.

“We found something,” said Sikarin Upala, MD, a second-year endocrinology fellow at the University of Chicago, who pointed out that three of the four reports he and his colleagues reviewed suggested improvement in semen motility. “But we still need to study more about whether bariatric surgery will affect infertility,” he continued.

Dr. Upala, who led the systematic review and meta-analysis of research into bariatric surgery and semen quality, spoke in an interview after his presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Researchers have linked obesity to infertility in men, but it’s not entirely clear how excess weight and sperm deficiencies are connected. As researchers explained in a 2018 report, “conflicting results have been observed in studies evaluating the correlation between [body mass index] and sperm parameters, such as sperm concentration and total sperm count.” However, they noted that it is “generally accepted” that men with obesity seem to be at higher risk of having a low sperm count or having azoospermia, which is the total lack of sperm in semen.

It’s also not clear whether weight loss directly improves male fertility. “We do know that androgen levels improve after weight-loss surgery, and that might be one factor among several that may contribute to improved male fertility,” Edward Lin, DO, MBA, FACS, professor of surgery and chief of gastrointestinal and general surgery at Emory University, Atlanta, said in an interview.

In their review, Dr. Upala and his colleagues analyzed four studies published between 2012 and 2018 that evaluated the effect of bariatric surgery on semen quality. All of the studies examined semen volume and sperm morphology and motility, and three examined sperm concentration.

A meta-analysis found that motility and volume improved after surgery; however, some of the studies (two for volume, one for motility) failed to show a statistically significant change.

There was no statistically significant difference in sperm morphology or concentration overall, although one study showed a statistically significant improvement in both categories.

Overall, “there might be a little bit of positive effect, but we couldn’t reach a good conclusion because there were too few studies,” Dr. Upala said.

Dr. Lin, director of the Emory Bariatrics Center, agreed that the review findings are limited. He said that although the findings hint at a positive effect on semen quality, “the jury is still out” when it comes to a link between bariatric surgery and male infertility.

“Multiple factors contribute to semen quality,” he added, pointing to vitamin deficiencies, micronutrient levels in the body, enzyme signaling pathways, and sperm chromatin integrity. “In fact, surgically or diet-induced weight loss may be associated with permissive malnutrition, which further exacerbates these deficiencies. Deficiencies in these areas can sometimes take months, if not years, to correct by taking vitamin D or copper or zinc, for example.”

Dr. Lin referred to a small study in which reporters observed semen abnormalities and subfertility after weight-loss surgery despite improvements in androgenic and quality of life levels.

Dr. Upala reported having no relevant disclosures.

LOS ANGELES – Cardiology patients can strap on a Holter monitor for a day or two to track their heart activity and get a brief but helpful glimpse at their cardiac health. Could patients with type 2 diabetes benefit by monitoring their blood sugar for a short period? Absolutely, according to an endocrinologist who says he’s had tremendous success with the temporary use of continuous glucose monitors (CGMs) in appropriate patients.

“There’s an actionable surprise with almost every patient,” said Daniel Einhorn, MD, FACP, FACE, medical director of Scripps Whittier Diabetes Institute and clinical professor of medicine at the University of California, San Diego.

The key is to use CGM data to pinpoint glucose spikes and then quickly make adjustments, typically over a period of 2 weeks. “This is about pattern recognition. We can do [CGM] over a week, see what the pattern is, and then try to fix something. Then they come back after the second week or send [the monitor] in, and they have the problem fixed. You have a happy patient and a happy family,” said Dr. Einhorn, who spoke in a presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

He highlighted how CGM data allow patients to track their blood sugar over extended periods of time and detect patterns. The data can uncover hidden hypoglycemia and hyperglycemia, he said, and is much more useful to patients than the self-monitoring of glucose levels or hemoglobin A_1c (HbA_1c) data.

Reading the patterns, adjusting behavior

Dr. Einhorn discussed several specific cases of patients who had changed their behavior in regard to food or medicine after CGM data disclosed certain blood sugar patterns.

Often, he said, patients say they’re surprised to find their well-being improves after they make adjustments, saying something along the lines of “I didn’t feel badly, but I feel better now.” According to Dr. Einhorn, “You hear that all the time.”

For example, he said, one patient knew his blood sugar occasionally topped 200 mg/dL, but he felt all right and didn’t want to take insulin. CGM monitoring over 6 days showed the patient had continuous glucose levels well over 200 mg/dL, especially at night. The patient accepted insulin, and a few months later his HbA_1c dropped from 10.4% to 6.6%, and his blood sugar level stayed near or below the target range of 154 mg/dL.

Dr. Einhorn said the CGM data can reveal a range of problems, including:

• The “breakfast bump” after carbohydrate-heavy breakfasts of cereal, toast, and juice. “Breakfast cereal is diabolical,” he said.
• Hypoglycemia hours after exercise.
• Nocturnal hypoglycemia.
• Hypoglycemia unawareness.

Insurance coverage of the CGM device varies widely, he said, and insurers may not cover it at all in type 2 diabetes or only pay if the patient takes insulin. Fortunately, he said, the devices can be inexpensive.
 

Temporary use is not for everyone

Dr. Einhorn cautioned that temporary use of CGM is not appropriate for every patient with type 2 diabetes. “There’s absolutely a place for [permanent] monitoring for those people who have to make decisions throughout the day, especially if they are taking insulin,” he said.

And anyone with type 1 diabetes should use CGM on an ongoing basis, he emphasized. “Type 1 is a different world, a different universe,” he said.

He also noted that some patients don’t fare well on CGM, even on a temporary basis. That would include patients who hate to wear devices (possibly out of embarrassment), those who can’t manage to switch over from self-monitoring, and those who can’t manage to understand the data.

Dr. Einhorn disclosed various types of relationships with a number of drug makers, including Abbott, Boehringer Ingelheim, Novo, Sanofi, Janssen, and others.

LOS ANGELES – Cardiology patients can strap on a Holter monitor for a day or two to track their heart activity and get a brief but helpful glimpse at their cardiac health. Could patients with type 2 diabetes benefit by monitoring their blood sugar for a short period? Absolutely, according to an endocrinologist who says he’s had tremendous success with the temporary use of continuous glucose monitors (CGMs) in appropriate patients.

“There’s an actionable surprise with almost every patient,” said Daniel Einhorn, MD, FACP, FACE, medical director of Scripps Whittier Diabetes Institute and clinical professor of medicine at the University of California, San Diego.

The key is to use CGM data to pinpoint glucose spikes and then quickly make adjustments, typically over a period of 2 weeks. “This is about pattern recognition. We can do [CGM] over a week, see what the pattern is, and then try to fix something. Then they come back after the second week or send [the monitor] in, and they have the problem fixed. You have a happy patient and a happy family,” said Dr. Einhorn, who spoke in a presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

He highlighted how CGM data allow patients to track their blood sugar over extended periods of time and detect patterns. The data can uncover hidden hypoglycemia and hyperglycemia, he said, and is much more useful to patients than the self-monitoring of glucose levels or hemoglobin A_1c (HbA_1c) data.

Reading the patterns, adjusting behavior

Dr. Einhorn discussed several specific cases of patients who had changed their behavior in regard to food or medicine after CGM data disclosed certain blood sugar patterns.

Often, he said, patients say they’re surprised to find their well-being improves after they make adjustments, saying something along the lines of “I didn’t feel badly, but I feel better now.” According to Dr. Einhorn, “You hear that all the time.”

For example, he said, one patient knew his blood sugar occasionally topped 200 mg/dL, but he felt all right and didn’t want to take insulin. CGM monitoring over 6 days showed the patient had continuous glucose levels well over 200 mg/dL, especially at night. The patient accepted insulin, and a few months later his HbA_1c dropped from 10.4% to 6.6%, and his blood sugar level stayed near or below the target range of 154 mg/dL.

Dr. Einhorn said the CGM data can reveal a range of problems, including:

• The “breakfast bump” after carbohydrate-heavy breakfasts of cereal, toast, and juice. “Breakfast cereal is diabolical,” he said.
• Hypoglycemia hours after exercise.
• Nocturnal hypoglycemia.
• Hypoglycemia unawareness.

Insurance coverage of the CGM device varies widely, he said, and insurers may not cover it at all in type 2 diabetes or only pay if the patient takes insulin. Fortunately, he said, the devices can be inexpensive.
 

Temporary use is not for everyone

Dr. Einhorn cautioned that temporary use of CGM is not appropriate for every patient with type 2 diabetes. “There’s absolutely a place for [permanent] monitoring for those people who have to make decisions throughout the day, especially if they are taking insulin,” he said.

And anyone with type 1 diabetes should use CGM on an ongoing basis, he emphasized. “Type 1 is a different world, a different universe,” he said.

He also noted that some patients don’t fare well on CGM, even on a temporary basis. That would include patients who hate to wear devices (possibly out of embarrassment), those who can’t manage to switch over from self-monitoring, and those who can’t manage to understand the data.

Dr. Einhorn disclosed various types of relationships with a number of drug makers, including Abbott, Boehringer Ingelheim, Novo, Sanofi, Janssen, and others.

LOS ANGELES – Cardiology patients can strap on a Holter monitor for a day or two to track their heart activity and get a brief but helpful glimpse at their cardiac health. Could patients with type 2 diabetes benefit by monitoring their blood sugar for a short period? Absolutely, according to an endocrinologist who says he’s had tremendous success with the temporary use of continuous glucose monitors (CGMs) in appropriate patients.

“There’s an actionable surprise with almost every patient,” said Daniel Einhorn, MD, FACP, FACE, medical director of Scripps Whittier Diabetes Institute and clinical professor of medicine at the University of California, San Diego.

The key is to use CGM data to pinpoint glucose spikes and then quickly make adjustments, typically over a period of 2 weeks. “This is about pattern recognition. We can do [CGM] over a week, see what the pattern is, and then try to fix something. Then they come back after the second week or send [the monitor] in, and they have the problem fixed. You have a happy patient and a happy family,” said Dr. Einhorn, who spoke in a presentation at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

He highlighted how CGM data allow patients to track their blood sugar over extended periods of time and detect patterns. The data can uncover hidden hypoglycemia and hyperglycemia, he said, and is much more useful to patients than the self-monitoring of glucose levels or hemoglobin A_1c (HbA_1c) data.

Reading the patterns, adjusting behavior

Dr. Einhorn discussed several specific cases of patients who had changed their behavior in regard to food or medicine after CGM data disclosed certain blood sugar patterns.

Often, he said, patients say they’re surprised to find their well-being improves after they make adjustments, saying something along the lines of “I didn’t feel badly, but I feel better now.” According to Dr. Einhorn, “You hear that all the time.”

For example, he said, one patient knew his blood sugar occasionally topped 200 mg/dL, but he felt all right and didn’t want to take insulin. CGM monitoring over 6 days showed the patient had continuous glucose levels well over 200 mg/dL, especially at night. The patient accepted insulin, and a few months later his HbA_1c dropped from 10.4% to 6.6%, and his blood sugar level stayed near or below the target range of 154 mg/dL.

Dr. Einhorn said the CGM data can reveal a range of problems, including:

• The “breakfast bump” after carbohydrate-heavy breakfasts of cereal, toast, and juice. “Breakfast cereal is diabolical,” he said.
• Hypoglycemia hours after exercise.
• Nocturnal hypoglycemia.
• Hypoglycemia unawareness.

Insurance coverage of the CGM device varies widely, he said, and insurers may not cover it at all in type 2 diabetes or only pay if the patient takes insulin. Fortunately, he said, the devices can be inexpensive.
 

Temporary use is not for everyone

Dr. Einhorn cautioned that temporary use of CGM is not appropriate for every patient with type 2 diabetes. “There’s absolutely a place for [permanent] monitoring for those people who have to make decisions throughout the day, especially if they are taking insulin,” he said.

And anyone with type 1 diabetes should use CGM on an ongoing basis, he emphasized. “Type 1 is a different world, a different universe,” he said.

He also noted that some patients don’t fare well on CGM, even on a temporary basis. That would include patients who hate to wear devices (possibly out of embarrassment), those who can’t manage to switch over from self-monitoring, and those who can’t manage to understand the data.

Dr. Einhorn disclosed various types of relationships with a number of drug makers, including Abbott, Boehringer Ingelheim, Novo, Sanofi, Janssen, and others.

LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.

Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”

According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:

• Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
• Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
• Lower overall costs.
• Fewer complications in the elderly.

When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.

Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.

Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.

LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.

Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”

According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:

• Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
• Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
• Lower overall costs.
• Fewer complications in the elderly.

When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.

Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.

Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.

LAS VEGAS – Two-thirds of colon resections in the United States are open procedures, but a colorectal surgeon told colleagues that evidence shows minimally invasive surgery deserves a wider place in his field.

Why? Because minimally invasive surgery – despite its limited utilization – is linked to multiple improved outcomes in colorectal surgery, said Matthew G. Mutch, MD, chief of colon and rectal surgery at Washington University, St. Louis, in a presentation at the Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“Our goal should be to offer minimally invasive surgery to as many patients as possible by as many different methods as needed,” Dr. Mutch said. “If you’re willing to take this on and do this over a regular basis, you’ll get over that learning curve and expand the number of patients you can offer laparoscopy to.”

According to Dr. Mutch, benefits of minimally invasive colorectal surgery include:

• Improved short-term outcomes – length of stay and return of bowel function, and morbidity and mortality. A 2012 retrospective study of 85,712 colon resections that found laparoscopic resections, when feasible, “had better outcomes than open colectomy in the immediate perioperative period.” (Ann Surg. 2012 Sep;256[3]462-8).
• Improved long-term outcomes: faster recovery, fewer hernias, and fewer bowel obstructions.
• Lower overall costs.
• Fewer complications in the elderly.

When it comes to laparoscopic colorectal surgery, Dr. Mutch cautioned that the robotic technology has unclear benefit in rectal cancer, and the cost in colorectal cancer is unclear.

Another alternative is to perform laparoscopic colorectal surgery through alternative extraction sites such as the rectum, vagina, stomach, and even a stoma site or perineal wound. Both transanal and transvaginal extraction are feasible and safe, he said, adding that transvaginal procedures are best performed in conjunction with a hysterectomy. One benefit of these procedures is that they avoid abdominal wall trauma. However, he cautioned that colorectal surgery is unique because a cancerous specimen cannot be morcellated and must instead be removed whole.

Dr. Mutch also discussed laparoendoscopic resection of colon polyps. Benefits include shorter length of stay and faster recovery, he said, but complications can include perforation and bleeding. And, he said, there’s currently no code for the procedure.

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Mutch has no relevant disclosures.

LOS ANGELES – There are plenty of options available if you’re looking to use medication to help your patient with diabetes lose weight, including existing diabetes drugs. Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.

Diabetes drugs help, but may need a boost

Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).

There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.

“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”

To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).

In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”

Consider insurance coverage and other factors

Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A_1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.

Newer weight-loss drugs ...

Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.

• Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
• Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
• Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
• Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).

... but watch out for safety in patients with heart disease

Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.

Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.

Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
 

LOS ANGELES – There are plenty of options available if you’re looking to use medication to help your patient with diabetes lose weight, including existing diabetes drugs. Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.

Diabetes drugs help, but may need a boost

Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).

There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.

“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”

To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).

In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”

Consider insurance coverage and other factors

Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A_1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.

Newer weight-loss drugs ...

Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.

• Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
• Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
• Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
• Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).

... but watch out for safety in patients with heart disease

Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.

Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.

Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
 

LOS ANGELES – There are plenty of options available if you’re looking to use medication to help your patient with diabetes lose weight, including existing diabetes drugs. Newer medications are much more powerful, but they come with cautions – insurer coverage can be a hurdle, and there are significant gaps in knowledge about their risks for patients with heart disease, Ken Fujioka, MD, told colleagues at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Fujioka, of Scripps Clinic in San Diego, shared some tips with his peers about using medications to reduce weight.

Diabetes drugs help, but may need a boost

Metformin can reduce weight by as much as 3%, Dr. Fujioka said. And there may be another benefit related to long-term weight loss maintenance, he said, citing a 15-year study of overweight or obese patients at high risk for diabetes who either received metformin, underwent an intensive lifestyle intervention, or took a placebo. Of the participants with weight loss of at least 5% after the first year, those originally assigned to receive metformin had the greatest weight loss during years 6-15. Older age, the amount of weight initially lost, and continued used of metformin were predictors of long-term weight loss maintenance, according to the researchers (Ann Intern Med. 2019 Apr 23. doi: 10.7326/M18-1605).

There are other options among diabetes drugs. Sodium-glucose cotransporter 2 (SGLT2) inhibitors – a class of drugs that includes canagliflozin (Invokana), dapagliflozin (Farxiga), and empagliflozin (Jardiance) – have a striking effect on weight loss, Dr. Fujioka said. They can cause 300 calories to be flushed out in the urine each day. But that typically doesn’t translate into weight loss of more than 20 pounds, he said, because the body doesn’t fully adjust to fewer calories.

“The patients begin to eat more,” he said. “They have to take in more calories to make up for [the loss]. They’re not consciously trying to do this. It’s a metabolic adaptation, so 2%-3% [weight loss] is about all you’ll get. You won’t get 10% or 20%.”

To drive up weight loss, Dr. Fujioka recommended adding the glucagonlike peptide–1 [GLP1] receptor diabetes drug exenatide (Byetta; Bydureon) or the appetite suppressant phentermine (Adipex-p; Lomaira) to an SGLT2 inhibitor. Recent studies have shown that the drug combinations have a greater impact on weight loss than when taken separately (Lancet Diabetes Endocrinol. 2016 Dec;4[12]:1004-16; Diabetes Care. 2017 May;40[5]:632-9).

In regard to phentermine, which acts similarly to amphetamine, Dr. Fujioka advised colleagues to be aware that “15 mg or less is really safe, but you drive pulse and heart rate beyond that.”

Consider insurance coverage and other factors

Often, insurers will pay for GLP1-receptor and SGLT2-inhibitor medications in patients with diabetes, even if their hemoglobin A_1c is in the healthy range, Dr. Fujioka said, but they’ll balk at paying for specific weight-loss medications, although that can vary by the region of the country. He added that cash discount cards are available for several weight-loss drugs.

Newer weight-loss drugs ...

Dr. Fujioka highlighted a quartet of weight-loss drugs that have been approved in recent years.

• Lorcaserin (Belviq), a selective serotonin 2C receptor agonist, has shown unique benefits in patients with diabetes. A large, multinational, randomized controlled trial found that the drug reduced the risk for incident diabetes, induced remission of hyperglycemia, and reduced the risk of microvascular complications in obese and overweight patients (Lancet. 2018 Nov 24;392[10161]:2269-79).
• Phentermine/topiramate (Qsymia), a combination of an antiseizure medication (topiramate) and an appetite suppressant (phentermine). A 2014 study found that the drug, together with lifestyle modification, effectively promoted weight loss and improved glycemic control in obese or overweight patients with type 2 diabetes (Diabetes Care. 2014 Dec;37[12]:3309-16).
• Naltrexone/bupropion (Contrave), a combination of an addiction drug (naltrexone) and an antidepressant (bupropion). Findings from a 2013 study reported that the drug “in overweight/obese patients with type 2 diabetes induced weight loss... was associated with improvements in glycemic control and select cardiovascular risk factors and was generally well tolerated with a safety profile similar to that in patients without diabetes.” (Diabetes Care. 2013 Dec;36[12]:4022-9).
• Liraglutide, an injectable GLP1 agonist that has been approved for diabetes (Victoza) and weight loss (Saxenda). Dr. Fujioka was coauthor for a study in which the findings suggested that the drug could prevent prediabetes from turning into diabetes. (Lancet. 2017 Apr 8;389[10077]:1399-409).

... but watch out for safety in patients with heart disease

Two of the newer weight-loss drugs are OK to prescribe for diabetic patients with heart disease, Dr. Fujioka said, but two are not, because no cardiac safety trials have been completed for them.

Liraglutide (at a dose of 3.0 mg) is considered safe based on previous data (Diabetes Obes Metab. 2018 Mar;20[3]:734-9), Dr. Fujioka said. Likewise, findings from a trial with lorcaserin in which 12,000 overweight or obese patients with atherosclerotic cardiovascular disease or multiple cardiovascular risk factors received either lorcaserin (10 mg twice daily) or placebo, suggested that lorcaserin helped sustain weight loss without a higher rate of major cardiovascular events compared with placebo (N Engl J Med. 2018 Sep 20;379[12]:1107-17).However, no such cardiac safety trials have been completed for naltrexone/bupropion or phentermine/topiramate, said Dr. Fujioka. As a result, he said he could not recommend either of them for patients with high-risk cardiovascular disease.

Dr. Fujioka disclosed relationships of various types with Novo Nordisk, Eisai, Gelesis, KVK Tech, Amgen, Sunovion, Boehringer Ingelheim, and Janssen Global Services.
 

LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology team reports successfully using insulin pumps to deliver hydrocortisone to patients with adrenal insufficiency who have fared poorly on oral medications.

“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.

“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.

LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology team reports successfully using insulin pumps to deliver hydrocortisone to patients with adrenal insufficiency who have fared poorly on oral medications.

“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.

“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.

LOS ANGELES – The venerable insulin pump is being repurposed: A Detroit-area endocrinology team reports successfully using insulin pumps to deliver hydrocortisone to patients with adrenal insufficiency who have fared poorly on oral medications.

“We’ve seen amazing results,” said endocrinologist Opada Alzohaili, MD, MBA, of Wayne State University, Detroit, coauthor of a study released at the annual scientific and clinical congress of the American Association of Clinical Endocrinologists.

Dr. Alzohaili said he and his colleagues developed the approach to manage patients who are “so sick that they go to the hospital 10-12 times a year.” Oral medication just did not control their disorder.

“Most of the time, we end up way overdosing them [on oral medication] just to prevent them from going to the hospital in adrenal crisis,” he said in an interview.

LOS ANGELES – Coronary artery calcium scores can provide crucial insight into atherosclerosis risk in patients with diabetes, according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.

In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.

“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”

According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.

In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.

Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.

“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”

And this advice holds up regardless of the gender, age, or ethnicity of a patient.

However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A_1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”

What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.

What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.

CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.

“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.

Dr. Budoff offered other insights into CAC and diabetes.

First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).

However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.

Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).

“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”

The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”

Dr. Budoff reported receiving grant funding from GE Healthcare.

LOS ANGELES – Coronary artery calcium scores can provide crucial insight into atherosclerosis risk in patients with diabetes, according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.

In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.

“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”

According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.

In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.

Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.

“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”

And this advice holds up regardless of the gender, age, or ethnicity of a patient.

However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A_1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”

What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.

What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.

CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.

“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.

Dr. Budoff offered other insights into CAC and diabetes.

First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).

However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.

Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).

“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”

The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”

Dr. Budoff reported receiving grant funding from GE Healthcare.

LOS ANGELES – Coronary artery calcium scores can provide crucial insight into atherosclerosis risk in patients with diabetes, according to a cardiologist who urged that endocrinologists embrace the tests when appropriate and use them to inform treatment decisions.

In the big picture, “you might want to think of this as the mammogram of the heart,” said Matthew J. Budoff, MD, professor of medicine at the University of California, Los Angeles, in a presentation at the annual scientific & clinical congress of the American Association of Clinical Endocrinologists.

“If we find a lot of plaque, we act on it,” Dr. Budoff said. “If we don’t, we reassure [patients] and test them down the road.”

According to Dr. Budoff, research confirms that the tests correlate with plaque progression and atherosclerotic burden and offer important insight into treatment decisions for diabetes. “Not all people with diabetes have atherosclerosis, and not all deserve the same therapy,” he said.

In other words, not every patient with diabetes needs to be on the same regimen, such as a statin.

Dr. Budoff pointed to recent research that revealed coronary artery calcium (CAC) scores of zero Agatston units are signs of excellent cardiac health in terms of clogged arteries – regardless of whether a patient is diabetic or not.

“Even patients with a score of zero in the setting of diabetes do very well,” said Dr. Budoff, who normally wouldn’t recommend a statin for those patients even though they have diabetes. “If you see a person without coronary calcium, their cardiovascular death rate is really, really low. Maybe you don’t have to be as aggressive with atherosclerosis. You can wait 5 years after a score of zero and reassess the risk.”

And this advice holds up regardless of the gender, age, or ethnicity of a patient.

However, Dr. Budoff cautioned against waiting too long for another assessment. “I don’t think we want to wait 10 years. A lot of things change over a decade: Our blood pressure and LDL cholesterol go up, our triglycerides and [hemoglobin] A_1Cs go up – our risk factors progress with age. I’d encourage you to not wait more than 5 years to retest [a patient] to see what’s going on.”

What if a CAC score is higher than zero? A score of more than 100 is a danger signal, Dr. Budoff said. “No matter how you look at the data, a patient with a high score has higher risk of cardiovascular death or dying in general.” This is especially true among women with diabetes for reasons that are not clear.

What to do if a patient’s score is over 100? “Get them on a baby aspirin and on a statin,” he said.

CAC scores lower than 100 are less worrisome in older people and more worrisome in younger people. An age-adjusted score of 5 in a 45-year-old woman, for example, is a cause for concern because any atherosclerosis is a problem at that age.

“If they have some plaque in their coronaries at age 40 or 45, it will grow over time,” he added.

Dr. Budoff offered other insights into CAC and diabetes.

First, based on CAC scores, asymptomatic, middle-aged patients with type 1 diabetes don’t seem to be at higher risk of coronary artery disease than the general population. About 70% of 1,205 patients followed for an average of 11 years had a CAC score of zero, according to findings from a study led by Dr. Budoff (JACC Cardiovasc Imaging. 2019 Mar 8. doi: 10.1016/j.jcmg.2019.01.014).

However, positive scores translate to more risk, and “the higher the score, the higher the risk,” he emphasized.

Second, CAC screening by itself can be a motivator for lifestyle changes in people with diabetes. A randomized, controlled trial reported in 2011 found that patients who were told about their scores improved on several health measures, including blood pressure, cholesterol levels, and weight (J Am Coll Cardiol. 2011 Apr 12;57[15]:1622-32).

“They were [more] willing to take their medicines. They lost weight, and they were better at diet and exercise,” Dr. Budoff said. “Showing them a calcium score and what it means was a big motivation.”

The study also found major reductions in medication and procedure cost among patients who got the CAC results. About half of them had a CAC score of zero, he said, and that means “we’re not going to run them on a treadmill or put them on a statin.”

Dr. Budoff reported receiving grant funding from GE Healthcare.

Think about what a puppet can do: Not much, since it’s typically controlled by a single hand. Then consider the skills of a marionette in the hands – both of them – of a talented performer: It can gesture and jump and even dance. A whole new world of movement opens up thanks to the capacity for fine-tuned control.

When it comes to GI endoscopy, revolutionary two-handed marionette-style control beckons on the horizon thanks to robotics. That’s the word from Josh DeFonzo, chief operating officer of Auris Health, who will present a keynote speech on “Opportunities in GI Over the Next Decade” at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

“I’ll be talking about where opportunities will lie in the GI space over the next decade,” Mr. DeFonzo said. “One of the major themes will be the need to accelerate technical capabilities in endoscopy. Noninvasive treatment is quite challenging for interventional endoscopists. They generally don’t have the tools they need to reach where they need to reach, see where they need to see, and perform complex tasks, at least not at scale.”

This is all changing thanks to the work of companies like Auris Health, which is working to advance endoscopy through flexible robotics. Auris Health, which was recently acquired by Johnson & Johnson, is offering robotic endoscopy to pulmonologists and developing it for gastroenterology.

The challenges of existing endoscopic technology, Mr. DeFonzo said, revolve around the limitations of access. “In the world of GI, it’s not difficult to get to polyps or cancerous lesions. It’s harder to do something when you’re there,” he said. “In the colon, stomach, and esophagus, you’re in a cylindrical hallway with a cylindrical device, and both are moving. You don’t have the stability to achieve traction, and you are usually limited to a single hand and single working channel.”

Robotic endoscopic technology offers physicians the ability to overcome these barriers through two-handed control and other advances. “It’s all about reach, vision, control, and the ability to perform tasks as a result of those three things,” he said. “The hope is empower endoscopists with more tools and capabilities to prevent patients from having to undergo surgery.”

Within the next 5 years, he predicts, physicians will be able to use robotic endoscopy to remove potentially cancerous lesions during colonoscopy instead of referring patients for colectomy. And over the longer term, perhaps over more than a decade, he expects patients will be able to undergo endoscopic removal of those lesions during colonoscopy instead of being referred.

Meanwhile, he said, scientists are advancing areas such as two-handed robotic control, Google Maps-style navigation based on preoperative scans, and pattern recognition to detect abnormalities such as lesions.

Think about what a puppet can do: Not much, since it’s typically controlled by a single hand. Then consider the skills of a marionette in the hands – both of them – of a talented performer: It can gesture and jump and even dance. A whole new world of movement opens up thanks to the capacity for fine-tuned control.

When it comes to GI endoscopy, revolutionary two-handed marionette-style control beckons on the horizon thanks to robotics. That’s the word from Josh DeFonzo, chief operating officer of Auris Health, who will present a keynote speech on “Opportunities in GI Over the Next Decade” at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

“I’ll be talking about where opportunities will lie in the GI space over the next decade,” Mr. DeFonzo said. “One of the major themes will be the need to accelerate technical capabilities in endoscopy. Noninvasive treatment is quite challenging for interventional endoscopists. They generally don’t have the tools they need to reach where they need to reach, see where they need to see, and perform complex tasks, at least not at scale.”

This is all changing thanks to the work of companies like Auris Health, which is working to advance endoscopy through flexible robotics. Auris Health, which was recently acquired by Johnson & Johnson, is offering robotic endoscopy to pulmonologists and developing it for gastroenterology.

The challenges of existing endoscopic technology, Mr. DeFonzo said, revolve around the limitations of access. “In the world of GI, it’s not difficult to get to polyps or cancerous lesions. It’s harder to do something when you’re there,” he said. “In the colon, stomach, and esophagus, you’re in a cylindrical hallway with a cylindrical device, and both are moving. You don’t have the stability to achieve traction, and you are usually limited to a single hand and single working channel.”

Robotic endoscopic technology offers physicians the ability to overcome these barriers through two-handed control and other advances. “It’s all about reach, vision, control, and the ability to perform tasks as a result of those three things,” he said. “The hope is empower endoscopists with more tools and capabilities to prevent patients from having to undergo surgery.”

Within the next 5 years, he predicts, physicians will be able to use robotic endoscopy to remove potentially cancerous lesions during colonoscopy instead of referring patients for colectomy. And over the longer term, perhaps over more than a decade, he expects patients will be able to undergo endoscopic removal of those lesions during colonoscopy instead of being referred.

Meanwhile, he said, scientists are advancing areas such as two-handed robotic control, Google Maps-style navigation based on preoperative scans, and pattern recognition to detect abnormalities such as lesions.

Think about what a puppet can do: Not much, since it’s typically controlled by a single hand. Then consider the skills of a marionette in the hands – both of them – of a talented performer: It can gesture and jump and even dance. A whole new world of movement opens up thanks to the capacity for fine-tuned control.

When it comes to GI endoscopy, revolutionary two-handed marionette-style control beckons on the horizon thanks to robotics. That’s the word from Josh DeFonzo, chief operating officer of Auris Health, who will present a keynote speech on “Opportunities in GI Over the Next Decade” at the 2019 AGA Tech Summit, sponsored by the AGA Center for GI Innovation and Technology.

“I’ll be talking about where opportunities will lie in the GI space over the next decade,” Mr. DeFonzo said. “One of the major themes will be the need to accelerate technical capabilities in endoscopy. Noninvasive treatment is quite challenging for interventional endoscopists. They generally don’t have the tools they need to reach where they need to reach, see where they need to see, and perform complex tasks, at least not at scale.”

This is all changing thanks to the work of companies like Auris Health, which is working to advance endoscopy through flexible robotics. Auris Health, which was recently acquired by Johnson & Johnson, is offering robotic endoscopy to pulmonologists and developing it for gastroenterology.

The challenges of existing endoscopic technology, Mr. DeFonzo said, revolve around the limitations of access. “In the world of GI, it’s not difficult to get to polyps or cancerous lesions. It’s harder to do something when you’re there,” he said. “In the colon, stomach, and esophagus, you’re in a cylindrical hallway with a cylindrical device, and both are moving. You don’t have the stability to achieve traction, and you are usually limited to a single hand and single working channel.”

Robotic endoscopic technology offers physicians the ability to overcome these barriers through two-handed control and other advances. “It’s all about reach, vision, control, and the ability to perform tasks as a result of those three things,” he said. “The hope is empower endoscopists with more tools and capabilities to prevent patients from having to undergo surgery.”

Within the next 5 years, he predicts, physicians will be able to use robotic endoscopy to remove potentially cancerous lesions during colonoscopy instead of referring patients for colectomy. And over the longer term, perhaps over more than a decade, he expects patients will be able to undergo endoscopic removal of those lesions during colonoscopy instead of being referred.

Meanwhile, he said, scientists are advancing areas such as two-handed robotic control, Google Maps-style navigation based on preoperative scans, and pattern recognition to detect abnormalities such as lesions.

An ingestible electronic capsule that measures intestinal gas. A talented toilet. Obesity subtype biomarkers, improved endoscopies, and an IBD wellness app. Could any of these five innovations transform medicine and lead to gastrointestinal glory?

Five companies will present their innovations to a panel of experts at this week's AGA Tech Summit Shark Tank event, brought to you by the AGA Center for GI Innovation and Technology. Stay tuned to GI & Hepatology News for the AGA Tech Summit Report, where we will provide more information on each product and announce the winner as decided by a panel of judges and the AGA Tech Summit audience. But first, check out the contestants and their products:

1. TrueLoo: Excreta-examining toilet

“TrueLoo is a replacement for a conventional toilet seat,” said Vikram Kashyap, CEO of Toi Labs. “The device acquires time-lapse images of a bowel movement or urination event automatically and under controlled conditions. These images are transmitted to a remote cloud server and analyzed to measure various properties related to the toilet event.”

According to Mr. Kashyap, the firm is developing a way to conduct fecal occult blood tests on the platform without requiring contact or direct sample handling.

2. Ultivision: Video endoscopy booster

“The Ultivision technology will be integrated seamlessly into the endoscopy workflow and provide feedback in real-time,” said University of California at Irvine gastroenterologist Jason B. Samarasena, MD, cofounder of DocBot. “As the endoscopist is performing the upper endoscopy, a lag-free video overlay will display boxes over suspicious lesions that the endoscopist should draw their attention to. When the area is more closely examined, the algorithm will deliver a prediction as to the likelihood that this tissue harbors dysplasia.”



3. Pheno Test: Know your obesity subtype

The Pheno Test aims to unveil obesity biomarkers which “are supported by a diagnostic algorithm... which has already been validated to predict weight response to obesity pharmacotherapy,” said Phenomix Sciences CEO Andres J. Acosta, MD, PhD, assistant professor of medicine and consultant in gastroenterology and hepatology at Mayo Clinic.

According to Dr. Acosta, a separate trial tracked patients with obesity, including some who were treated differently based on their phenotype. Those patients lost more than double their body weight compared with those who received standard of care and had fewer adverse effects linked to treatment.
 

4. Oshi: Meet the “all in one” IBD app

The Oshi app, which is now available for Apple iOS and Android, allows patients with IBD to track their symptoms and “uncover hidden patterns affecting wellness,” said Dan Weinstein, MBA, CEO of Oshi Health.

Patients can also read about IBD news, hear from other patients about their experiences, and ask questions of health professionals. “We are expanding to include proven digital tools to enhance IBD care such as medication adherence, treatment history logs, at-home fecal calprotectin testing, and more,” Mr. Weinstein said.
 

5. Atmo Gas Capsule: Swallow your way to GI insights

An ingestible electronic capsule the size of a large vitamin tablet gathers “digital health data in the form of gas concentrations as it passes through the gut for the screening and diagnosis of gastrointestinal disorders and for assessing effects of dietary treatments on the gut,” said Malcolm Hebblewhite, MBA, CEO of Atmo Biosciences.

The capsule transmits data to a small receiver and on to a smartphone, Mr. Hebblewhite said. “The real-time data is displayed for the user with more complex information accessible by the practitioner remotely via the cloud.”

An ingestible electronic capsule that measures intestinal gas. A talented toilet. Obesity subtype biomarkers, improved endoscopies, and an IBD wellness app. Could any of these five innovations transform medicine and lead to gastrointestinal glory?

Five companies will present their innovations to a panel of experts at this week's AGA Tech Summit Shark Tank event, brought to you by the AGA Center for GI Innovation and Technology. Stay tuned to GI & Hepatology News for the AGA Tech Summit Report, where we will provide more information on each product and announce the winner as decided by a panel of judges and the AGA Tech Summit audience. But first, check out the contestants and their products:

1. TrueLoo: Excreta-examining toilet

“TrueLoo is a replacement for a conventional toilet seat,” said Vikram Kashyap, CEO of Toi Labs. “The device acquires time-lapse images of a bowel movement or urination event automatically and under controlled conditions. These images are transmitted to a remote cloud server and analyzed to measure various properties related to the toilet event.”

According to Mr. Kashyap, the firm is developing a way to conduct fecal occult blood tests on the platform without requiring contact or direct sample handling.

2. Ultivision: Video endoscopy booster

“The Ultivision technology will be integrated seamlessly into the endoscopy workflow and provide feedback in real-time,” said University of California at Irvine gastroenterologist Jason B. Samarasena, MD, cofounder of DocBot. “As the endoscopist is performing the upper endoscopy, a lag-free video overlay will display boxes over suspicious lesions that the endoscopist should draw their attention to. When the area is more closely examined, the algorithm will deliver a prediction as to the likelihood that this tissue harbors dysplasia.”



3. Pheno Test: Know your obesity subtype

The Pheno Test aims to unveil obesity biomarkers which “are supported by a diagnostic algorithm... which has already been validated to predict weight response to obesity pharmacotherapy,” said Phenomix Sciences CEO Andres J. Acosta, MD, PhD, assistant professor of medicine and consultant in gastroenterology and hepatology at Mayo Clinic.

According to Dr. Acosta, a separate trial tracked patients with obesity, including some who were treated differently based on their phenotype. Those patients lost more than double their body weight compared with those who received standard of care and had fewer adverse effects linked to treatment.
 

4. Oshi: Meet the “all in one” IBD app

The Oshi app, which is now available for Apple iOS and Android, allows patients with IBD to track their symptoms and “uncover hidden patterns affecting wellness,” said Dan Weinstein, MBA, CEO of Oshi Health.

Patients can also read about IBD news, hear from other patients about their experiences, and ask questions of health professionals. “We are expanding to include proven digital tools to enhance IBD care such as medication adherence, treatment history logs, at-home fecal calprotectin testing, and more,” Mr. Weinstein said.
 

5. Atmo Gas Capsule: Swallow your way to GI insights

An ingestible electronic capsule the size of a large vitamin tablet gathers “digital health data in the form of gas concentrations as it passes through the gut for the screening and diagnosis of gastrointestinal disorders and for assessing effects of dietary treatments on the gut,” said Malcolm Hebblewhite, MBA, CEO of Atmo Biosciences.

The capsule transmits data to a small receiver and on to a smartphone, Mr. Hebblewhite said. “The real-time data is displayed for the user with more complex information accessible by the practitioner remotely via the cloud.”

An ingestible electronic capsule that measures intestinal gas. A talented toilet. Obesity subtype biomarkers, improved endoscopies, and an IBD wellness app. Could any of these five innovations transform medicine and lead to gastrointestinal glory?

Five companies will present their innovations to a panel of experts at this week's AGA Tech Summit Shark Tank event, brought to you by the AGA Center for GI Innovation and Technology. Stay tuned to GI & Hepatology News for the AGA Tech Summit Report, where we will provide more information on each product and announce the winner as decided by a panel of judges and the AGA Tech Summit audience. But first, check out the contestants and their products:

1. TrueLoo: Excreta-examining toilet

“TrueLoo is a replacement for a conventional toilet seat,” said Vikram Kashyap, CEO of Toi Labs. “The device acquires time-lapse images of a bowel movement or urination event automatically and under controlled conditions. These images are transmitted to a remote cloud server and analyzed to measure various properties related to the toilet event.”

According to Mr. Kashyap, the firm is developing a way to conduct fecal occult blood tests on the platform without requiring contact or direct sample handling.

2. Ultivision: Video endoscopy booster

“The Ultivision technology will be integrated seamlessly into the endoscopy workflow and provide feedback in real-time,” said University of California at Irvine gastroenterologist Jason B. Samarasena, MD, cofounder of DocBot. “As the endoscopist is performing the upper endoscopy, a lag-free video overlay will display boxes over suspicious lesions that the endoscopist should draw their attention to. When the area is more closely examined, the algorithm will deliver a prediction as to the likelihood that this tissue harbors dysplasia.”



3. Pheno Test: Know your obesity subtype

The Pheno Test aims to unveil obesity biomarkers which “are supported by a diagnostic algorithm... which has already been validated to predict weight response to obesity pharmacotherapy,” said Phenomix Sciences CEO Andres J. Acosta, MD, PhD, assistant professor of medicine and consultant in gastroenterology and hepatology at Mayo Clinic.

According to Dr. Acosta, a separate trial tracked patients with obesity, including some who were treated differently based on their phenotype. Those patients lost more than double their body weight compared with those who received standard of care and had fewer adverse effects linked to treatment.
 

4. Oshi: Meet the “all in one” IBD app

The Oshi app, which is now available for Apple iOS and Android, allows patients with IBD to track their symptoms and “uncover hidden patterns affecting wellness,” said Dan Weinstein, MBA, CEO of Oshi Health.

Patients can also read about IBD news, hear from other patients about their experiences, and ask questions of health professionals. “We are expanding to include proven digital tools to enhance IBD care such as medication adherence, treatment history logs, at-home fecal calprotectin testing, and more,” Mr. Weinstein said.
 

5. Atmo Gas Capsule: Swallow your way to GI insights

An ingestible electronic capsule the size of a large vitamin tablet gathers “digital health data in the form of gas concentrations as it passes through the gut for the screening and diagnosis of gastrointestinal disorders and for assessing effects of dietary treatments on the gut,” said Malcolm Hebblewhite, MBA, CEO of Atmo Biosciences.

The capsule transmits data to a small receiver and on to a smartphone, Mr. Hebblewhite said. “The real-time data is displayed for the user with more complex information accessible by the practitioner remotely via the cloud.”

LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m².

In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”

As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m²) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.

“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”

There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.

Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”

In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m². But this standard has evolved in recent years.

In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.

“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”

The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.

Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.

LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m².

In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”

As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m²) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.

“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”

There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.

Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”

In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m². But this standard has evolved in recent years.

In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.

“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”

The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.

Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.

LAS VEGAS – Once reserved for the most obese patients, bariatric surgery is on the road to becoming an option for millions of Americans who are just a step beyond overweight, even those with a body mass index as low as 30 kg/m².

In regard to patients with lower levels of obesity, “we should be intervening in this chronic disease earlier rather than later,” said Stacy A. Brethauer, MD, professor of surgery at the Ohio State University, Columbus, in a presentation about new standards for bariatric surgery at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

Bariatric treatment “should be offered after nonsurgical [weight-loss] therapy has failed,” he said. “That’s not where you stop. You continue to escalate as you would for heart disease or cancer.”

As Dr. Brethauer noted, research suggests that all categories of obesity – including so-called class 1 obesity (defined as a BMI from 30.0 to 34.9 kg/m²) – boost the risk of multiple diseases, including hypertension, coronary artery disease, congestive heart failure, stroke, asthma, pulmonary embolism, gallbladder disease, several types of cancer, osteoarthritis, and chronic back pain.

“There is no question that class 1 obesity is clearly putting people at risk,” he said. “Ultimately, you can conclude from all this evidence that class 1 is a chronic disease, and it deserves to be treated effectively.”

There are, of course, various nonsurgical treatments for obesity, including diet and exercise and pharmacotherapy. However, systematic reviews have found that people find it extremely difficult to keep the weight off after 1 year regardless of the strategy they adopt.

Beyond a year, Dr. Brethauer said, “you get poor maintenance of weight control, and you get poor control of metabolic burden. You don’t have a durable efficacy.”

In the past, bariatric surgery wasn’t considered an option for patients with class 1 obesity. It’s traditionally been reserved for patients with BMIs at or above 35 kg/m². But this standard has evolved in recent years.

In 2018, Dr. Brethauer coauthored an updated position statement by the American Society for Metabolic and Bariatric Surgery that encouraged bariatric surgery in certain mildly obese patients.

“For most people with class I obesity,” the statement on bariatric surgery states, “it is clear that the nonsurgical group of therapies will not provide a durable solution to their disease of obesity.”

The statement went on to say that “surgical intervention should be considered after failure of nonsurgical treatments” in the class 1 population.

Review the AGA Practice guide on Obesity and Weight management, Education and Resources (POWER) white paper, which provides physicians with a comprehensive, multi-disciplinary process to guide and personalize innovative obesity care for safe and effective weight management. Learn more at http://ow.ly/WV8l30oeyYv.

LAS VEGAS – Communicate with your pharmacists to keep nurse phone calls and empty medication-dispensing devices at bay. Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.

Randy Dotinga/MDedge News

April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”

As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”

Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.

Dr. Smith offered these tips about specific postsurgery medications:

• Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
• Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
• Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
• Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
• Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
• Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
• Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
• Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
• Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.

LAS VEGAS – Communicate with your pharmacists to keep nurse phone calls and empty medication-dispensing devices at bay. Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.

Randy Dotinga/MDedge News

April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”

As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”

Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.

Dr. Smith offered these tips about specific postsurgery medications:

• Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
• Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
• Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
• Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
• Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
• Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
• Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
• Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
• Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.

LAS VEGAS – Communicate with your pharmacists to keep nurse phone calls and empty medication-dispensing devices at bay. Watch out for overlapping medication orders. Beware of gabapentin mishaps, and embrace Tylenol – but not always.

Randy Dotinga/MDedge News

April Smith, PharmD, associate professor of pharmacy practice at Creighton University, Omaha, offered these tips about postoperative care to surgeons at the 2019 Annual Minimally Invasive Surgery Symposium by Global Academy for Medical Education.

“We’re probably one of the most underutilized professions you have on your team,” she said, adding that “we have to know what you’re doing to help you.”

As she explained, “if you’re going to have a new order set, let us know that, so we can be your allies in helping nurses and other people understand why we’re doing what we’re doing. I’m on the same floor, and the nurses are coming up to me and asking me questions. If I can explain to them why we’re doing these things, they’ll get on board a lot faster and save you a lot of phone calls. I know you’re surgeons and you hate that [phone calls].”

Better communication with pharmacists can also boost the stocking of enhanced-recovery medications in automatic dispensing machines, she said, so they’re ready when patients need them.

Dr. Smith offered these tips about specific postsurgery medications:

• Scopolamine is a “great drug for post-op vomiting and nausea,” Dr. Smith said. But do not use it in patients over 65, and it’s contraindicated in glaucoma. Beware of these notable side effects: Blurry vision, constipation, and urinary retention. Dexamethasone and ondansetron can be used as an alternative, she said.
• Use of the blood thinner enoxaparin after discharge may become more common as surgical stays become shorter, Dr. Smith said. She urged surgeons to keep its cost in mind: a 10-day course can be as little as $2 with Medicaid or as much as $140 (a cash price for patients without coverage).
• Make sure to adjust medications based on preoperative or intraoperative doses, she said, to avoid endangering patients by inadvertently doubling up on doses. And watch out for previous use of gabapentin, which is part of enhanced-recovery protocols. Patients who take the drug at home should be put back on their typical dose.
• Also, she warned, “don’t give gabapentin to someone who’s never had it before plus an opioid.” This, she said, can cause delirium.
• Consider starting liquids the night of surgery so patients can begin taking their home medications such as sleep, chronic pain, and psychiatric drugs. Patients will be more stable and satisfied, Dr. Smith said.
• Don’t prescribe hard-to-find medications like oxycodone oral solution or oral ketorolac. These drugs will send patients from pharmacy to pharmacy in search of them, Dr. Smith said.
• Embrace a “Meds to Beds” program if possible. These programs enlist on-site pharmacies to deliver medications to bedside for patients to take home.
• Consider Tylenol as a postoperative painkiller with scheduled doses and be aware that you can prescribe the over-the-counter adult liquid form. However, Dr. Smith cautioned that Tylenol is “not great” on an as-needed basis. Gabapentin and celecoxib (unless contraindicated) are also helpful for postop pain relief, and they’re inexpensive, she said. Three to five days should be enough in most minimally invasive surgeries.
• Don’t overprescribe opioids. “The more we prescribe, the more they will consume,” Dr. Smith said. Check the American College of Surgeons guidelines regarding the ideal number of postsurgery, 5-mg doses of oxycodone to prescribe to opioid-naive patients at discharge. No more than 10 or 15 pills are recommended for several types of general surgery (J Amer Coll Surg. 2018;227:411-8).

Global Academy for Medical Education and this news organization are owned by the same parent company. Dr. Smith reports no relevant disclosures.