Federal Practitioner

Myoclonus was diagnosed in about half of hospitalized COVID-19 patients who were evaluated for movement disorders, data from 50 cases show.

Abnormal movements often occur as complications from critical illness, and neurologic consultation can determine whether patients have experienced a seizure or stroke. However, restriction of bedside assessment in the wake of the COVID-19 pandemic increases the risk that abnormal movements will be missed, Jeffrey R. Clark and Eric M. Liotta, MD, of Northwestern University, Chicago, and colleagues wrote.

“Given the limited reports of abnormal movements in hospitalized COVID-19 patients and increased recognition of neurologic manifestations of COVID-19, we sought to examine the frequency and etiology of this finding as an indication of neurologic consultation,” they said.

In a study published in the Journal of the Neurological Sciences, the researchers reviewed data from the first 50 consecutive patients with COVID-19 symptoms who were hospitalized at a single center and underwent neurologic consultation between March 17, 2020, and May 18, 2020.

Overall, 11 patients (22.0%) of patients experienced abnormal movement, and all were admitted to the ICU within 7 days of meeting criteria for severe COVID-19. These patients included nine men and two women with an age range of 36-78 years. The most common comorbidities were obesity, hypertension, diabetes, chronic kidney disease, and coronary artery disease.

Myoclonus (generalized and focal) was the most common abnormal movement, and present in 6 of the 11 patients. Three cases were attributed to high-intensity sedation, and three to toxic-metabolic disturbances. In two patients, abnormal movements were attributed to focal seizures in the setting of encephalopathy, with focal facial twitching. An additional two patients experienced tremors; one showed an acute subdural hemorrhage on CT imaging. The second patient showed no sign of stroke or other abnormality on MRI and the tremor improved during the hospital stay. One patient who experienced abnormal high-amplitude nonrhythmic movements of the lower extremities was diagnosed with serotonin syndrome that resolved after discontinuing high-dose fentanyl.

The study findings were limited by several factors, including the small study population and limited availability of MRI, the researchers noted. Assessing severe COVID-19 cases in the ICU setting presents a challenge because of limited patient participation and the potentially confounding effects of sedation and mechanical ventilation.

However, the results highlight the importance of bedside consultation for neurologic evaluation to implement timely, directed treatments, the researchers said.

“A heightened awareness of abnormal eye movements, or subtle facial tremoring, may be the first steps in recognizing potentially dangerous neurologic manifestations,” and clinicians caring for patients with severe COVID-19 should be able to recognize abnormal movements and seek neurologic consultation when indicated, they emphasized.

The study was supported in part by grants to coauthors Nicholas J. Reish, MD, and Dr. Liotta from the National Institutes of Health. The researchers had no financial conflicts to disclose.

Myoclonus was diagnosed in about half of hospitalized COVID-19 patients who were evaluated for movement disorders, data from 50 cases show.

Abnormal movements often occur as complications from critical illness, and neurologic consultation can determine whether patients have experienced a seizure or stroke. However, restriction of bedside assessment in the wake of the COVID-19 pandemic increases the risk that abnormal movements will be missed, Jeffrey R. Clark and Eric M. Liotta, MD, of Northwestern University, Chicago, and colleagues wrote.

“Given the limited reports of abnormal movements in hospitalized COVID-19 patients and increased recognition of neurologic manifestations of COVID-19, we sought to examine the frequency and etiology of this finding as an indication of neurologic consultation,” they said.

In a study published in the Journal of the Neurological Sciences, the researchers reviewed data from the first 50 consecutive patients with COVID-19 symptoms who were hospitalized at a single center and underwent neurologic consultation between March 17, 2020, and May 18, 2020.

Overall, 11 patients (22.0%) of patients experienced abnormal movement, and all were admitted to the ICU within 7 days of meeting criteria for severe COVID-19. These patients included nine men and two women with an age range of 36-78 years. The most common comorbidities were obesity, hypertension, diabetes, chronic kidney disease, and coronary artery disease.

Myoclonus (generalized and focal) was the most common abnormal movement, and present in 6 of the 11 patients. Three cases were attributed to high-intensity sedation, and three to toxic-metabolic disturbances. In two patients, abnormal movements were attributed to focal seizures in the setting of encephalopathy, with focal facial twitching. An additional two patients experienced tremors; one showed an acute subdural hemorrhage on CT imaging. The second patient showed no sign of stroke or other abnormality on MRI and the tremor improved during the hospital stay. One patient who experienced abnormal high-amplitude nonrhythmic movements of the lower extremities was diagnosed with serotonin syndrome that resolved after discontinuing high-dose fentanyl.

The study findings were limited by several factors, including the small study population and limited availability of MRI, the researchers noted. Assessing severe COVID-19 cases in the ICU setting presents a challenge because of limited patient participation and the potentially confounding effects of sedation and mechanical ventilation.

However, the results highlight the importance of bedside consultation for neurologic evaluation to implement timely, directed treatments, the researchers said.

“A heightened awareness of abnormal eye movements, or subtle facial tremoring, may be the first steps in recognizing potentially dangerous neurologic manifestations,” and clinicians caring for patients with severe COVID-19 should be able to recognize abnormal movements and seek neurologic consultation when indicated, they emphasized.

The study was supported in part by grants to coauthors Nicholas J. Reish, MD, and Dr. Liotta from the National Institutes of Health. The researchers had no financial conflicts to disclose.

Myoclonus was diagnosed in about half of hospitalized COVID-19 patients who were evaluated for movement disorders, data from 50 cases show.

Abnormal movements often occur as complications from critical illness, and neurologic consultation can determine whether patients have experienced a seizure or stroke. However, restriction of bedside assessment in the wake of the COVID-19 pandemic increases the risk that abnormal movements will be missed, Jeffrey R. Clark and Eric M. Liotta, MD, of Northwestern University, Chicago, and colleagues wrote.

“Given the limited reports of abnormal movements in hospitalized COVID-19 patients and increased recognition of neurologic manifestations of COVID-19, we sought to examine the frequency and etiology of this finding as an indication of neurologic consultation,” they said.

In a study published in the Journal of the Neurological Sciences, the researchers reviewed data from the first 50 consecutive patients with COVID-19 symptoms who were hospitalized at a single center and underwent neurologic consultation between March 17, 2020, and May 18, 2020.

Overall, 11 patients (22.0%) of patients experienced abnormal movement, and all were admitted to the ICU within 7 days of meeting criteria for severe COVID-19. These patients included nine men and two women with an age range of 36-78 years. The most common comorbidities were obesity, hypertension, diabetes, chronic kidney disease, and coronary artery disease.

Myoclonus (generalized and focal) was the most common abnormal movement, and present in 6 of the 11 patients. Three cases were attributed to high-intensity sedation, and three to toxic-metabolic disturbances. In two patients, abnormal movements were attributed to focal seizures in the setting of encephalopathy, with focal facial twitching. An additional two patients experienced tremors; one showed an acute subdural hemorrhage on CT imaging. The second patient showed no sign of stroke or other abnormality on MRI and the tremor improved during the hospital stay. One patient who experienced abnormal high-amplitude nonrhythmic movements of the lower extremities was diagnosed with serotonin syndrome that resolved after discontinuing high-dose fentanyl.

The study findings were limited by several factors, including the small study population and limited availability of MRI, the researchers noted. Assessing severe COVID-19 cases in the ICU setting presents a challenge because of limited patient participation and the potentially confounding effects of sedation and mechanical ventilation.

However, the results highlight the importance of bedside consultation for neurologic evaluation to implement timely, directed treatments, the researchers said.

“A heightened awareness of abnormal eye movements, or subtle facial tremoring, may be the first steps in recognizing potentially dangerous neurologic manifestations,” and clinicians caring for patients with severe COVID-19 should be able to recognize abnormal movements and seek neurologic consultation when indicated, they emphasized.

The study was supported in part by grants to coauthors Nicholas J. Reish, MD, and Dr. Liotta from the National Institutes of Health. The researchers had no financial conflicts to disclose.

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

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

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

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

Among U.S. patients who regularly undergo hemodialysis, 20% had some degree of hesitancy about receiving a COVID-19 vaccine in a survey of 1,515 patients conducted during January and February 2021.
 

The most frequently cited concern associated with hesitancy over vaccination against the SARS-CoV-2 virus was with regard to possible adverse effects. This was cited by more than half of the patients who were concerned about being vaccinated.

Hesitancy rates were highest among people aged 44 years or younger, women, people who identified as non-Hispanic Black or non-Hispanic other (generally Native American or Pacific Islander), those with less than some college education, and those without a history of influenza vaccination, Pablo Garcia, MD, reported at the National Kidney Foundation (NKF) 2021 Spring Clinical Meetings.
 

Hesitancy or access?

Overall, however, the findings suggest that the main barrier to COVID-19 vaccine uptake is “access rather than hesitancy,” explained Dr. Garcia, a nephrologist at Stanford (Calif.) University. He predicts that this barrier will soon resolve, in part because of a Centers for Disease Control and Prevention program launched in March 2021 that is supplying COVID-19 vaccine to U.S. dialysis centers to administer to their patients.

“This will facilitate access to the vaccine” for patients who regularly receive hemodialysis, Dr. Garcia said during his presentation.

“Administering vaccines in dialysis clinics will help. Patients are already accustomed to receiving influenza vaccine in the clinic,” said Joseph A. Vassalotti, MD, a nephrologist at Mount Sinai Hospital, New York, and chief medical officer for the NKF.

Dr. Vassalotti cited the importance of protecting the vulnerable population of people who regularly receive hemodialysis. Among those patients, there was a 37% spike in all-cause mortality during peak weeks of the pandemic compared with similar periods during 2017-2019.
 

Any level of vaccine hesitancy is concerning

In an interview, he said, “Vaccination is the key to reducing this burden, so any level of vaccine hesitancy is concerning” with regard to patients who regularly undergo dialysis.

Hesitancy among patients who undergo dialysis appears to be less than in the general U.S. population, according to a series of surveys conducted from April through December 2020. In that series, hesitancy rates approached 50% in a sample of more than 8,000 people.

Hesitancy among people overall may have recently increased, at least for the short term, because of concerns over rare thrombotic events among people who receive certain types of COVID-19 vaccine, Dr. Vassalotti noted.

Dr. Garcia and associates conducted their survey from Jan. 8 to Feb. 11, 2021, among patients who regularly received hemodialysis at any of 150 randomly selected dialysis clinics that treat 30 or more patients and are managed by U.S. Renal Care. The study enrolled patients in 22 states. Most of the patients were aged 45-79 years; 30% were non-Hispanic White; 30% were Black, and 24% were Hispanic. The survey included 24 questions and took about 10 minutes to complete.

In reply to the statement, “If COVID-19 vaccine was proven safe and effective for the general population I would seek to get it,” 20% gave a reply of definitely not, probably not, or unsure; 79% answered either probably or definitely yes.

Another question asked about willingness to receive a vaccine if it was shown to be safe and effective for people receiving dialysis. In answer to that question, 19% said definitely not, probably not, or unsure.
 

Possible adverse effects an issue

Asked the reason why they were hesitant to receive the vaccine, 53% cited possible adverse effects; 19% cited general unease about vaccines; 19% said they did not think the COVID-19 vaccines would work; 17% said they did not think they needed a COVID-19 vaccine; and 15% said they had read or heard that COVID-19 vaccines were dangerous.

A set of questions asked survey respondents about their primary source of information about COVID-19 vaccines. About three-quarters cited television news; about 35% cited members of their dialysis clinic staff; about 30% cited friends and family; 20% cited social media; 20% cited their nephrologists; and roughly 15% cited newspapers.

The results suggest that potentially effective interventions to promote vaccine uptake include showing informational videos to patients during dialysis sessions and encouraging the staff at dialysis centers to proactively educate patients about COVID-19 vaccines and to promote uptake, suggest Dr. Garcia and Dr. Vassalotti.

Dr. Vassalotti noted that in a recent single-center survey of 90 U.S. patients undergoing hemodialysis that included 75 (85%) Black persons, the prevalence of hesitancy about COVID-19 vaccines was 50%. Hesitancy was often linked with gaps in patient education.

“We need broad educational measures, as well as targeting specific demographic groups” among whom the level of hesitancy is high, said Dr. Vassalotti.

He noted that patients who undergo dialysis are receptive to messages from dialysis clinic staff members and that this offers an “opportunity to understand misconceptions that underlie hesitancy and address them on an individual basis.”

The NKF has prepared a fact sheet for educating patients with kidney disease about the efficacy and safety of COVID-19 vaccines, Dr. Vassalotti noted.

Dr. Garcia has disclosed no relevant financial relationships. Dr. Vassalotti is an adviser and consultant to Renalytix AI and is a consultant to Janssen.

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

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Patients with heart failure get pneumonia at a rate almost three times greater than expected and, once they do get pneumonia, have about a fourfold greater risk of death, investigators for a retrospective analysis of 13,000 patients from two landmark randomized HF trials have found.

Catherine Hackett/MDedge News

The investigators also found that HF patients with preserved ejection fraction (HFpEF) are at the highest risk of developing pneumonia. The findings underscore the importance of patients with HF getting a pneumonia vaccination, they found.

The analysis showed that 6.3% of patients in the PARADIGM-HF trial and 10.6% of those in the PARAGON-HF trial developed pneumonia, reported the study authors, led by John J.V. McMurray, MD, of the British Heart Foundation Cardiovascular Research Center at the University of Glasgow in Scotland (J Am Coll Cardiol. 2021;77:1961-73).

“The main reason for doing this study was the fact that many heart failure patients are not vaccinated, as they should be, against pneumonia – both pneumococcus and influenza vaccination,” Dr. McMurray said in an interview. “We wanted to document the frequency and consequences of pneumonia in patients with heart failure to help highlight this deficiency in care.”

Dr. McMurray said he believes this is the first study to document the incidence of pneumonia and pneumonia-related outcomes according to the two major ejection fraction phenotypes.
 

PARADIGM-HF and PARAGON-HF

The post hoc analysis consisted of 8,399 patients with HF with reduced ejection fraction (HFrEF) in PARADIGM-HF (Eur J Heart Fail. 2013 Sep;15[9]:1062-73) and 4,796 patients with HFpEF in PARAGON-HF (N Engl J Med. 2014 Sep 11;371[11]:993-1004). The analysis focused on the 528 and 510 patients in each study, respectively, who developed pneumonia. Those rates translated to an incidence rate of 29 per 1,000 patient-years (95% confidence interval, 27-31) in PARADIGM-HF and 39 per 1,000 patient-years (95% CI, 36-42) in PARAGON-HF.

After pneumonia, the risk of death in patients increased substantially. In PARADIGM-HF, the adjusted hazard ratio for the risk of death from any cause after pneumonia was 4.34 (95% CI, 3.73-5.05). In PARAGON-HF, it was 3.76 (95% CI, 3.09-4.58). HF patients who contracted pneumonia also tended to have HF longer than their counterparts who didn’t develop pneumonia, but the frequency of previous hospitalization for HF didn’t vary between the pneumonia and no-pneumonia groups.

Patients who developed pneumonia tended to be older (average age of 66.9 years vs. 64.6 years, P < .001) and male (83.9% vs. 77.8%, P < .001). The mean age of patients in PARADIGM-HF was almost a decade younger than those in PARAGON-HF, 64 vs. 73 years.

Pneumonia patients also had worse Kansas City Cardiomyopathy Questionnaire scores (76 vs. 80 on average), but no difference in New York Heart Association functional class. “In general, patients who developed pneumonia had more symptoms and signs and HF than those who did not develop pneumonia,” Dr. McMurray and colleagues wrote.

Pneumonia patients also had higher rates of chronic obstructive pulmonary disease (26% vs. 12%), diabetes (43% vs. 34%), and atrial fibrillation (46% vs. 36%).

Another reason for conducting the study, Dr. McMurray said, “was the prior findings in patients with coronary disease and acute myocardial infarction that the risk associated with an episode of pneumonia [e.g., in subsequent vascular events and deaths] persisted long after the acute event. We wanted to see if this was also the case for heart failure, and indeed it was.”

For example, the adjusted HR for cardiovascular death or hospitalization in the first month following an episode of pneumonia was 9.48 (range of 6.85-13.12, P < .001), leveling off to 1.59 after 3 months or more.
 

Vaccination crucial in HF patients

Dr. McMurray noted that this study emphasizes the importance of pneumonia vaccination for patients with HF. “Given that we have so few treatments to offer patients with HFpEF, this makes the potential value of vaccination in these patients all the greater,” he said.

The COVID-19 pandemic, Dr. McMurray said, is a “good reminder of the dangers of a respiratory infection and the importance of vaccination in these patients. COVID-19 has interesting parallels in being a systemic disease and one with postacute, persisting effects.”

The persistent risk for adverse cardiovascular events 3 months and later after pneumonia is a novel finding of the study, wrote Donna Mancini, MD, and Gregory Gibson, MD, in an invited commentary (J Am Coll Cardiol. 2021;77:1974-6). Both are with the Icahn School of Medicine at Mt. Sinai in New York. The post hoc study also “serves as an important reminder” of pneumonia risk in patients with HF, especially during the pandemic, they wrote.

“Although vaccination alone appears unlikely to be a panacea, it is a readily accessible tool for mitigating disease severity and improving outcomes,” Dr. Mancini and Dr. Gibson wrote. “After all, an ounce of prevention is worth a pound of cure.”

Novartis provided funding for the PARADIGM-HF and PARAGON-HF trials, and Dr. McMurray and coauthors disclosed financial relationships with Novartis. Dr. Mancini and Dr. Gibson have no relevant financial relationships to disclose.

Chronic lymphocytic leukemia (CLL) patients present significant problems with regard to COVID-19 disease, according to a literature review by Yousef Roosta, MD, of Urmia (Iran) University of Medical Sciences, and colleagues.

Diagnostic interaction between CLL and COVID-19 provides a major challenge. CLL patients have a lower rate of anti–SARS-CoV-2 IgG development, and evidence shows worse therapeutic outcomes in these patients, according to study published in Leukemia Research Reports.

The researchers assessed 20 retrieved articles, 11 of which examined patients with CLL and with concomitant COVID-19; and 9 articles were designed as prospective or retrospective case series of such patients. The studies were assessed qualitatively by the QUADAS-2 tool.
 

Troubling results

Although the overall prevalence of CLL and COVID-19 concurrence was low, at 0.6% (95% confidence interval 0.5%-0.7%) according to the meta-analysis, the results showed some special challenges in the diagnosis and care of these patients.

Diagnostic difficulties are a unique problem. Lymphopenia is common in patients with COVID-19, while lymphocytosis may be considered a transient or even rare finding. The interplay between the two diseases is sometimes very misleading for specialists, and in patients with lymphocytosis, the diagnosis of CLL may be completely ignored, according to the researchers. They added that when performing a diagnostic approach for concurrent COVID-19 and CLL, due to differences in the amount and type of immune response, “relying on serological testing, and especially the evaluation of the anti–SARS-CoV-2 IgG levels may not be beneficial,” they indicated.

In addition, studies showed unacceptable therapeutic outcome in patients with concurrent CLL and COVID-19, with mortality ranging from 33% to 41.7%, showing a need to revise current treatment protocols, according to the authors. In one study, 85.7% of surviving patients showed a considerable decrease in functional class and significant fatigue, with such a poor prognosis occurring more commonly in the elderly.

With regard to treatment, “it is quite obvious that despite the use of current standard protocols, the prognosis of these patients will be much worse than the prognosis of CLL patients with no evidence of COVID-19. Even in the first-line treatment protocol for these patients, there is no agreement in combination therapy with selected CLL drugs along with management protocols of COVID-19 patients,” the researchers stated.

“[The] different hematological behaviors of two diseases might mimic the detection of COVID-19 in the CLL state and vise versa. Also, due to the low level of immune response against SARS-CoV-2 in CLL patients, both scheduled immunological-based diagnosis and treatment may fail,” the researchers added.

The authors reported that they had no disclosures.

[email protected]

Chronic lymphocytic leukemia (CLL) patients present significant problems with regard to COVID-19 disease, according to a literature review by Yousef Roosta, MD, of Urmia (Iran) University of Medical Sciences, and colleagues.

Diagnostic interaction between CLL and COVID-19 provides a major challenge. CLL patients have a lower rate of anti–SARS-CoV-2 IgG development, and evidence shows worse therapeutic outcomes in these patients, according to study published in Leukemia Research Reports.

The researchers assessed 20 retrieved articles, 11 of which examined patients with CLL and with concomitant COVID-19; and 9 articles were designed as prospective or retrospective case series of such patients. The studies were assessed qualitatively by the QUADAS-2 tool.
 

Troubling results

Although the overall prevalence of CLL and COVID-19 concurrence was low, at 0.6% (95% confidence interval 0.5%-0.7%) according to the meta-analysis, the results showed some special challenges in the diagnosis and care of these patients.

Diagnostic difficulties are a unique problem. Lymphopenia is common in patients with COVID-19, while lymphocytosis may be considered a transient or even rare finding. The interplay between the two diseases is sometimes very misleading for specialists, and in patients with lymphocytosis, the diagnosis of CLL may be completely ignored, according to the researchers. They added that when performing a diagnostic approach for concurrent COVID-19 and CLL, due to differences in the amount and type of immune response, “relying on serological testing, and especially the evaluation of the anti–SARS-CoV-2 IgG levels may not be beneficial,” they indicated.

In addition, studies showed unacceptable therapeutic outcome in patients with concurrent CLL and COVID-19, with mortality ranging from 33% to 41.7%, showing a need to revise current treatment protocols, according to the authors. In one study, 85.7% of surviving patients showed a considerable decrease in functional class and significant fatigue, with such a poor prognosis occurring more commonly in the elderly.

With regard to treatment, “it is quite obvious that despite the use of current standard protocols, the prognosis of these patients will be much worse than the prognosis of CLL patients with no evidence of COVID-19. Even in the first-line treatment protocol for these patients, there is no agreement in combination therapy with selected CLL drugs along with management protocols of COVID-19 patients,” the researchers stated.

“[The] different hematological behaviors of two diseases might mimic the detection of COVID-19 in the CLL state and vise versa. Also, due to the low level of immune response against SARS-CoV-2 in CLL patients, both scheduled immunological-based diagnosis and treatment may fail,” the researchers added.

The authors reported that they had no disclosures.

[email protected]

Chronic lymphocytic leukemia (CLL) patients present significant problems with regard to COVID-19 disease, according to a literature review by Yousef Roosta, MD, of Urmia (Iran) University of Medical Sciences, and colleagues.

Diagnostic interaction between CLL and COVID-19 provides a major challenge. CLL patients have a lower rate of anti–SARS-CoV-2 IgG development, and evidence shows worse therapeutic outcomes in these patients, according to study published in Leukemia Research Reports.

The researchers assessed 20 retrieved articles, 11 of which examined patients with CLL and with concomitant COVID-19; and 9 articles were designed as prospective or retrospective case series of such patients. The studies were assessed qualitatively by the QUADAS-2 tool.
 

Troubling results

Although the overall prevalence of CLL and COVID-19 concurrence was low, at 0.6% (95% confidence interval 0.5%-0.7%) according to the meta-analysis, the results showed some special challenges in the diagnosis and care of these patients.

Diagnostic difficulties are a unique problem. Lymphopenia is common in patients with COVID-19, while lymphocytosis may be considered a transient or even rare finding. The interplay between the two diseases is sometimes very misleading for specialists, and in patients with lymphocytosis, the diagnosis of CLL may be completely ignored, according to the researchers. They added that when performing a diagnostic approach for concurrent COVID-19 and CLL, due to differences in the amount and type of immune response, “relying on serological testing, and especially the evaluation of the anti–SARS-CoV-2 IgG levels may not be beneficial,” they indicated.

In addition, studies showed unacceptable therapeutic outcome in patients with concurrent CLL and COVID-19, with mortality ranging from 33% to 41.7%, showing a need to revise current treatment protocols, according to the authors. In one study, 85.7% of surviving patients showed a considerable decrease in functional class and significant fatigue, with such a poor prognosis occurring more commonly in the elderly.

With regard to treatment, “it is quite obvious that despite the use of current standard protocols, the prognosis of these patients will be much worse than the prognosis of CLL patients with no evidence of COVID-19. Even in the first-line treatment protocol for these patients, there is no agreement in combination therapy with selected CLL drugs along with management protocols of COVID-19 patients,” the researchers stated.

“[The] different hematological behaviors of two diseases might mimic the detection of COVID-19 in the CLL state and vise versa. Also, due to the low level of immune response against SARS-CoV-2 in CLL patients, both scheduled immunological-based diagnosis and treatment may fail,” the researchers added.

The authors reported that they had no disclosures.

[email protected]

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

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

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

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

Low-fat diets appear to decrease testosterone levels in men, but further randomized, controlled trials are needed to confirm this effect, the authors of a meta-analysis of six small intervention studies concluded.

A total of 206 healthy men with normal testosterone received a high-fat diet followed by a low-fat diet (or vice versa), and their mean total testosterone levels were 10%-15% lower (but still in the normal range) during the low-fat diet.

The study by registered nutritionist Joseph Whittaker, MSc, University of Worcester (England), and statistician Kexin Wu, MSc, University of Warwick, Coventry, England, was published online in the Journal of Steroid Biochemistry and Molecular Biology.

“I think our results are consistent and fairly strong, but they are not strong enough to give blanket recommendations,” Mr. Whittaker said in an interview.

However, “if somebody has low testosterone, particularly borderline, they could try increasing their fat intake, maybe on a Mediterranean diet,” he said, and see if that works to increase their testosterone by 60 ng/dL, the weighted mean difference in total testosterone levels between the low-fat versus high-fat diet interventions in this meta-analysis.

“A Mediterranean diet is a good way to increase ‘healthy fats,’ mono- and polyunsaturated fatty acids, which will likely decrease cardiovascular disease risk, and boost testosterone at the same time,” Mr. Whittaker noted.

Olive oil has been shown to boost testosterone more than butter, and it also reduces CVD, he continued. Nuts are high in “healthy fats” and consistently decrease CVD and mortality and may boost testosterone. Other sources of “good fat” in a healthy diet include avocado, and red meat and poultry in moderation.

“It is controversial, but our results also indicate that foods with saturated fatty acids may boost testosterone,” he added, noting however that such foods are also associated with an increase in cholesterol.
 

Is waning testosterone explained by leaner diet?

Men need healthy testosterone levels for good physical performance, mental health, and sexual health, and low levels are associated with a higher risk of heart disease, diabetes, and Alzheimer’s disease, according to a statement about this research issued by the University of Worcester.

Although testosterone levels do decline with advancing age, there has also been an additional age-independent and persistent decline in testosterone levels that began roughly after nutrition guidelines began recommending a lower-fat diet in 1965.

Fat consumption dropped from 45% of the diet in 1965 to 35% of the diet in 1991, and stayed around that lower level through to 2011.

However, it is not clear if this decrease in dietary fat intake might explain part of the concurrent decline in men’s testosterone levels.

Mr. Whittaker and Mr. Wu conducted a systematic literature review and identified six crossover intervention studies that compared testosterone levels during low-fat versus high-fat diets – Dorgan 1996, Wang 2005, Hamalainen 1984, Hill 1980, Reed 1987, and Hill 1979 – and then they combined these studies in a meta-analysis.

Five studies each enrolled 6-43 healthy men from North America, the United Kingdom, and Scandinavia, and the sixth study (Hill 1980) enrolled 34 healthy men from North America and 39 farm laborers from South Africa.

Overall, on average, the men were aged 34-54 years and slightly overweight (a mean body mass index of roughly 27 kg/m²) with normal testosterone (i.e., >300 ng/dL, based on the 2018 American Urological Association guidelines criteria).

Most men received a high-fat diet (40% of calories from fat) first, followed by a low-fat diet (on average 20% of calories from fat; range, 7%-25%), but the subgroup of men from South Africa received the low-fat diet first.

To put this into context, U.K. guidelines recommend a fat intake of less than 35% of daily calories, and U.S. guidelines recommend a fat intake of 20%-35% of daily calories.

The low-and high-fat interventions ranged from 2 to 10 weeks.  
 

Lowest testosterone levels with low-fat vegetarian diets

Overall, on average, the men’s total testosterone was 475 mg/dL when they were consuming a low-fat diet and 532 mg/dL when they were consuming a high-fat diet.

However, the South African men had higher testosterone levels when they consumed a low-fat diet. This suggests that “men with European ancestry may experience a greater decrease in testosterone in response to a low-fat diet,” the researchers wrote.

The decrease in total testosterone in the low-fat versus high-fat diet was largest (26%) in the two studies of men who consumed a vegetarian diet (Hill 1979 and Hill 1980). These diets may have been low in zinc, since a marginal zinc deficiency has been shown to decrease total testosterone, Mr. Whittaker and Mr. Wu speculated.

The meta-analysis also showed that levels of free testosterone, urinary testosterone, and dihydrotestosterone declined during the low-fat diet, whereas levels of luteinizing hormone or sex hormone binding globulin were similar with both diets.
 

Men with low testosterone and overweight, obesity

What nutritional advice should practitioners give to men who have low testosterone and overweight/obesity?

“If you are very overweight, losing weight is going to dramatically improve your testosterone,” Mr. Whittaker said.

However, proponents of various diets are often in stark disagreement about the merits of a low-fat versus low-carbohydrate diet to lose weight.

“In general,” he continued, “the literature shows low-carb (high-fat) diets are better for weight loss [although many will disagree with that statement].”

Although nutrition guidelines have stressed the importance of limiting fat intake, fat in the diet is also associated with lower triglyceride levels and blood pressure and higher HDL cholesterol levels, and now in this study, higher testosterone levels.
 

More research needed

The researchers acknowledge study limitations: The meta-analysis included just a few small studies with heterogeneous designs and findings, and there was possible bias from confounding variables.

“Ideally, we would like to see a few more studies to confirm our results,” Mr. Whittaker said in the statement. “However, these studies may never come; normally researchers want to find new results, not replicate old ones. In the meantime, men with low testosterone would be wise to avoid low-fat diets.”

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. The authors disclosed no relevant financial relationships.

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

The U.S. Food and Drug Administration has approved the immunotherapy nivolumab (Opdivo, Bristol-Myers Squibb) in conjunction with certain chemotherapies for the frontline treatment of advanced or metastatic gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.

This is the first immunotherapy approved for the frontline treatment of gastric cancers, the agency says in a press release.

The approval comes after nivolumab received Priority Review and Orphan Drug designations for this indication. There are approximately 28,000 new diagnoses of gastric cancer annually in the United States, and overall survival is generally poor with currently available therapy, points out the FDA.

“Today’s approval is the first treatment in more than a decade to show a survival benefit for patients with advanced or metastatic gastric cancer who are being treated for the first time,” Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, states in an FDA press release.

Efficacy in the gastric cancer setting was demonstrated in the randomized, phase 3, open-label CheckMate 649 study of 1,518 untreated patients. Median survival was 13.8 months among those treated with nivolumab, compared with 11.6 months with chemotherapy alone (hazard ratio, 0.80; P = .0002).

Common side effects experienced by patients in the nivolumab group included peripheral neuropathy, nausea, fatigue, diarrhea, vomiting, decreased appetite, abdominal pain, constipation, and musculoskeletal pain.

Nivolumab is also approved for numerous other cancers. Other known adverse effects include immune-mediated inflammation of the lungs, colon, liver, endocrine glands, and kidneys.

“Patients should tell their health care providers if they have immune system problems, lung or breathing problems, liver problems, have had an organ transplant, or are pregnant or plan to become pregnant before starting treatment,” the FDA states.

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

The U.S. Food and Drug Administration has approved the immunotherapy nivolumab (Opdivo, Bristol-Myers Squibb) in conjunction with certain chemotherapies for the frontline treatment of advanced or metastatic gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.

This is the first immunotherapy approved for the frontline treatment of gastric cancers, the agency says in a press release.

The approval comes after nivolumab received Priority Review and Orphan Drug designations for this indication. There are approximately 28,000 new diagnoses of gastric cancer annually in the United States, and overall survival is generally poor with currently available therapy, points out the FDA.

“Today’s approval is the first treatment in more than a decade to show a survival benefit for patients with advanced or metastatic gastric cancer who are being treated for the first time,” Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, states in an FDA press release.

Efficacy in the gastric cancer setting was demonstrated in the randomized, phase 3, open-label CheckMate 649 study of 1,518 untreated patients. Median survival was 13.8 months among those treated with nivolumab, compared with 11.6 months with chemotherapy alone (hazard ratio, 0.80; P = .0002).

Common side effects experienced by patients in the nivolumab group included peripheral neuropathy, nausea, fatigue, diarrhea, vomiting, decreased appetite, abdominal pain, constipation, and musculoskeletal pain.

Nivolumab is also approved for numerous other cancers. Other known adverse effects include immune-mediated inflammation of the lungs, colon, liver, endocrine glands, and kidneys.

“Patients should tell their health care providers if they have immune system problems, lung or breathing problems, liver problems, have had an organ transplant, or are pregnant or plan to become pregnant before starting treatment,” the FDA states.

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

The U.S. Food and Drug Administration has approved the immunotherapy nivolumab (Opdivo, Bristol-Myers Squibb) in conjunction with certain chemotherapies for the frontline treatment of advanced or metastatic gastric cancer, gastroesophageal junction cancer, and esophageal adenocarcinoma.

This is the first immunotherapy approved for the frontline treatment of gastric cancers, the agency says in a press release.

The approval comes after nivolumab received Priority Review and Orphan Drug designations for this indication. There are approximately 28,000 new diagnoses of gastric cancer annually in the United States, and overall survival is generally poor with currently available therapy, points out the FDA.

“Today’s approval is the first treatment in more than a decade to show a survival benefit for patients with advanced or metastatic gastric cancer who are being treated for the first time,” Richard Pazdur, MD, director of the FDA’s Oncology Center of Excellence and acting director of the Office of Oncologic Diseases in the FDA’s Center for Drug Evaluation and Research, states in an FDA press release.

Efficacy in the gastric cancer setting was demonstrated in the randomized, phase 3, open-label CheckMate 649 study of 1,518 untreated patients. Median survival was 13.8 months among those treated with nivolumab, compared with 11.6 months with chemotherapy alone (hazard ratio, 0.80; P = .0002).

Common side effects experienced by patients in the nivolumab group included peripheral neuropathy, nausea, fatigue, diarrhea, vomiting, decreased appetite, abdominal pain, constipation, and musculoskeletal pain.

Nivolumab is also approved for numerous other cancers. Other known adverse effects include immune-mediated inflammation of the lungs, colon, liver, endocrine glands, and kidneys.

“Patients should tell their health care providers if they have immune system problems, lung or breathing problems, liver problems, have had an organ transplant, or are pregnant or plan to become pregnant before starting treatment,” the FDA states.

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

Progress is being made in the quest for an oral treatment for sickle cell disease. In preclinical trials, a new drug has shown the ability to induce blood cells to produce fetal hemoglobin at levels predicted to prevent sickling. The new small-molecule drug could be formulated into a convenient daily oral dosage, according to researchers who presented their results at the spring meeting of the American Chemical Society, which was held virtually.

The new drug candidate, designated FTX-6058 by Fulcrum Therapeutics, was developed using a proprietary small-molecule probe and CRISPR guide RNA libraries to screen “a disease-relevant cell model that allowed us to pinpoint a treatment target,” said Ivan V. Efremov, PhD, senior director, head of medicinal chemistry at the company, who presented the research.

Even though sickle cell patients carry genes leading to defective adult hemoglobin, they still carry stem cells in their bone marrow with the potential to produce fetal hemoglobin. FTX-6058 attaches to a protein inside these bone marrow stem cells destined to become mature red blood cells and reinstates their fetal hemoglobin expression, according to Dr. Efremov.

“What is really key is FTX-6058 upregulates fetal hemoglobin across all red blood cells, a pancellular distribution,” he explained, adding that if “some red blood cells did not express this, they could still sickle and cause disease symptoms.”

The premise behind the development of the drug evolved from the example of patients with sickle cell genes who also have a mutation that causes fetal hemoglobin production. The presence of fetal hemoglobin provides significant benefits to patients with sickle cell disease. At around 5%-10% levels of fetal hemoglobin expression, mortality is reduced. By 10%-25% levels of fetal hemoglobin, recurring events including vaso-occlusive crises, acute chest syndrome, and hospitalization are reduced. When fetal hemoglobin levels reaches around 25%-30%, enough red blood cell function is restored so that these patients become asymptomatic, Dr. Efremov said.

FTX-6058 was designed to mimic this effect.

FTX-6058 inhibits the action of the polycomb repressive complex 2 (PRC2) via binding to the EED subunit. PRC2 acts as a histone methyltransferase to control gene expression. Inhibition of PRC2 leads to significant fetal hemoglobin protein expression in both cell and mouse models. Other such inhibitors are under study for the suppression of cancer progression.

Preclinical experiments comparing FTX-6058 with the fetal hemoglobin booster, hydroxyurea, approved in the 1990s, showed the new drug candidate outperforms the current treatment, Christopher Moxham, PhD, chief scientific officer of Fulcrum Therapeutics, said in a company press release. The company began a phase 1 safety trial in healthy adult volunteers last year after preclinical experiments with FTX-6058 in human-derived cell assay systems and mouse models also showed an increase in fetal hemoglobin to meet the 25%-30% asymptomatic symptom threshold level.
 

Ongoing studies

The researchers plan to launch phase 2 clinical trial enrolling patients with sickle cell disease by end of 2021. In addition, further characterization of the therapeutic molecule is continuing, using genomics and additional cell assay systems to expand details FTX-6058’s mode of action.

The company also is looking to explore the use of FTX-6058 in patients with beta-thalassemia to supplement their reduced hemoglobin production.

The pharmacologic profile of FTX-6058 indicates that the drug has the potential to be administered as a once-a-day oral formulation, Dr. Efremov stated. Both the preclinical PK [pharmacokinetic] data and “the emerging PK from the human clinical study supports once-a-day oral administration, which obviously offers significant convenience to patients,” he added.

Fulcrum Therapeutics is funding the studies.

[email protected]

Progress is being made in the quest for an oral treatment for sickle cell disease. In preclinical trials, a new drug has shown the ability to induce blood cells to produce fetal hemoglobin at levels predicted to prevent sickling. The new small-molecule drug could be formulated into a convenient daily oral dosage, according to researchers who presented their results at the spring meeting of the American Chemical Society, which was held virtually.

The new drug candidate, designated FTX-6058 by Fulcrum Therapeutics, was developed using a proprietary small-molecule probe and CRISPR guide RNA libraries to screen “a disease-relevant cell model that allowed us to pinpoint a treatment target,” said Ivan V. Efremov, PhD, senior director, head of medicinal chemistry at the company, who presented the research.

Even though sickle cell patients carry genes leading to defective adult hemoglobin, they still carry stem cells in their bone marrow with the potential to produce fetal hemoglobin. FTX-6058 attaches to a protein inside these bone marrow stem cells destined to become mature red blood cells and reinstates their fetal hemoglobin expression, according to Dr. Efremov.

“What is really key is FTX-6058 upregulates fetal hemoglobin across all red blood cells, a pancellular distribution,” he explained, adding that if “some red blood cells did not express this, they could still sickle and cause disease symptoms.”

The premise behind the development of the drug evolved from the example of patients with sickle cell genes who also have a mutation that causes fetal hemoglobin production. The presence of fetal hemoglobin provides significant benefits to patients with sickle cell disease. At around 5%-10% levels of fetal hemoglobin expression, mortality is reduced. By 10%-25% levels of fetal hemoglobin, recurring events including vaso-occlusive crises, acute chest syndrome, and hospitalization are reduced. When fetal hemoglobin levels reaches around 25%-30%, enough red blood cell function is restored so that these patients become asymptomatic, Dr. Efremov said.

FTX-6058 was designed to mimic this effect.

FTX-6058 inhibits the action of the polycomb repressive complex 2 (PRC2) via binding to the EED subunit. PRC2 acts as a histone methyltransferase to control gene expression. Inhibition of PRC2 leads to significant fetal hemoglobin protein expression in both cell and mouse models. Other such inhibitors are under study for the suppression of cancer progression.

Preclinical experiments comparing FTX-6058 with the fetal hemoglobin booster, hydroxyurea, approved in the 1990s, showed the new drug candidate outperforms the current treatment, Christopher Moxham, PhD, chief scientific officer of Fulcrum Therapeutics, said in a company press release. The company began a phase 1 safety trial in healthy adult volunteers last year after preclinical experiments with FTX-6058 in human-derived cell assay systems and mouse models also showed an increase in fetal hemoglobin to meet the 25%-30% asymptomatic symptom threshold level.
 

Ongoing studies

The researchers plan to launch phase 2 clinical trial enrolling patients with sickle cell disease by end of 2021. In addition, further characterization of the therapeutic molecule is continuing, using genomics and additional cell assay systems to expand details FTX-6058’s mode of action.

The company also is looking to explore the use of FTX-6058 in patients with beta-thalassemia to supplement their reduced hemoglobin production.

The pharmacologic profile of FTX-6058 indicates that the drug has the potential to be administered as a once-a-day oral formulation, Dr. Efremov stated. Both the preclinical PK [pharmacokinetic] data and “the emerging PK from the human clinical study supports once-a-day oral administration, which obviously offers significant convenience to patients,” he added.

Fulcrum Therapeutics is funding the studies.

[email protected]

Progress is being made in the quest for an oral treatment for sickle cell disease. In preclinical trials, a new drug has shown the ability to induce blood cells to produce fetal hemoglobin at levels predicted to prevent sickling. The new small-molecule drug could be formulated into a convenient daily oral dosage, according to researchers who presented their results at the spring meeting of the American Chemical Society, which was held virtually.

The new drug candidate, designated FTX-6058 by Fulcrum Therapeutics, was developed using a proprietary small-molecule probe and CRISPR guide RNA libraries to screen “a disease-relevant cell model that allowed us to pinpoint a treatment target,” said Ivan V. Efremov, PhD, senior director, head of medicinal chemistry at the company, who presented the research.

Even though sickle cell patients carry genes leading to defective adult hemoglobin, they still carry stem cells in their bone marrow with the potential to produce fetal hemoglobin. FTX-6058 attaches to a protein inside these bone marrow stem cells destined to become mature red blood cells and reinstates their fetal hemoglobin expression, according to Dr. Efremov.

“What is really key is FTX-6058 upregulates fetal hemoglobin across all red blood cells, a pancellular distribution,” he explained, adding that if “some red blood cells did not express this, they could still sickle and cause disease symptoms.”

The premise behind the development of the drug evolved from the example of patients with sickle cell genes who also have a mutation that causes fetal hemoglobin production. The presence of fetal hemoglobin provides significant benefits to patients with sickle cell disease. At around 5%-10% levels of fetal hemoglobin expression, mortality is reduced. By 10%-25% levels of fetal hemoglobin, recurring events including vaso-occlusive crises, acute chest syndrome, and hospitalization are reduced. When fetal hemoglobin levels reaches around 25%-30%, enough red blood cell function is restored so that these patients become asymptomatic, Dr. Efremov said.

FTX-6058 was designed to mimic this effect.

FTX-6058 inhibits the action of the polycomb repressive complex 2 (PRC2) via binding to the EED subunit. PRC2 acts as a histone methyltransferase to control gene expression. Inhibition of PRC2 leads to significant fetal hemoglobin protein expression in both cell and mouse models. Other such inhibitors are under study for the suppression of cancer progression.

Preclinical experiments comparing FTX-6058 with the fetal hemoglobin booster, hydroxyurea, approved in the 1990s, showed the new drug candidate outperforms the current treatment, Christopher Moxham, PhD, chief scientific officer of Fulcrum Therapeutics, said in a company press release. The company began a phase 1 safety trial in healthy adult volunteers last year after preclinical experiments with FTX-6058 in human-derived cell assay systems and mouse models also showed an increase in fetal hemoglobin to meet the 25%-30% asymptomatic symptom threshold level.
 

Ongoing studies

The researchers plan to launch phase 2 clinical trial enrolling patients with sickle cell disease by end of 2021. In addition, further characterization of the therapeutic molecule is continuing, using genomics and additional cell assay systems to expand details FTX-6058’s mode of action.

The company also is looking to explore the use of FTX-6058 in patients with beta-thalassemia to supplement their reduced hemoglobin production.

The pharmacologic profile of FTX-6058 indicates that the drug has the potential to be administered as a once-a-day oral formulation, Dr. Efremov stated. Both the preclinical PK [pharmacokinetic] data and “the emerging PK from the human clinical study supports once-a-day oral administration, which obviously offers significant convenience to patients,” he added.

Fulcrum Therapeutics is funding the studies.

[email protected]

Annual cases of sexually transmitted infections in the United States jumped for the sixth year in a row in 2019, according to a new Centers for Disease Control and Prevention report that highlights an increase in congenital syphilis and rising rates of syphilis, chlamydia, and gonorrhea in men, especially men who have sex with men (MSM).

The report says nothing about STI rates during the COVID-19 pandemic, when both casual sex and disease screening and surveillance declined significantly, at least in the early months. But epidemiologist Patricia Kissinger, PhD, MPH, from Tulane University School, New Orleans, said in an interview that the findings reflect how “a confluence of factors” drove up rates before the age of COVID. Those factors include online dating, the opioid epidemic, the decline in condom use in the MSM community as HIV became more preventable, and indifference among policy makers and the community at large.

The CDC report, based on data from local health departments, says there were 129,813 cases of syphilis in 2019, up 74% since 2015. Almost 2,000 cases of congenital syphilis were reported, up 279% since 2015, and 128 infants died.

“There’s no reason for us to have congenital syphilis,” said Dr. Kissinger, who noted that the disease can cause birth defects and meningitis in addition to death. “Women should be screened, and it’s relatively easy to treat via penicillin injections.”

Indeed, medical guidelines suggest that pregnant women be routinely tested for syphilis. But that doesn’t always happen because “it falls through the cracks,” Dr. Kissinger said. Or, she added, women might not be tested enough times during their pregnancies: “You have to screen women in the third trimester. You can’t just do it in the first trimester because people do have sex when they’re pregnant.”

Rising congenital syphilis numbers have convinced at least one health system to take action. As of June 1, the University of California, San Diego, will routinely test pregnant women in the emergency department for syphilis in addition to HIV and hepatitis C, Martin Hoenigl, MD, a UCSF infectious disease specialist, said in an interview.

The CDC report also notes 1.8 million cases of chlamydia in 2019, a jump of 19% in 4 years, and a 56% increase in gonorrhea in that time period, to a total of 616,392 cases.

The report says increasing gonorrhea and chlamydia cases in men, especially MSM, could be caused by increased testing/screening, increased transmission, or both. Although women are generally diagnosed with chlamydia more often than men, the report says, numbers among men grew by 32% from 2015 to 2019. And since 2013, rates of gonorrhea among men have risen at a much faster clip than among women.

MSM accounted for most male cases of primary and secondary syphilis in 2019, although the report said the apparent long-term rise in these cases might be slowing.

Many MSM no longer use condoms because they’re using pre-exposure prophylaxis (PrEP) or have undetectable levels of HIV because of treatment, said Jeffrey Klausner, MD, MPH, an STI specialist at the University of Southern California in Los Angeles, said in an interview.

Many MSM might be getting screened much more often for STIs than in the past because frequent screening is required for those on PrEP. However, Dr. Kissinger said some clinics weren’t able to test at times during the pandemic because of a swab shortage. In addition, patients of all types avoided routine medical care during the pandemic, and some medical professionals in the infectious disease field were redirected to COVID care.

Clinical trials have been investigating a possible preventive STI strategy in MSM who don’t wear condoms – prophylaxis, either before or after exposure, with the antibiotic doxycycline. “That’s a very good solution,” Dr. Klausner said, but he believes bigger challenges remain. According to him, the existence of the report itself – which offers statistics from 2 years ago instead of more relevant recent numbers – is evidence of how the federal government isn’t doing enough to fight STIs. “If we’re taking the STD epidemic seriously, there should be timely and regular reporting.” Dr. Klausner said he likes the idea of monthly reports, as well as more funding for prevention.

Instead, he noted, the federal government cut STI prevention funding by 40% in inflation-adjusted dollars from 2002-2003 to 2018-2019, according to the National Coalition of STD Directors. “Burying your head in the sand and hoping the problem goes away is not an effective strategy,” he said.

It’s not clear whether STI rates are on the decline because of pandemic restrictions and stay-at-home orders. Surveys suggest that a dip in casual sex early in pandemic – when much of society shut down – was only temporary, Dr. Klausner said.

Dr. Kissinger disclosed no relevant financial relationships. Dr. Hoenigl reported receiving research funding via his university from Gilead. Dr. Klausner has recently provided consulting services to Danaher, Cepheid, Roche, GlaxoSmithKline, Talis Bio, SpeeDx, and Visby Medical, all manufacturers of diagnostic assays for STIs.

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

Annual cases of sexually transmitted infections in the United States jumped for the sixth year in a row in 2019, according to a new Centers for Disease Control and Prevention report that highlights an increase in congenital syphilis and rising rates of syphilis, chlamydia, and gonorrhea in men, especially men who have sex with men (MSM).

The report says nothing about STI rates during the COVID-19 pandemic, when both casual sex and disease screening and surveillance declined significantly, at least in the early months. But epidemiologist Patricia Kissinger, PhD, MPH, from Tulane University School, New Orleans, said in an interview that the findings reflect how “a confluence of factors” drove up rates before the age of COVID. Those factors include online dating, the opioid epidemic, the decline in condom use in the MSM community as HIV became more preventable, and indifference among policy makers and the community at large.

The CDC report, based on data from local health departments, says there were 129,813 cases of syphilis in 2019, up 74% since 2015. Almost 2,000 cases of congenital syphilis were reported, up 279% since 2015, and 128 infants died.

“There’s no reason for us to have congenital syphilis,” said Dr. Kissinger, who noted that the disease can cause birth defects and meningitis in addition to death. “Women should be screened, and it’s relatively easy to treat via penicillin injections.”

Indeed, medical guidelines suggest that pregnant women be routinely tested for syphilis. But that doesn’t always happen because “it falls through the cracks,” Dr. Kissinger said. Or, she added, women might not be tested enough times during their pregnancies: “You have to screen women in the third trimester. You can’t just do it in the first trimester because people do have sex when they’re pregnant.”

Rising congenital syphilis numbers have convinced at least one health system to take action. As of June 1, the University of California, San Diego, will routinely test pregnant women in the emergency department for syphilis in addition to HIV and hepatitis C, Martin Hoenigl, MD, a UCSF infectious disease specialist, said in an interview.

The CDC report also notes 1.8 million cases of chlamydia in 2019, a jump of 19% in 4 years, and a 56% increase in gonorrhea in that time period, to a total of 616,392 cases.

The report says increasing gonorrhea and chlamydia cases in men, especially MSM, could be caused by increased testing/screening, increased transmission, or both. Although women are generally diagnosed with chlamydia more often than men, the report says, numbers among men grew by 32% from 2015 to 2019. And since 2013, rates of gonorrhea among men have risen at a much faster clip than among women.

MSM accounted for most male cases of primary and secondary syphilis in 2019, although the report said the apparent long-term rise in these cases might be slowing.

Many MSM no longer use condoms because they’re using pre-exposure prophylaxis (PrEP) or have undetectable levels of HIV because of treatment, said Jeffrey Klausner, MD, MPH, an STI specialist at the University of Southern California in Los Angeles, said in an interview.

Many MSM might be getting screened much more often for STIs than in the past because frequent screening is required for those on PrEP. However, Dr. Kissinger said some clinics weren’t able to test at times during the pandemic because of a swab shortage. In addition, patients of all types avoided routine medical care during the pandemic, and some medical professionals in the infectious disease field were redirected to COVID care.

Clinical trials have been investigating a possible preventive STI strategy in MSM who don’t wear condoms – prophylaxis, either before or after exposure, with the antibiotic doxycycline. “That’s a very good solution,” Dr. Klausner said, but he believes bigger challenges remain. According to him, the existence of the report itself – which offers statistics from 2 years ago instead of more relevant recent numbers – is evidence of how the federal government isn’t doing enough to fight STIs. “If we’re taking the STD epidemic seriously, there should be timely and regular reporting.” Dr. Klausner said he likes the idea of monthly reports, as well as more funding for prevention.

Instead, he noted, the federal government cut STI prevention funding by 40% in inflation-adjusted dollars from 2002-2003 to 2018-2019, according to the National Coalition of STD Directors. “Burying your head in the sand and hoping the problem goes away is not an effective strategy,” he said.

It’s not clear whether STI rates are on the decline because of pandemic restrictions and stay-at-home orders. Surveys suggest that a dip in casual sex early in pandemic – when much of society shut down – was only temporary, Dr. Klausner said.

Dr. Kissinger disclosed no relevant financial relationships. Dr. Hoenigl reported receiving research funding via his university from Gilead. Dr. Klausner has recently provided consulting services to Danaher, Cepheid, Roche, GlaxoSmithKline, Talis Bio, SpeeDx, and Visby Medical, all manufacturers of diagnostic assays for STIs.

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

Annual cases of sexually transmitted infections in the United States jumped for the sixth year in a row in 2019, according to a new Centers for Disease Control and Prevention report that highlights an increase in congenital syphilis and rising rates of syphilis, chlamydia, and gonorrhea in men, especially men who have sex with men (MSM).

The report says nothing about STI rates during the COVID-19 pandemic, when both casual sex and disease screening and surveillance declined significantly, at least in the early months. But epidemiologist Patricia Kissinger, PhD, MPH, from Tulane University School, New Orleans, said in an interview that the findings reflect how “a confluence of factors” drove up rates before the age of COVID. Those factors include online dating, the opioid epidemic, the decline in condom use in the MSM community as HIV became more preventable, and indifference among policy makers and the community at large.

The CDC report, based on data from local health departments, says there were 129,813 cases of syphilis in 2019, up 74% since 2015. Almost 2,000 cases of congenital syphilis were reported, up 279% since 2015, and 128 infants died.

“There’s no reason for us to have congenital syphilis,” said Dr. Kissinger, who noted that the disease can cause birth defects and meningitis in addition to death. “Women should be screened, and it’s relatively easy to treat via penicillin injections.”

Indeed, medical guidelines suggest that pregnant women be routinely tested for syphilis. But that doesn’t always happen because “it falls through the cracks,” Dr. Kissinger said. Or, she added, women might not be tested enough times during their pregnancies: “You have to screen women in the third trimester. You can’t just do it in the first trimester because people do have sex when they’re pregnant.”

Rising congenital syphilis numbers have convinced at least one health system to take action. As of June 1, the University of California, San Diego, will routinely test pregnant women in the emergency department for syphilis in addition to HIV and hepatitis C, Martin Hoenigl, MD, a UCSF infectious disease specialist, said in an interview.

The CDC report also notes 1.8 million cases of chlamydia in 2019, a jump of 19% in 4 years, and a 56% increase in gonorrhea in that time period, to a total of 616,392 cases.

The report says increasing gonorrhea and chlamydia cases in men, especially MSM, could be caused by increased testing/screening, increased transmission, or both. Although women are generally diagnosed with chlamydia more often than men, the report says, numbers among men grew by 32% from 2015 to 2019. And since 2013, rates of gonorrhea among men have risen at a much faster clip than among women.

MSM accounted for most male cases of primary and secondary syphilis in 2019, although the report said the apparent long-term rise in these cases might be slowing.

Many MSM no longer use condoms because they’re using pre-exposure prophylaxis (PrEP) or have undetectable levels of HIV because of treatment, said Jeffrey Klausner, MD, MPH, an STI specialist at the University of Southern California in Los Angeles, said in an interview.

Many MSM might be getting screened much more often for STIs than in the past because frequent screening is required for those on PrEP. However, Dr. Kissinger said some clinics weren’t able to test at times during the pandemic because of a swab shortage. In addition, patients of all types avoided routine medical care during the pandemic, and some medical professionals in the infectious disease field were redirected to COVID care.

Clinical trials have been investigating a possible preventive STI strategy in MSM who don’t wear condoms – prophylaxis, either before or after exposure, with the antibiotic doxycycline. “That’s a very good solution,” Dr. Klausner said, but he believes bigger challenges remain. According to him, the existence of the report itself – which offers statistics from 2 years ago instead of more relevant recent numbers – is evidence of how the federal government isn’t doing enough to fight STIs. “If we’re taking the STD epidemic seriously, there should be timely and regular reporting.” Dr. Klausner said he likes the idea of monthly reports, as well as more funding for prevention.

Instead, he noted, the federal government cut STI prevention funding by 40% in inflation-adjusted dollars from 2002-2003 to 2018-2019, according to the National Coalition of STD Directors. “Burying your head in the sand and hoping the problem goes away is not an effective strategy,” he said.

It’s not clear whether STI rates are on the decline because of pandemic restrictions and stay-at-home orders. Surveys suggest that a dip in casual sex early in pandemic – when much of society shut down – was only temporary, Dr. Klausner said.

Dr. Kissinger disclosed no relevant financial relationships. Dr. Hoenigl reported receiving research funding via his university from Gilead. Dr. Klausner has recently provided consulting services to Danaher, Cepheid, Roche, GlaxoSmithKline, Talis Bio, SpeeDx, and Visby Medical, all manufacturers of diagnostic assays for STIs.

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

As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.

Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.^1,2

The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.

As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.³ Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.⁴

Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.⁵ Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
 

Early vs. late presentation

Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.

Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic⁶ and social pressures – and a host of new societal expectations.

It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
 

Distance forced by pandemic offers challenges

Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.

That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.

The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.

Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.

Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress⁷ [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.

Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.

Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease⁸ and type 2 diabetes,⁹ so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.

Other possible comorbidities

There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.¹⁰ Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.¹¹

We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.

For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.^12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
 

Treatment strategies

Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,¹⁴ and clinicians have been exploring the efficacy of select medications, sometimes with limited success.¹⁵ Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.

The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.

However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.

Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.

The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.

Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.

Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.

Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.¹⁶ Numerous services and resources are available to patients and their families that can improve mental health and well-being.

Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.

Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.

Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.¹⁷

The road to treatment success

Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.¹⁸ These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.

Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
 

Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.

2. ADDitude Magazine. 2020 Jul 23.

3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.

4. N Engl J Med. 2013 Nov 14;369(20):1935-44.

5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.

6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.

7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.

8. Case Rep Cardiol. 2016. doi: 10.1155/2016/2343691.

9. Curr Diab Rep. 2019 Jun 27;19(8):46. doi: 10.1007/s11892-019-1174-x.

10. Curr Psychiatry Rep. 2014 Mar;16(3):436. doi: 10.1007/s/11920-013-0436-6.

11. Current Psychiatry. 2014 Dec;13(12):e3-4.

12. BMC Psychiatry. 2020;20(40). doi: 10.1186/s/12888-020-02707-9.

13. Psychol Addict Behav. 2016 Mar;30(2):252–62.

14. ADDitude Magazine. 2017 Apr 6.

15. Harv Mental Health Letter. 2009 Nov.

16. MGM J Med Sci. 2020 Jul 17(3):161-2.

17. J Child Psychol Psychiatry. 2020 Jul 7.

18. Int J Disaster Risk Reduct. 2020 Dec;51. doi: 10.1016/j.ijdrr.2020.101845.

As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.

Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.^1,2

The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.

As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.³ Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.⁴

Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.⁵ Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
 

Early vs. late presentation

Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.

Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic⁶ and social pressures – and a host of new societal expectations.

It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
 

Distance forced by pandemic offers challenges

Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.

That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.

The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.

Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.

Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress⁷ [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.

Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.

Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease⁸ and type 2 diabetes,⁹ so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.

Other possible comorbidities

There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.¹⁰ Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.¹¹

We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.

For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.^12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
 

Treatment strategies

Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,¹⁴ and clinicians have been exploring the efficacy of select medications, sometimes with limited success.¹⁵ Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.

The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.

However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.

Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.

The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.

Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.

Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.

Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.¹⁶ Numerous services and resources are available to patients and their families that can improve mental health and well-being.

Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.

Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.

Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.¹⁷

The road to treatment success

Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.¹⁸ These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.

Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
 

Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.

2. ADDitude Magazine. 2020 Jul 23.

3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.

4. N Engl J Med. 2013 Nov 14;369(20):1935-44.

5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.

6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.

7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.

8. Case Rep Cardiol. 2016. doi: 10.1155/2016/2343691.

9. Curr Diab Rep. 2019 Jun 27;19(8):46. doi: 10.1007/s11892-019-1174-x.

10. Curr Psychiatry Rep. 2014 Mar;16(3):436. doi: 10.1007/s/11920-013-0436-6.

11. Current Psychiatry. 2014 Dec;13(12):e3-4.

12. BMC Psychiatry. 2020;20(40). doi: 10.1186/s/12888-020-02707-9.

13. Psychol Addict Behav. 2016 Mar;30(2):252–62.

14. ADDitude Magazine. 2017 Apr 6.

15. Harv Mental Health Letter. 2009 Nov.

16. MGM J Med Sci. 2020 Jul 17(3):161-2.

17. J Child Psychol Psychiatry. 2020 Jul 7.

18. Int J Disaster Risk Reduct. 2020 Dec;51. doi: 10.1016/j.ijdrr.2020.101845.

As some countries brace for yet another possible surge in the COVID-19 pandemic – particularly among young adults who have not yet been vaccinated – clinicians should remain wary of the cardinal symptoms of adult ADHD.

Research from an Israeli study shows that individuals with unmedicated ADHD are 52% more likely to test positive for the virus.^1,2

The symptoms of ADHD, including impulsiveness and inability to follow directions, combined with the tendency to leave adults with ADHD on their own to sort out COVID-19–related protocols – make these individuals susceptible to exposure.

As we know, ADHD is a condition characterized by a pervasive pattern of impulsivity and/or inattention, which greatly reduces organizational capabilities by interfering at the developmental level.³ Other key symptoms include short attention span, hyperactivity, restlessness, difficulty in prioritizing tasks, and an absence of time awareness. Symptom presentation of ADHD is contingent upon the nature of the individual’s overall mental health and etiologic issues that may be traced back to the brain’s development.⁴

Diagnosing ADHD in adults is relatively difficult, because a formal diagnosis generally requires symptoms to show up between the ages of 6 and 12.⁵ Also, clinicians can interview parents and family members to assess whether the classical features of ADHD were present in childhood for those suspected of having the condition.
 

Early vs. late presentation

Among the preschool population, it has been observed that emerging ADHD symptoms may progress with time or remain relatively constant with respect to the activities that children partake in. In some instances, impulsive behavior, especially compared with other symptoms, might be identified quickly by the attentive parent or caregiver. However, when ADHD appears in adulthood, it is possible that prior ADHD symptoms escaped detection – only to be diagnosed later in life because of varying presentations and the increased organizational demands of adulthood.

Meanwhile, diagnosis in adolescence can bring a different set of challenges to the forefront as teenagers face problems with self-management and responsibilities of daily living. These young people must cope with academic⁶ and social pressures – and a host of new societal expectations.

It is essential to understand how all of those societal factors have affected ADHD and its aspects, especially within the context of COVID-19. The coronavirus has introduced myriad challenges at the global level. Individuals with ADHD exhibit neurodevelopmental and corollary attention deficit issues that make them more susceptible to environmental stressors. Physical distancing practices might aggravate existing behavioral problems.
 

Distance forced by pandemic offers challenges

Despite the widespread adoption of telemedicine during the pandemic, some physicians think that the delivery of optimal care and the ability to adequately address patients’ health-related concerns have been compromised. Certainly, in the case of addressing the needs of patients with ADHD or related learning disorders, in-person examinations and clinical visits are best.

That is also the case for ADHD patients with comorbid sleep disorders. For those patients, it might be prudent to explore lifestyle changes (for example, improvements in sleep hygiene practices) before resorting to the use of pharmacologic agents such as hypnotics and melatonin. Along similar lines, the European ADHD Guideline Group (EAGG) advises the use of pharmacotherapy after the successful completion of a physical exam; patients already adhering to a treatment plan should continue therapy without interruption. Clinicians caring for patients with adult ADHD have faced a dilemma because treatment breaks increase the likelihood of illnesses resulting from the pandemic. Also, the inability to conduct treatment in person because of the pandemic raises concerns about pharmacotherapy.

The pandemic has affected the course of pediatric care and also has presented new challenges for adolescents as they begin to tackle unique problems related to their health concerns. In prepandemic times, teachers played integral roles in the diagnostic process, because they were able to readily identify children and teenagers with mental and physical challenges. In stark contrast, connecting with students online may not allow teachers to identify skill deficits in young patients or in adults with ADHD.

Furthermore, adults with ADHD and medical comorbidities may be at increased risk of disease exposure directly resulting from an inability to address their social and/or emotional well-being adequately. The social distancing and other mitigation measures advised by public health experts ensure safety and protection but also can present numerous hurdles for children, teenagers, adults – and their respective families.

Individuals with adult ADHD and other psychiatric disorders may downplay their psychological distress⁷ [for example, sleep dysfunction, issues concerning activities of daily living], and view it as being the natural product of the COVID-19 environment. As a result of their misconceptions, they may avoid increasing their medication dose to control emergent symptoms of hyperactivity and impulsivity, instead opting to manage stress without aid from health care professionals. The absence of patient-provider interactivity and the integration of telemedicine has introduced unnecessary obstacles with respect to medication management and therapy as well as general access to expert advice. It is of utmost importance for clinicians to identify at-risk patients and reeducate the adult ADHD patient on issues concerning medication intake and psychological wellness.

Individuals with developmental disorders may experience numerous setbacks when trying to navigate their environments. The lack of correct feedback, supervision, and guidance may adversely affect adults with ADHD, contributing toward a lack of self-esteem and social awareness.

Individuals with adult ADHD are more likely than are their younger counterparts to have medical comorbidities, such as cardiovascular disease⁸ and type 2 diabetes,⁹ so it is crucial to prescribe dietary instructions to patients. Sometimes patients with adult ADHD lack support in the form of acceptance by family and peers, so it is critical for the patient to come to terms with his/her condition and seek professional help, incorporating effective strategies wherever needed to maintain day-to-day functioning.

Other possible comorbidities

There can be risk factors associated with isolation of adults who have depression and/or anxiety, poor eating habits, and maladaptive behaviors. Other adverse health-related issues may include substance use disorder.¹⁰ Drug use suppresses developmental growth and may induce ADHD symptom exacerbation. Consistent with Khantzian’s self-medication hypothesis, among individuals with ADHD, including those who lack a formal diagnosis, there is a tendency to gravitate toward illicit substances, in particular, stimulants.¹¹

We also know that adolescents are known to engage in normal risk-taking and social experimentation. Given that, the notion of boundary setting becomes a complicated affair during a pandemic. Adults may no longer be involved in the same types of risk-taking behaviors, but enforced self-isolation coupled with unchecked consumption of various social medial platforms continue to take a toll on personal development. Socialization plays an enormous role in maintaining psychological health, and social media is no substitute for in-person interactions. Such platforms can reduce mental growth opportunities and affect ADHD adults unfavorably.

For instance, it has been reported that women with adult ADHD are more likely to present with negative cognitive biases and symptoms of anxiety as a function of social media use.^12,13 As clinicians, we should recommend introducing activities with the aim of enhancing self-acceptance, mindfulness, and the ability to engage in healthy lifestyles. A holistic framework that focuses on psychological wellness and physical fitness will ensure treatment success. Medication management may prove to be a challenge because of differences in dosing, response schedules, and agreed-upon diagnostic criteria used for young patients, compared with those needed for adults.
 

Treatment strategies

Before the pandemic, researchers were observing an increase globally in the ADHD diagnosis,¹⁴ and clinicians have been exploring the efficacy of select medications, sometimes with limited success.¹⁵ Stimulant medication, combined with behavioral interventions, is supported by evidenced-based medicine and is the treatment of choice for childhood ADHD.

The stimulant remedy considered to be the most efficacious for adult ADHD is methylphenidate or dextroamphetamine.

However, be sure to proceed with caution and prepare a thorough work-up, because there can be cardiovascular risk factors associated with these medications with a pronounced increase in heart rate and blood pressure.

Stimulant medications are known to increase the risk of stroke or myocardial infarction for individuals with preexisting cardiovascular anomalies or structural anomalies. The American Heart Association no longer recommends a baseline EKG before commencing stimulant therapy with the exception of preexisting cardiac risk. Nonstimulant medications such as atomoxetine are available as alternatives.

The process of finding therapies that will reduce symptoms of ADHD takes considerable time, and individuals may fail to notice improvements, at least initially.

Before prescribing any medicine or therapies, it is important to evaluate for factors that are specific to ADHD and rule out the presence of other learning or developmental disorders, to prevent negative consequences.

Health care professionals can introduce nonspecific interventions as a means of tackling complicated cases of adult ADHD, especially those that coincide with underlying medical conditions (for example, cardiovascular disease, seizure disorders, and/or eating disorders). In such cases, stimulant medications may lead to symptom exacerbation, and the health care professional should carry out a systematic evaluation (risks vs. benefits of drug classes), despite the limitations of online appointments over the course of the pandemic.

Moreover, ADHD symptoms can take on a more severe form within the context of preexisting mood and anxiety disorders. Unfortunately, these comorbidities may have a negative prognostic outcome, too, thereby increasing other health-related risk factors. Psychological interventions can be implemented via online assessments because of recent technological advances worldwide, providing a new level of confidence and social engagement. EEG-assisted biofeedback is an example of new technological modalities that may help improve the overall performance and functionality of individuals with adult ADHD.¹⁶ Numerous services and resources are available to patients and their families that can improve mental health and well-being.

Other nonpharmacologic choices also play an instrumental role in bringing harmony and organization into a patient’s life through the use of daily planners, alarms, and to-do lists. In addition, therapists can provide treatment that helps individuals get motivated and reduce their anxiety levels. Behavioral therapies support patient initiatives by increasing their productivity, activity management, and satisfaction. Cognitive-behavioral therapy (CBT), and marriage counseling and family therapy are modalities that may help adults with ADHD change underlying thoughts and perceptions and develop coping skills and self-esteem.

Appropriate to the pandemic situation is another treatment, e-therapy, which includes text-based communication, video calling, and phone calls. It is a low-cost and convenient alternative for people. For some patients, traveling to a particular clinic or counseling center can be difficult, and there is a shortage of counselors worldwide, so it is beneficial to talk with a counselor on a video/phone call or through social media. It is crucial for the ADHD coach to be trained with relevant knowledge to make plans, set goals, and manage a patient’s schedule of activities. For the counselor, sharing tips based on personal experience and making the appropriate suggestions allows adults with ADHD to stay motivated and focus on the task at hand. It should be noted that counselors play an important role in reducing stress levels for those diagnosed with ADHD, allowing patients to lead productive lives and achieve career goals.

Various online support communities can provide patients and their parents with educational resources, to address issues connected to ADHD in a professional manner.¹⁷

The road to treatment success

Any delays in treating adults with ADHD can lead to a frustrating situation in which the entire family will be affected. As stated earlier, numerous support groups are available to adults with ADHD, and some of those groups can offer valuable tips about addressing stress management and the diverse roles that parents and family members may play in patient care.¹⁸ These groups provide a network for people to exchange ideas and recommend strategies. Online support groups may connect patients directly with key opinion leaders and health care providers.

Individuals with ADHD often experience problems with organization and concentration – especially within the context of the pandemic – and receiving guidance from counselors will provide an opportunity to learn valuable coping strategies and manage symptoms, recognizing and mitigating any mood swings associated with anxiety or depression that emerge alongside their ADHD. Psychotherapy is instrumental in patient care, and individuals with adult ADHD should be taught to acknowledge the role of medications (for example, neglect, divert, or self-medicate). A holistic approach to managing ADHD symptoms is necessary for optimal functioning and independence.
 

Dr. Aman is a faculty member in the biology department of City Colleges of Chicago. She is a postdoctoral researcher at the International Maternal and Child Health Foundation (IMCHF), Montreal; a fellow, medical staff development, from the American Academy of Medical Management; and a Masters Online Teacher, University of Illinois at Chicago. Dr. Aman disclosed no relevant financial relationships. Dr. Islam is a medical adviser for the IMCHF, Montreal, and is based in New York. He is a postdoctoral fellow, psychopharmacologist, and a board-certified medical affairs specialist. Dr. Islam disclosed no relevant financial relationships. Dr. Karama is a psychiatrist at the Douglas Mental Health University Institute, Montreal. He is an assistant professor at the department of psychiatry, McGill University, also in Montreal. He has no disclosures. Dr. Choudhry is the chief scientific officer and head of the department of mental health and clinical research at the IMCHF. He has no disclosures.

References

1. J Atten Disord. 2020. doi: 10.1177/1087054720943271.

2. ADDitude Magazine. 2020 Jul 23.

3. Management of ADHD in Adults: What the Science Says. 2007 Oct 9. Guilford Press.

4. N Engl J Med. 2013 Nov 14;369(20):1935-44.

5. J Clin Psychiatry. 2002;63 Suppl 12:29-35.

6. J Atten Dis. 2015 Jan 12. doi: 10.1177/1087054144566076.

7. Psychiatry Res. 2020 Oct;292. doi: 10.1016/j.psychres.2020.113345.

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