Conference Coverage

PHILADELPHIA – The prescribing, counseling, and use of hormone therapy (HT) to treat menopausal symptoms is substantially more common among white women than among Black women, according to a review of published studies presented at the annual meeting of the Menopause Society (formerly The North American Menopause Society).

“Gaps in treatment can be used to inform health care providers about menopausal HT prescribing disparities, with the goal of improving equitable and advanced patient care among disadvantaged populations,” wrote Danette Conklin, PhD, an assistant professor of psychiatry and reproductive biology at Case Western Reserve University, Cleveland, and a psychologist at University Hospitals Cleveland Medical Center; Sally MacPhedran, MD, an associate professor of reproductive biology at Case Western Reserve University and an ob.gyn at MetroHealth Medical Center, also in Cleveland; and their colleagues.

The researchers combed through PubMed, CINAHL, Cochrane Library, Web of Science and PsychInfo databases to identify all studies conducted in the United States since 1940 that contained data on patient demographics and prescribing patterns for hormone therapy to treat menopausal symptoms. In addition to excluding men, children, teens, trans men, and women who had contraindications for HT, the investigators excluded randomized clinical trials so that prescribing patterns would not be based on protocols or RCT participatory criteria.

The researchers identified 20 studies, ranging from 1973 through 2015, including 9 national studies and the others across different U.S. regions. They then analyzed differences in HT prescribing according to age, race/ethnicity, education, income, insurance type, body mass index, and mental health, including alcohol or substance use.

Seven of the studies assessed HT use based on patient surveys, seven used medical or medication records showing an HT prescription, two studies used insurance claims to show an HT prescription, and one study surveyed patients about whether they received an HT prescription. Another four studies used surveys that asked patients whether they received HT counseling but did not indicate if the patients received a prescription.

Half of the studies showed racial disparities in HT prescribing. In all of them, Black women used or were prescribed or counseled on using HT less than white, Hispanic, or Asian women. White women had greater use, prescribing, or counseling than all other races/ethnicities except one study in which Hispanic women were prescribed vaginal estrogen more often than white women.

Six of the studies showed education disparities in which menopausal women with lower education levels used less HT or were prescribed or counseled on HT less than women with higher education.
 

Complex reasons

Monica Christmas, MD, an associate professor of obstetrics and gynecology at the University of Chicago and director of the Menopause Program and the Center for Women’s Integrated Health, said the study’s findings were not surprising, but the reasons for the racial disparities are likely complex.

Implicit bias in providers is likely one contributing factor, with some providers not thinking of offering HT to certain patients or not expecting the patients to be interested in it. Providers may also hesitate to prescribe HT to patients with more comorbidities because of concerns about HT risks, so if Black patients have more comorbidities, that could play a role in how many are offered or counseled on HT, she said.

“Probably the biggest take home is that it is important to be asking all of our patients about their symptoms and being proactive about talking about it,” Dr. Christmas said in an interview.

At the same time, in her anecdotal experience at a previous institution, Dr. Christmas noticed that her Black patients were less receptive to using hormone therapy than her White patients even though her Black patients tended to exhibit or report greater or more severe symptoms. But there’s been a “paradigm shift” more recently, Dr. Christmas said. With awareness about menopause growing in the media and particularly on social media, and with greater awareness about racial disparities in menopausal symptoms and care – including that shown in Dr. Christmas’s work in the SWAN Study – Dr. Christmas has had more Black patients asking about HT and other treatments for their menopausal symptoms more recently.

“Just 10 years ago, I was trying to talk to people about hormones, and I’ve been giving them to people that need them for a long time, and I couldn’t,” Dr. Christmas said. “Now people are coming in, saying ‘no one’s ever talked to me about it’ or ‘I deserve this.’ It shows you the persuasion that social media and the Internet have on our thinking too, and I think that’s going to be interesting to look at, to see how that impacts people’s perception about wanting treatment.”

Dr. Conklin agreed that reasons for the disparities likely involve a combination of factors, including providers’ assumptions about different racial groups’ knowledge and receptiveness toward different treatments. One of the studies in their review also reported provider barriers to prescribing HT, which included lack of time, lack of adequate knowledge, and concern about risks to patients’ health.

“Medical providers tend to have less time with their patients compared to PhDs, and that time factor really makes a big difference in terms of what the focus is going to be in that [short] appointment,” Dr. Conklin said in an interview. “Perhaps from a provider point of view, they are prioritizing what they think is more important to their patient and not really listening deeply to what their patient is saying.”
 

Educating clinicians

Potentially supporting that possibility, Dr. Conklin and Dr. MacPhedran also had a poster at the conference that looked at prescribing of HT in both Black and White women with a diagnosis of depression, anxiety, or bipolar disorder.

“In a population with a high percentage of Black patients known to have more menopause symptoms, the data demonstrated a surprisingly low rate of documented menopause symptoms (11%) compared to prior reports of up to 80%,” the researchers reported. “This low rate may be related to patient reporting, physician inquiry, or physician documentation of menopause symptoms.” They further found that White women with menopause symptoms and one of those psychiatric diagnosis were 40% more likely to receive an HT prescription for menopausal symptoms than Black women with the same diagnoses and symptoms.

Dr. Conklin emphasized the importance of providers not overlooking women who have mental health disorders when it comes to treating menopausal symptoms, particularly since mental health conditions and menopausal symptoms can exacerbate each other.

“Their depression could worsen irritability, and anxiety can worsen during the transition, and it could be overlooked or thought of as another [psychiatric] episode,” Dr. Conklin said. Providers may need to “dig a little deeper,” especially if patients are reporting having hot flashes or brain fog.

A key way to help overcome the racial disparities – whether they result from systemic issues, implicit bias or assumptions, or patients’ own reticence – is education, Dr. Conklin said. She recommended that providers have educational material about menopause and treatments for menopausal symptoms in the waiting room and then ask patients about their symptoms and invite patients to ask questions.

Dr. MacPhedran added that education for clinicians is key as well.

“Now is a great time – menopause is hot, menopause is interesting, and it’s getting a little bit of a push in terms of research dollars,” Dr. MacPhedran said. “That will trickle down to more emphasis in medical education, whether that’s nurse practitioners, physicians, PAs, or midwives. Everybody needs more education on menopause so they can be more comfortable asking and answering these questions.”

Dr. Conklin said she would like to see expanded education on menopause for medical residents and in health psychology curricula as well.

Among the 13 studies that found disparities in prescribing patterns by age, seven studies showed that older women used or were prescribed or counseled on HT more often than younger women. Four studies found the opposite, with older women less likely to use or be prescribed or counseled about HT. One study had mixed results, and one study had expected prescribing patterns.

Five studies found income disparities and five studies found disparities by medical conditions in terms of HT use, prescribing, or counseling. Other disparities identified in smaller numbers of studies (four or fewer) included natural versus surgical menopause, insurance coverage, body mass index, geographic region, smoking and alcohol use.

The two biggest limitations of the research were its heterogeneity and the small number of studies included, which points to how scarce research on racial disparities in HT use really are, Dr. Conklin said.

The research did not use any external funding. The authors had no industry disclosures. Dr. Christmas has done an educational video for FertilityIQ.

PHILADELPHIA – The prescribing, counseling, and use of hormone therapy (HT) to treat menopausal symptoms is substantially more common among white women than among Black women, according to a review of published studies presented at the annual meeting of the Menopause Society (formerly The North American Menopause Society).

“Gaps in treatment can be used to inform health care providers about menopausal HT prescribing disparities, with the goal of improving equitable and advanced patient care among disadvantaged populations,” wrote Danette Conklin, PhD, an assistant professor of psychiatry and reproductive biology at Case Western Reserve University, Cleveland, and a psychologist at University Hospitals Cleveland Medical Center; Sally MacPhedran, MD, an associate professor of reproductive biology at Case Western Reserve University and an ob.gyn at MetroHealth Medical Center, also in Cleveland; and their colleagues.

The researchers combed through PubMed, CINAHL, Cochrane Library, Web of Science and PsychInfo databases to identify all studies conducted in the United States since 1940 that contained data on patient demographics and prescribing patterns for hormone therapy to treat menopausal symptoms. In addition to excluding men, children, teens, trans men, and women who had contraindications for HT, the investigators excluded randomized clinical trials so that prescribing patterns would not be based on protocols or RCT participatory criteria.

The researchers identified 20 studies, ranging from 1973 through 2015, including 9 national studies and the others across different U.S. regions. They then analyzed differences in HT prescribing according to age, race/ethnicity, education, income, insurance type, body mass index, and mental health, including alcohol or substance use.

Seven of the studies assessed HT use based on patient surveys, seven used medical or medication records showing an HT prescription, two studies used insurance claims to show an HT prescription, and one study surveyed patients about whether they received an HT prescription. Another four studies used surveys that asked patients whether they received HT counseling but did not indicate if the patients received a prescription.

Half of the studies showed racial disparities in HT prescribing. In all of them, Black women used or were prescribed or counseled on using HT less than white, Hispanic, or Asian women. White women had greater use, prescribing, or counseling than all other races/ethnicities except one study in which Hispanic women were prescribed vaginal estrogen more often than white women.

Six of the studies showed education disparities in which menopausal women with lower education levels used less HT or were prescribed or counseled on HT less than women with higher education.
 

Complex reasons

Monica Christmas, MD, an associate professor of obstetrics and gynecology at the University of Chicago and director of the Menopause Program and the Center for Women’s Integrated Health, said the study’s findings were not surprising, but the reasons for the racial disparities are likely complex.

Implicit bias in providers is likely one contributing factor, with some providers not thinking of offering HT to certain patients or not expecting the patients to be interested in it. Providers may also hesitate to prescribe HT to patients with more comorbidities because of concerns about HT risks, so if Black patients have more comorbidities, that could play a role in how many are offered or counseled on HT, she said.

“Probably the biggest take home is that it is important to be asking all of our patients about their symptoms and being proactive about talking about it,” Dr. Christmas said in an interview.

At the same time, in her anecdotal experience at a previous institution, Dr. Christmas noticed that her Black patients were less receptive to using hormone therapy than her White patients even though her Black patients tended to exhibit or report greater or more severe symptoms. But there’s been a “paradigm shift” more recently, Dr. Christmas said. With awareness about menopause growing in the media and particularly on social media, and with greater awareness about racial disparities in menopausal symptoms and care – including that shown in Dr. Christmas’s work in the SWAN Study – Dr. Christmas has had more Black patients asking about HT and other treatments for their menopausal symptoms more recently.

“Just 10 years ago, I was trying to talk to people about hormones, and I’ve been giving them to people that need them for a long time, and I couldn’t,” Dr. Christmas said. “Now people are coming in, saying ‘no one’s ever talked to me about it’ or ‘I deserve this.’ It shows you the persuasion that social media and the Internet have on our thinking too, and I think that’s going to be interesting to look at, to see how that impacts people’s perception about wanting treatment.”

Dr. Conklin agreed that reasons for the disparities likely involve a combination of factors, including providers’ assumptions about different racial groups’ knowledge and receptiveness toward different treatments. One of the studies in their review also reported provider barriers to prescribing HT, which included lack of time, lack of adequate knowledge, and concern about risks to patients’ health.

“Medical providers tend to have less time with their patients compared to PhDs, and that time factor really makes a big difference in terms of what the focus is going to be in that [short] appointment,” Dr. Conklin said in an interview. “Perhaps from a provider point of view, they are prioritizing what they think is more important to their patient and not really listening deeply to what their patient is saying.”
 

Educating clinicians

Potentially supporting that possibility, Dr. Conklin and Dr. MacPhedran also had a poster at the conference that looked at prescribing of HT in both Black and White women with a diagnosis of depression, anxiety, or bipolar disorder.

“In a population with a high percentage of Black patients known to have more menopause symptoms, the data demonstrated a surprisingly low rate of documented menopause symptoms (11%) compared to prior reports of up to 80%,” the researchers reported. “This low rate may be related to patient reporting, physician inquiry, or physician documentation of menopause symptoms.” They further found that White women with menopause symptoms and one of those psychiatric diagnosis were 40% more likely to receive an HT prescription for menopausal symptoms than Black women with the same diagnoses and symptoms.

Dr. Conklin emphasized the importance of providers not overlooking women who have mental health disorders when it comes to treating menopausal symptoms, particularly since mental health conditions and menopausal symptoms can exacerbate each other.

“Their depression could worsen irritability, and anxiety can worsen during the transition, and it could be overlooked or thought of as another [psychiatric] episode,” Dr. Conklin said. Providers may need to “dig a little deeper,” especially if patients are reporting having hot flashes or brain fog.

A key way to help overcome the racial disparities – whether they result from systemic issues, implicit bias or assumptions, or patients’ own reticence – is education, Dr. Conklin said. She recommended that providers have educational material about menopause and treatments for menopausal symptoms in the waiting room and then ask patients about their symptoms and invite patients to ask questions.

Dr. MacPhedran added that education for clinicians is key as well.

“Now is a great time – menopause is hot, menopause is interesting, and it’s getting a little bit of a push in terms of research dollars,” Dr. MacPhedran said. “That will trickle down to more emphasis in medical education, whether that’s nurse practitioners, physicians, PAs, or midwives. Everybody needs more education on menopause so they can be more comfortable asking and answering these questions.”

Dr. Conklin said she would like to see expanded education on menopause for medical residents and in health psychology curricula as well.

Among the 13 studies that found disparities in prescribing patterns by age, seven studies showed that older women used or were prescribed or counseled on HT more often than younger women. Four studies found the opposite, with older women less likely to use or be prescribed or counseled about HT. One study had mixed results, and one study had expected prescribing patterns.

Five studies found income disparities and five studies found disparities by medical conditions in terms of HT use, prescribing, or counseling. Other disparities identified in smaller numbers of studies (four or fewer) included natural versus surgical menopause, insurance coverage, body mass index, geographic region, smoking and alcohol use.

The two biggest limitations of the research were its heterogeneity and the small number of studies included, which points to how scarce research on racial disparities in HT use really are, Dr. Conklin said.

The research did not use any external funding. The authors had no industry disclosures. Dr. Christmas has done an educational video for FertilityIQ.

PHILADELPHIA – The prescribing, counseling, and use of hormone therapy (HT) to treat menopausal symptoms is substantially more common among white women than among Black women, according to a review of published studies presented at the annual meeting of the Menopause Society (formerly The North American Menopause Society).

“Gaps in treatment can be used to inform health care providers about menopausal HT prescribing disparities, with the goal of improving equitable and advanced patient care among disadvantaged populations,” wrote Danette Conklin, PhD, an assistant professor of psychiatry and reproductive biology at Case Western Reserve University, Cleveland, and a psychologist at University Hospitals Cleveland Medical Center; Sally MacPhedran, MD, an associate professor of reproductive biology at Case Western Reserve University and an ob.gyn at MetroHealth Medical Center, also in Cleveland; and their colleagues.

The researchers combed through PubMed, CINAHL, Cochrane Library, Web of Science and PsychInfo databases to identify all studies conducted in the United States since 1940 that contained data on patient demographics and prescribing patterns for hormone therapy to treat menopausal symptoms. In addition to excluding men, children, teens, trans men, and women who had contraindications for HT, the investigators excluded randomized clinical trials so that prescribing patterns would not be based on protocols or RCT participatory criteria.

The researchers identified 20 studies, ranging from 1973 through 2015, including 9 national studies and the others across different U.S. regions. They then analyzed differences in HT prescribing according to age, race/ethnicity, education, income, insurance type, body mass index, and mental health, including alcohol or substance use.

Seven of the studies assessed HT use based on patient surveys, seven used medical or medication records showing an HT prescription, two studies used insurance claims to show an HT prescription, and one study surveyed patients about whether they received an HT prescription. Another four studies used surveys that asked patients whether they received HT counseling but did not indicate if the patients received a prescription.

Half of the studies showed racial disparities in HT prescribing. In all of them, Black women used or were prescribed or counseled on using HT less than white, Hispanic, or Asian women. White women had greater use, prescribing, or counseling than all other races/ethnicities except one study in which Hispanic women were prescribed vaginal estrogen more often than white women.

Six of the studies showed education disparities in which menopausal women with lower education levels used less HT or were prescribed or counseled on HT less than women with higher education.
 

Complex reasons

Monica Christmas, MD, an associate professor of obstetrics and gynecology at the University of Chicago and director of the Menopause Program and the Center for Women’s Integrated Health, said the study’s findings were not surprising, but the reasons for the racial disparities are likely complex.

Implicit bias in providers is likely one contributing factor, with some providers not thinking of offering HT to certain patients or not expecting the patients to be interested in it. Providers may also hesitate to prescribe HT to patients with more comorbidities because of concerns about HT risks, so if Black patients have more comorbidities, that could play a role in how many are offered or counseled on HT, she said.

“Probably the biggest take home is that it is important to be asking all of our patients about their symptoms and being proactive about talking about it,” Dr. Christmas said in an interview.

At the same time, in her anecdotal experience at a previous institution, Dr. Christmas noticed that her Black patients were less receptive to using hormone therapy than her White patients even though her Black patients tended to exhibit or report greater or more severe symptoms. But there’s been a “paradigm shift” more recently, Dr. Christmas said. With awareness about menopause growing in the media and particularly on social media, and with greater awareness about racial disparities in menopausal symptoms and care – including that shown in Dr. Christmas’s work in the SWAN Study – Dr. Christmas has had more Black patients asking about HT and other treatments for their menopausal symptoms more recently.

“Just 10 years ago, I was trying to talk to people about hormones, and I’ve been giving them to people that need them for a long time, and I couldn’t,” Dr. Christmas said. “Now people are coming in, saying ‘no one’s ever talked to me about it’ or ‘I deserve this.’ It shows you the persuasion that social media and the Internet have on our thinking too, and I think that’s going to be interesting to look at, to see how that impacts people’s perception about wanting treatment.”

Dr. Conklin agreed that reasons for the disparities likely involve a combination of factors, including providers’ assumptions about different racial groups’ knowledge and receptiveness toward different treatments. One of the studies in their review also reported provider barriers to prescribing HT, which included lack of time, lack of adequate knowledge, and concern about risks to patients’ health.

“Medical providers tend to have less time with their patients compared to PhDs, and that time factor really makes a big difference in terms of what the focus is going to be in that [short] appointment,” Dr. Conklin said in an interview. “Perhaps from a provider point of view, they are prioritizing what they think is more important to their patient and not really listening deeply to what their patient is saying.”
 

Educating clinicians

Potentially supporting that possibility, Dr. Conklin and Dr. MacPhedran also had a poster at the conference that looked at prescribing of HT in both Black and White women with a diagnosis of depression, anxiety, or bipolar disorder.

“In a population with a high percentage of Black patients known to have more menopause symptoms, the data demonstrated a surprisingly low rate of documented menopause symptoms (11%) compared to prior reports of up to 80%,” the researchers reported. “This low rate may be related to patient reporting, physician inquiry, or physician documentation of menopause symptoms.” They further found that White women with menopause symptoms and one of those psychiatric diagnosis were 40% more likely to receive an HT prescription for menopausal symptoms than Black women with the same diagnoses and symptoms.

Dr. Conklin emphasized the importance of providers not overlooking women who have mental health disorders when it comes to treating menopausal symptoms, particularly since mental health conditions and menopausal symptoms can exacerbate each other.

“Their depression could worsen irritability, and anxiety can worsen during the transition, and it could be overlooked or thought of as another [psychiatric] episode,” Dr. Conklin said. Providers may need to “dig a little deeper,” especially if patients are reporting having hot flashes or brain fog.

A key way to help overcome the racial disparities – whether they result from systemic issues, implicit bias or assumptions, or patients’ own reticence – is education, Dr. Conklin said. She recommended that providers have educational material about menopause and treatments for menopausal symptoms in the waiting room and then ask patients about their symptoms and invite patients to ask questions.

Dr. MacPhedran added that education for clinicians is key as well.

“Now is a great time – menopause is hot, menopause is interesting, and it’s getting a little bit of a push in terms of research dollars,” Dr. MacPhedran said. “That will trickle down to more emphasis in medical education, whether that’s nurse practitioners, physicians, PAs, or midwives. Everybody needs more education on menopause so they can be more comfortable asking and answering these questions.”

Dr. Conklin said she would like to see expanded education on menopause for medical residents and in health psychology curricula as well.

Among the 13 studies that found disparities in prescribing patterns by age, seven studies showed that older women used or were prescribed or counseled on HT more often than younger women. Four studies found the opposite, with older women less likely to use or be prescribed or counseled about HT. One study had mixed results, and one study had expected prescribing patterns.

Five studies found income disparities and five studies found disparities by medical conditions in terms of HT use, prescribing, or counseling. Other disparities identified in smaller numbers of studies (four or fewer) included natural versus surgical menopause, insurance coverage, body mass index, geographic region, smoking and alcohol use.

The two biggest limitations of the research were its heterogeneity and the small number of studies included, which points to how scarce research on racial disparities in HT use really are, Dr. Conklin said.

The research did not use any external funding. The authors had no industry disclosures. Dr. Christmas has done an educational video for FertilityIQ.

TOPLINE:

Dyspareunia is a major indicator of urinary tract infections, being present in 83% of cases. The symptom is especially accurate at identifying UTIs in nonmenopausal women, researchers have found.

METHODOLOGY:

• Dyspareunia is a common symptom of UTIs, especially in premenopausal women, but is rarely inquired about during patient evaluations, according to researchers from Florida Atlantic University. 
• In 2010, the researchers found that among 3,000 of their female Latinx patients aged 17-72 years in South Florida, 80% of those with UTIs reported experiencing pain during sexual intercourse. 
• Since then, they have studied an additional 2,500 patients from the same population.

TAKEAWAY:

• Among all 5,500 patients, 83% of those who had UTIs experienced dyspareunia.
• Eighty percent of women of reproductive age with dyspareunia had an undiagnosed UTI.
• During the perimenopausal and postmenopausal years, dyspareunia was more often associated with genitourinary syndrome than UTIs.
• Ninety-four percent of women with UTI-associated dyspareunia responded positively to antibiotics.

IN PRACTICE:

“We have found that this symptom is extremely important as part of the symptomatology of UTI [and is] frequently found along with the classical symptoms,” the researchers reported. “Why has something so clear, so frequently present, never been described? The answer is simple: Physicians and patients do not talk about sex, despite dyspareunia being more a clinical symptom than a sexual one. Medical schools and residency programs in all areas, especially in obstetrics and gynecology, urology, and psychiatry, have been neglecting the education of physicians-in-training in this important aspect of human health. In conclusion, this is [proof] of how medicine has sometimes been influenced by religion, culture, and social norms far away from science.”

SOURCE:

The data were presented at the 2023 meeting of the Menopause Society. The study was led by Alberto Dominguez-Bali, MD, from Florida Atlantic University, Boca Raton, Fla.

LIMITATIONS:

The study authors reported no limitations.

DISCLOSURES:

The authors reported no relevant financial relationships.

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

TOPLINE:

Dyspareunia is a major indicator of urinary tract infections, being present in 83% of cases. The symptom is especially accurate at identifying UTIs in nonmenopausal women, researchers have found.

METHODOLOGY:

• Dyspareunia is a common symptom of UTIs, especially in premenopausal women, but is rarely inquired about during patient evaluations, according to researchers from Florida Atlantic University. 
• In 2010, the researchers found that among 3,000 of their female Latinx patients aged 17-72 years in South Florida, 80% of those with UTIs reported experiencing pain during sexual intercourse. 
• Since then, they have studied an additional 2,500 patients from the same population.

TAKEAWAY:

• Among all 5,500 patients, 83% of those who had UTIs experienced dyspareunia.
• Eighty percent of women of reproductive age with dyspareunia had an undiagnosed UTI.
• During the perimenopausal and postmenopausal years, dyspareunia was more often associated with genitourinary syndrome than UTIs.
• Ninety-four percent of women with UTI-associated dyspareunia responded positively to antibiotics.

IN PRACTICE:

“We have found that this symptom is extremely important as part of the symptomatology of UTI [and is] frequently found along with the classical symptoms,” the researchers reported. “Why has something so clear, so frequently present, never been described? The answer is simple: Physicians and patients do not talk about sex, despite dyspareunia being more a clinical symptom than a sexual one. Medical schools and residency programs in all areas, especially in obstetrics and gynecology, urology, and psychiatry, have been neglecting the education of physicians-in-training in this important aspect of human health. In conclusion, this is [proof] of how medicine has sometimes been influenced by religion, culture, and social norms far away from science.”

SOURCE:

The data were presented at the 2023 meeting of the Menopause Society. The study was led by Alberto Dominguez-Bali, MD, from Florida Atlantic University, Boca Raton, Fla.

LIMITATIONS:

The study authors reported no limitations.

DISCLOSURES:

The authors reported no relevant financial relationships.

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

TOPLINE:

Dyspareunia is a major indicator of urinary tract infections, being present in 83% of cases. The symptom is especially accurate at identifying UTIs in nonmenopausal women, researchers have found.

METHODOLOGY:

• Dyspareunia is a common symptom of UTIs, especially in premenopausal women, but is rarely inquired about during patient evaluations, according to researchers from Florida Atlantic University. 
• In 2010, the researchers found that among 3,000 of their female Latinx patients aged 17-72 years in South Florida, 80% of those with UTIs reported experiencing pain during sexual intercourse. 
• Since then, they have studied an additional 2,500 patients from the same population.

TAKEAWAY:

• Among all 5,500 patients, 83% of those who had UTIs experienced dyspareunia.
• Eighty percent of women of reproductive age with dyspareunia had an undiagnosed UTI.
• During the perimenopausal and postmenopausal years, dyspareunia was more often associated with genitourinary syndrome than UTIs.
• Ninety-four percent of women with UTI-associated dyspareunia responded positively to antibiotics.

IN PRACTICE:

“We have found that this symptom is extremely important as part of the symptomatology of UTI [and is] frequently found along with the classical symptoms,” the researchers reported. “Why has something so clear, so frequently present, never been described? The answer is simple: Physicians and patients do not talk about sex, despite dyspareunia being more a clinical symptom than a sexual one. Medical schools and residency programs in all areas, especially in obstetrics and gynecology, urology, and psychiatry, have been neglecting the education of physicians-in-training in this important aspect of human health. In conclusion, this is [proof] of how medicine has sometimes been influenced by religion, culture, and social norms far away from science.”

SOURCE:

The data were presented at the 2023 meeting of the Menopause Society. The study was led by Alberto Dominguez-Bali, MD, from Florida Atlantic University, Boca Raton, Fla.

LIMITATIONS:

The study authors reported no limitations.

DISCLOSURES:

The authors reported no relevant financial relationships.

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

SAN DIEGO – While mechanical subcision of fat septa with a scalpel or a large bore needle is a tried-and-true treatment for cellulite, other technologies have emerged as alternatives.

A noninvasive treatment, rapid acoustic pulse (RAP) technology (RESONIC), was cleared by the Food and Drug Administration in 2021 for short-term improvement in the appearance of cellulite. The device emits rapid acoustic pulses (shock waves) that are transmitted through the skin to rupture or shear the fibrotic septa; release of the septa results in the smoothing of skin dimples, Arisa E. Ortiz, MD, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. RAP, however, was “taken off the market temporarily to refine the design.”

Dr. Arisa E. Ortiz

According to Dr. Ortiz, RAP’s repetition rate and short rise time provides microscopic mechanical disruption to the targeted cellular level structures and vacuoles, while high peak pressure and the fast repetition rate exploit the viscoelastic nature of tissue. Compressed pulses from electronic filtering and the reflector shape eliminate cavitation, heat, and pain. Researchers have postulated that the procedure stimulates collagenesis and angiogenesis.

“There’s no heat to this; it just uses sound,” Dr. Ortiz explained. “It’s also time dependent. The longer you do the treatment, the more disruption of the septa you see. The procedure takes 20-30 minutes. Unlike other treatments, it’s not just for discreet dimples. You can treat entire areas like the buttock or posterior leg,” said Dr. Ortiz, who did not use the RAP device in her practice.

Another device, targeted verifiable subcision (TVS, marketed as Avéli), is FDA cleared for temporary reduction in the appearance of cellulite in the buttock and thigh areas of adult women. “But studies show lasting results, at least through a year,” Dr. Ortiz said. The device features a light-guided probe and a hook. The light enables clinicians to navigate under the skin, while the hook releases a tiny blade that severs the septa. “Once you find the septa, then you activate the blade and release the septa. You go right to left because the direction of the blade is on the left of the probe. Then you go back to verify that you got everything that was creating that dimple.”

Previous devices, she said, would “blindly shear the area, so you would find the dimple and blindly cut, so there was no way to verify that you got the target dimple. The results were sometimes mediocre because you didn’t really know if you effectively treated the area.”

Iuliia Mikhalitskaia/Getty Images

She emphasized that TVS is only useful for discreet dimples. “Many patients who come in asking for cellulite treatment have a lot of laxity and rippled texture,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. “This is not going to be appropriate for those cases. Setting expectations is important. If patients have laxity and discreet dimples and it’s just the dimples that bother them, that’s fine. They just need to understand the difference,” she said, noting that this is “safe for all skin types.”

Tumescent anesthesia is used to control pain during the procedure. The most common adverse events are bruising and soreness. Results from a pivotal trial showed that clinically significant improvements in the primary endpoint, Cellulite Severity Scale scores, were sustained 1 year after treatment. “Hemosiderin staining can occur, but it eventually dissipates on its own,” Dr. Ortiz added. “You can use laser to speed up healing but sometimes that can make it worse, so you want to be careful with that. Most of the time I have patients wait it out; it does go away on its own.”

She noted that the development of RAP and TVS have helped clinicians better understand the makeup of septa. “We used to think of septa as singular bands that are vertically oriented in cellulite, but what we’ve realized is that it’s more like a network of septa,” she said.

Another noninvasive technology, synchronous parallel ultrasound beam technology from Sofwave (marketed as SUPERB), was FDA cleared in December 2022 for the short-term improvement in the appearance of cellulite. The device has seven parallel beam transducers that increase tissue temperatures of the treatment area to 60-70° C, inducing collagen remodeling and collagen denaturation, she said.

In the pivotal study of 68 women, two blinded reviewers reported an 89% improvement rate for both cellulite and skin laxity, after two treatments 2-4 weeks apart, according to data she presented at the meeting. The mean pain score during treatment was 4.55 on a scale of 1-10. No safety issues were observed and immediate responses were limited to erythema and edema.

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies, including receipt of speaker fees and honoraria from Sofwave. She is also cochair of MOAS.

SAN DIEGO – While mechanical subcision of fat septa with a scalpel or a large bore needle is a tried-and-true treatment for cellulite, other technologies have emerged as alternatives.

A noninvasive treatment, rapid acoustic pulse (RAP) technology (RESONIC), was cleared by the Food and Drug Administration in 2021 for short-term improvement in the appearance of cellulite. The device emits rapid acoustic pulses (shock waves) that are transmitted through the skin to rupture or shear the fibrotic septa; release of the septa results in the smoothing of skin dimples, Arisa E. Ortiz, MD, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. RAP, however, was “taken off the market temporarily to refine the design.”

Dr. Arisa E. Ortiz

According to Dr. Ortiz, RAP’s repetition rate and short rise time provides microscopic mechanical disruption to the targeted cellular level structures and vacuoles, while high peak pressure and the fast repetition rate exploit the viscoelastic nature of tissue. Compressed pulses from electronic filtering and the reflector shape eliminate cavitation, heat, and pain. Researchers have postulated that the procedure stimulates collagenesis and angiogenesis.

“There’s no heat to this; it just uses sound,” Dr. Ortiz explained. “It’s also time dependent. The longer you do the treatment, the more disruption of the septa you see. The procedure takes 20-30 minutes. Unlike other treatments, it’s not just for discreet dimples. You can treat entire areas like the buttock or posterior leg,” said Dr. Ortiz, who did not use the RAP device in her practice.

Another device, targeted verifiable subcision (TVS, marketed as Avéli), is FDA cleared for temporary reduction in the appearance of cellulite in the buttock and thigh areas of adult women. “But studies show lasting results, at least through a year,” Dr. Ortiz said. The device features a light-guided probe and a hook. The light enables clinicians to navigate under the skin, while the hook releases a tiny blade that severs the septa. “Once you find the septa, then you activate the blade and release the septa. You go right to left because the direction of the blade is on the left of the probe. Then you go back to verify that you got everything that was creating that dimple.”

Previous devices, she said, would “blindly shear the area, so you would find the dimple and blindly cut, so there was no way to verify that you got the target dimple. The results were sometimes mediocre because you didn’t really know if you effectively treated the area.”

Iuliia Mikhalitskaia/Getty Images

She emphasized that TVS is only useful for discreet dimples. “Many patients who come in asking for cellulite treatment have a lot of laxity and rippled texture,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. “This is not going to be appropriate for those cases. Setting expectations is important. If patients have laxity and discreet dimples and it’s just the dimples that bother them, that’s fine. They just need to understand the difference,” she said, noting that this is “safe for all skin types.”

Tumescent anesthesia is used to control pain during the procedure. The most common adverse events are bruising and soreness. Results from a pivotal trial showed that clinically significant improvements in the primary endpoint, Cellulite Severity Scale scores, were sustained 1 year after treatment. “Hemosiderin staining can occur, but it eventually dissipates on its own,” Dr. Ortiz added. “You can use laser to speed up healing but sometimes that can make it worse, so you want to be careful with that. Most of the time I have patients wait it out; it does go away on its own.”

She noted that the development of RAP and TVS have helped clinicians better understand the makeup of septa. “We used to think of septa as singular bands that are vertically oriented in cellulite, but what we’ve realized is that it’s more like a network of septa,” she said.

Another noninvasive technology, synchronous parallel ultrasound beam technology from Sofwave (marketed as SUPERB), was FDA cleared in December 2022 for the short-term improvement in the appearance of cellulite. The device has seven parallel beam transducers that increase tissue temperatures of the treatment area to 60-70° C, inducing collagen remodeling and collagen denaturation, she said.

In the pivotal study of 68 women, two blinded reviewers reported an 89% improvement rate for both cellulite and skin laxity, after two treatments 2-4 weeks apart, according to data she presented at the meeting. The mean pain score during treatment was 4.55 on a scale of 1-10. No safety issues were observed and immediate responses were limited to erythema and edema.

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies, including receipt of speaker fees and honoraria from Sofwave. She is also cochair of MOAS.

SAN DIEGO – While mechanical subcision of fat septa with a scalpel or a large bore needle is a tried-and-true treatment for cellulite, other technologies have emerged as alternatives.

A noninvasive treatment, rapid acoustic pulse (RAP) technology (RESONIC), was cleared by the Food and Drug Administration in 2021 for short-term improvement in the appearance of cellulite. The device emits rapid acoustic pulses (shock waves) that are transmitted through the skin to rupture or shear the fibrotic septa; release of the septa results in the smoothing of skin dimples, Arisa E. Ortiz, MD, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. RAP, however, was “taken off the market temporarily to refine the design.”

Dr. Arisa E. Ortiz

According to Dr. Ortiz, RAP’s repetition rate and short rise time provides microscopic mechanical disruption to the targeted cellular level structures and vacuoles, while high peak pressure and the fast repetition rate exploit the viscoelastic nature of tissue. Compressed pulses from electronic filtering and the reflector shape eliminate cavitation, heat, and pain. Researchers have postulated that the procedure stimulates collagenesis and angiogenesis.

“There’s no heat to this; it just uses sound,” Dr. Ortiz explained. “It’s also time dependent. The longer you do the treatment, the more disruption of the septa you see. The procedure takes 20-30 minutes. Unlike other treatments, it’s not just for discreet dimples. You can treat entire areas like the buttock or posterior leg,” said Dr. Ortiz, who did not use the RAP device in her practice.

Another device, targeted verifiable subcision (TVS, marketed as Avéli), is FDA cleared for temporary reduction in the appearance of cellulite in the buttock and thigh areas of adult women. “But studies show lasting results, at least through a year,” Dr. Ortiz said. The device features a light-guided probe and a hook. The light enables clinicians to navigate under the skin, while the hook releases a tiny blade that severs the septa. “Once you find the septa, then you activate the blade and release the septa. You go right to left because the direction of the blade is on the left of the probe. Then you go back to verify that you got everything that was creating that dimple.”

Previous devices, she said, would “blindly shear the area, so you would find the dimple and blindly cut, so there was no way to verify that you got the target dimple. The results were sometimes mediocre because you didn’t really know if you effectively treated the area.”

Iuliia Mikhalitskaia/Getty Images

She emphasized that TVS is only useful for discreet dimples. “Many patients who come in asking for cellulite treatment have a lot of laxity and rippled texture,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. “This is not going to be appropriate for those cases. Setting expectations is important. If patients have laxity and discreet dimples and it’s just the dimples that bother them, that’s fine. They just need to understand the difference,” she said, noting that this is “safe for all skin types.”

Tumescent anesthesia is used to control pain during the procedure. The most common adverse events are bruising and soreness. Results from a pivotal trial showed that clinically significant improvements in the primary endpoint, Cellulite Severity Scale scores, were sustained 1 year after treatment. “Hemosiderin staining can occur, but it eventually dissipates on its own,” Dr. Ortiz added. “You can use laser to speed up healing but sometimes that can make it worse, so you want to be careful with that. Most of the time I have patients wait it out; it does go away on its own.”

She noted that the development of RAP and TVS have helped clinicians better understand the makeup of septa. “We used to think of septa as singular bands that are vertically oriented in cellulite, but what we’ve realized is that it’s more like a network of septa,” she said.

Another noninvasive technology, synchronous parallel ultrasound beam technology from Sofwave (marketed as SUPERB), was FDA cleared in December 2022 for the short-term improvement in the appearance of cellulite. The device has seven parallel beam transducers that increase tissue temperatures of the treatment area to 60-70° C, inducing collagen remodeling and collagen denaturation, she said.

In the pivotal study of 68 women, two blinded reviewers reported an 89% improvement rate for both cellulite and skin laxity, after two treatments 2-4 weeks apart, according to data she presented at the meeting. The mean pain score during treatment was 4.55 on a scale of 1-10. No safety issues were observed and immediate responses were limited to erythema and edema.

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies, including receipt of speaker fees and honoraria from Sofwave. She is also cochair of MOAS.

SAN DIEGO – Despite the popularity of fractional lasers cleared for skin rejuvenation in the past decade, fully ablative laser resurfacing is still preferred by some patients because it usually requires only one treatment for reproducible results, according to Arisa E. Ortiz, MD.

Dr. Arisa E. Ortiz

“Fractional resurfacing is great because there is less downtime, but the results are not as dramatic as with fully ablative resurfacing,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. In her practice, she said, “we do a combination,” which can include “fully ablative around the mouth and eyes and fractional everywhere else.”

Key drawbacks to fully ablative laser resurfacing include significant downtime and extensive wound care, “so it’s not for everybody,” she said. Prolonged erythema following treatment is expected, “so patients need to plan for this. It can last 3-4 months, and it will continue to fade and can be covered up with makeup, but it does last a while,” she noted. “One of the things that made ablative resurfacing fall out of favor was the delayed and permanent hypopigmentation where there’s a stark line of demarcation because you can’t treat the neck [with this modality], so patients have this pearly white looking face that appears 6 months after the treatment,” she added.

Preoperatively, Dr. Ortiz asks patients what other cosmetic procedures they have had in the past. For example, if they have had a facelift, they might have neck skin on their jawline, which will react differently to fully ablative resurfacing than facial skin. “I don’t perform fully ablative resurfacing on the neck or body, or in patients with darker skin types,” she said.

To optimize results, she recommends pretreatment of the area with a neuromodulator a week or 2 before the procedure, “so that they’re not actively contracting and recreating creases,” she said. Studies, she noted, have shown that this approach results in better outcomes. She also asks patients to apply a tripeptide serum daily a week or 2 prior to their procedure to stimulate wound healing and collagen remodeling.

For antibiotic and antiviral prophylaxis, Dr. Ortiz typically prescribes doxycycline 100 mg b.i.d. for 7 days and valacyclovir 500 mg b.i.d. for 7 days and asks patients to start the course the night before the procedure. “If they break through the antiviral, I increase to zoster dosing,” she said. “I make sure they have my cell phone number and call me right away if that happens. I don’t routinely prescribe an antifungal, but you can if you want to.”

For anesthesia, Dr. Ortiz applies lidocaine 23%/tetracaine 7% an hour before the procedure and performs nerve blocks at the mentalis, infraorbital, supraorbital, and nasalis muscles. “I also do local infiltration with a three-pronged Mesoram adapter,” she said. “That has changed the comfort level for these patients. I don’t offer any sedation in my practice but that is an option if you have it available. If you’re going to be resurfacing within the orbital rim you need to know how to place corneal shields. Only use injectable lidocaine in this area because if topical lidocaine gets into the eye, it can cause a chemical corneal abrasion. Nothing happens to their vision permanently, but it’s extremely painful for 24-48 hours.”

Dr. Ortiz described postoperative wound care as “the hardest part” of fully ablative laser resurfacing treatments. The treated area will look “bloody and crusty” for 1-2 weeks. She instructs patients to do vinegar soaks four times per day for 2-3 weeks, “depending on how quickly they heal,” she said. She also counsels patients to apply petrolatum ointment to the area and provides them with a bottle of hypochlorous acid spray, an antiseptic – which also helps with the itching they may experience. “They need to avoid the sun, so I recommend full face visors,” she added.

In her clinical experience, postoperative pain medications are not required. “If the patient calls you on day 3 with increased pain, that’s usually a sign of infection; don’t ignore that,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. In a case of suspected infection, she asks the patient to come in right away, and obtains a bacterial culture. “If they break through the doxycycline, it’s usually a gram-negative infection, so I’ll treat them prophylactically for that,” she said.

“Significant itching may be a sign of Candida infection,” she noted. “Because the epidermis has been disrupted, if they have systemic symptoms then you want to consider IV antibiotics because the infection can spread rapidly.”

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.

SAN DIEGO – Despite the popularity of fractional lasers cleared for skin rejuvenation in the past decade, fully ablative laser resurfacing is still preferred by some patients because it usually requires only one treatment for reproducible results, according to Arisa E. Ortiz, MD.

Dr. Arisa E. Ortiz

“Fractional resurfacing is great because there is less downtime, but the results are not as dramatic as with fully ablative resurfacing,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. In her practice, she said, “we do a combination,” which can include “fully ablative around the mouth and eyes and fractional everywhere else.”

Key drawbacks to fully ablative laser resurfacing include significant downtime and extensive wound care, “so it’s not for everybody,” she said. Prolonged erythema following treatment is expected, “so patients need to plan for this. It can last 3-4 months, and it will continue to fade and can be covered up with makeup, but it does last a while,” she noted. “One of the things that made ablative resurfacing fall out of favor was the delayed and permanent hypopigmentation where there’s a stark line of demarcation because you can’t treat the neck [with this modality], so patients have this pearly white looking face that appears 6 months after the treatment,” she added.

Preoperatively, Dr. Ortiz asks patients what other cosmetic procedures they have had in the past. For example, if they have had a facelift, they might have neck skin on their jawline, which will react differently to fully ablative resurfacing than facial skin. “I don’t perform fully ablative resurfacing on the neck or body, or in patients with darker skin types,” she said.

To optimize results, she recommends pretreatment of the area with a neuromodulator a week or 2 before the procedure, “so that they’re not actively contracting and recreating creases,” she said. Studies, she noted, have shown that this approach results in better outcomes. She also asks patients to apply a tripeptide serum daily a week or 2 prior to their procedure to stimulate wound healing and collagen remodeling.

For antibiotic and antiviral prophylaxis, Dr. Ortiz typically prescribes doxycycline 100 mg b.i.d. for 7 days and valacyclovir 500 mg b.i.d. for 7 days and asks patients to start the course the night before the procedure. “If they break through the antiviral, I increase to zoster dosing,” she said. “I make sure they have my cell phone number and call me right away if that happens. I don’t routinely prescribe an antifungal, but you can if you want to.”

For anesthesia, Dr. Ortiz applies lidocaine 23%/tetracaine 7% an hour before the procedure and performs nerve blocks at the mentalis, infraorbital, supraorbital, and nasalis muscles. “I also do local infiltration with a three-pronged Mesoram adapter,” she said. “That has changed the comfort level for these patients. I don’t offer any sedation in my practice but that is an option if you have it available. If you’re going to be resurfacing within the orbital rim you need to know how to place corneal shields. Only use injectable lidocaine in this area because if topical lidocaine gets into the eye, it can cause a chemical corneal abrasion. Nothing happens to their vision permanently, but it’s extremely painful for 24-48 hours.”

Dr. Ortiz described postoperative wound care as “the hardest part” of fully ablative laser resurfacing treatments. The treated area will look “bloody and crusty” for 1-2 weeks. She instructs patients to do vinegar soaks four times per day for 2-3 weeks, “depending on how quickly they heal,” she said. She also counsels patients to apply petrolatum ointment to the area and provides them with a bottle of hypochlorous acid spray, an antiseptic – which also helps with the itching they may experience. “They need to avoid the sun, so I recommend full face visors,” she added.

In her clinical experience, postoperative pain medications are not required. “If the patient calls you on day 3 with increased pain, that’s usually a sign of infection; don’t ignore that,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. In a case of suspected infection, she asks the patient to come in right away, and obtains a bacterial culture. “If they break through the doxycycline, it’s usually a gram-negative infection, so I’ll treat them prophylactically for that,” she said.

“Significant itching may be a sign of Candida infection,” she noted. “Because the epidermis has been disrupted, if they have systemic symptoms then you want to consider IV antibiotics because the infection can spread rapidly.”

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.

SAN DIEGO – Despite the popularity of fractional lasers cleared for skin rejuvenation in the past decade, fully ablative laser resurfacing is still preferred by some patients because it usually requires only one treatment for reproducible results, according to Arisa E. Ortiz, MD.

Dr. Arisa E. Ortiz

“Fractional resurfacing is great because there is less downtime, but the results are not as dramatic as with fully ablative resurfacing,” Dr. Ortiz, director of laser and cosmetic dermatology at the University of California, San Diego, said at the annual Masters of Aesthetics Symposium. In her practice, she said, “we do a combination,” which can include “fully ablative around the mouth and eyes and fractional everywhere else.”

Key drawbacks to fully ablative laser resurfacing include significant downtime and extensive wound care, “so it’s not for everybody,” she said. Prolonged erythema following treatment is expected, “so patients need to plan for this. It can last 3-4 months, and it will continue to fade and can be covered up with makeup, but it does last a while,” she noted. “One of the things that made ablative resurfacing fall out of favor was the delayed and permanent hypopigmentation where there’s a stark line of demarcation because you can’t treat the neck [with this modality], so patients have this pearly white looking face that appears 6 months after the treatment,” she added.

Preoperatively, Dr. Ortiz asks patients what other cosmetic procedures they have had in the past. For example, if they have had a facelift, they might have neck skin on their jawline, which will react differently to fully ablative resurfacing than facial skin. “I don’t perform fully ablative resurfacing on the neck or body, or in patients with darker skin types,” she said.

To optimize results, she recommends pretreatment of the area with a neuromodulator a week or 2 before the procedure, “so that they’re not actively contracting and recreating creases,” she said. Studies, she noted, have shown that this approach results in better outcomes. She also asks patients to apply a tripeptide serum daily a week or 2 prior to their procedure to stimulate wound healing and collagen remodeling.

For antibiotic and antiviral prophylaxis, Dr. Ortiz typically prescribes doxycycline 100 mg b.i.d. for 7 days and valacyclovir 500 mg b.i.d. for 7 days and asks patients to start the course the night before the procedure. “If they break through the antiviral, I increase to zoster dosing,” she said. “I make sure they have my cell phone number and call me right away if that happens. I don’t routinely prescribe an antifungal, but you can if you want to.”

For anesthesia, Dr. Ortiz applies lidocaine 23%/tetracaine 7% an hour before the procedure and performs nerve blocks at the mentalis, infraorbital, supraorbital, and nasalis muscles. “I also do local infiltration with a three-pronged Mesoram adapter,” she said. “That has changed the comfort level for these patients. I don’t offer any sedation in my practice but that is an option if you have it available. If you’re going to be resurfacing within the orbital rim you need to know how to place corneal shields. Only use injectable lidocaine in this area because if topical lidocaine gets into the eye, it can cause a chemical corneal abrasion. Nothing happens to their vision permanently, but it’s extremely painful for 24-48 hours.”

Dr. Ortiz described postoperative wound care as “the hardest part” of fully ablative laser resurfacing treatments. The treated area will look “bloody and crusty” for 1-2 weeks. She instructs patients to do vinegar soaks four times per day for 2-3 weeks, “depending on how quickly they heal,” she said. She also counsels patients to apply petrolatum ointment to the area and provides them with a bottle of hypochlorous acid spray, an antiseptic – which also helps with the itching they may experience. “They need to avoid the sun, so I recommend full face visors,” she added.

In her clinical experience, postoperative pain medications are not required. “If the patient calls you on day 3 with increased pain, that’s usually a sign of infection; don’t ignore that,” said Dr. Ortiz, who is also president-elect of the American Society for Laser Medicine and Surgery. In a case of suspected infection, she asks the patient to come in right away, and obtains a bacterial culture. “If they break through the doxycycline, it’s usually a gram-negative infection, so I’ll treat them prophylactically for that,” she said.

“Significant itching may be a sign of Candida infection,” she noted. “Because the epidermis has been disrupted, if they have systemic symptoms then you want to consider IV antibiotics because the infection can spread rapidly.”

Dr. Ortiz disclosed having financial relationships with several pharmaceutical and device companies. She is also cochair of the MOAS.

This year’s annual meeting of the European Association for the Study of Diabetes offers an in-depth look into “disease-modifying and disrupting therapies” in both type 1 and type 2 diabetes.

Noteworthy at the meeting, taking place Oct. 3-6, in Hamburg, Germany, will be final detailed data from the SURMOUNT-4 trial of the “twincretin” tirzepatide (Mounjaro, Lilly) on obesity. The top-line results, announced by the company in July, showed an average 21.1% weight loss at 36 weeks with tirzepatide injections once weekly among adults with overweight or obesity. The drug is approved in the United States and Europe for treating type 2 diabetes, and approval for obesity is expected in the United States later this year.

In addition, a symposium will present a new EASD/American Diabetes Association (ADA) consensus report, Hyperglycaemic Crisis in Adult Patients with Diabetes, scheduled to be simultaneously published in Diabetologia and Diabetes Care on Oct. 6.  

Aside from those, much of the EASD meeting content will feature smaller studies on both type 2 and type 1 diabetes, along with award lectures, symposia, debates, and lots of discussion on hot topics in diabetes and clinical challenges including complications. In essence, it will provide a forum for in-depth follow-up to the jam-packed clinical trial–filled agenda at the ADA meeting in June, said EASD Honorary Secretary Tina Vilsbøll, MD, clinical professor and head of clinic at the Steno Diabetes Center, Copenhagen.

“There were so many large trials at ADA that we just took them in without really having a chance to discuss them. ... There’s so much to discuss with all these new treatments, how do we place them in obesity and diabetes? ... All the data that we have from ADA will make good discussions at EASD,” Dr. Vilsbøll said in an interview.

Indeed, said EASD President Chantal Mathieu, MD, PhD, chair of endocrinology at University Hospital Gasthuisberg Leuven, Belgium, “We always come after ADA. That puts us in a position where we can take deeper dives into the data. ... EASD is a calmer meeting where you can really look at the details.”
 

Type 2 diabetes: Disease modifying in many ways

Dr. Mathieu told this news organization that a unifying theme for much of the EASD meeting’s content is “We are now entering the era of disease-modifying and disease-disrupting therapies” in both diabetes types.

In type 2, this means “getting to the root, which is obesity, so you’ll see a lot of presentations on the incretin system, but you also don’t get type 2 diabetes if you have an iron-clad beta cell. ... So, we also gave a lot of attention to basic translational research that helps us to understand the role of the beta cell in type 2 diabetes.”

In addition to SURMOUNT-4, there will be oral abstract sessions with follow-up data from the SURPASS series of studies of tirzepatide in type 2 diabetes, other abstract sessions, symposia about incretins and obesity, and an oral abstract session on beta cell function in both diabetes types.

Three debates will address controversial questions in the type 2 diabetes arena. In one, speakers will take opposite sides on “Initial combined therapy for type 2 diabetes: Should diabetes follow hypertension?”

In another, speakers will argue over “Is lasting remission of type 2 diabetes feasible in the real-world setting?” That’s an important question, Dr. Vilsbøll said.

“A person might be able to have a remission but go back if they regain the weight. Do we really have remission? How do we define it? Now, suddenly, we have tools to help people go in the right direction. Now we’re in a place where we can actually help our patients with their cravings and their body weight and all that. It’s more fun to discuss when we have the tools.”

A third debate will tackle the question of whether all people with type 2 diabetes and chronic kidney disease should be on [sodium-glucose co-transporter 2] (SGLT2) inhibitors “by default.”

The Minkowski Prize Lecture will address the regulation of energy and glucose metabolism by the dual incretin receptor agonists, while the EASD-Lilly Anniversary Prize Lecture will be about the role of ectopic lipid in insulin resistance and cardiometabolic disease.
 

Type 1 diabetes: Both disease modifying and disruptive

For type 1 diabetes, “disease-modifying” and “disruptive” approaches on the meeting agenda include new data on immune modulation for people in early stages in order to prevent or delay insulin dependence, islet transplantation including the use of stem cell–derived beta cells, and the latest in technology including automated insulin delivery systems, also known colloquially as the “artificial pancreas.”

Prize lectures about type 1 diabetes will include the Claude Bernard Lecture, on etiologies of autoimmune diabetes, the Albert Renold Lecture, on “disrupted RNA editing as a path to type 1 diabetes,” and the EASD/Novo Nordisk Foundation Diabetes Prize for Excellence Lecture on automated insulin delivery.

Focus on complications: The known and the emerging

The meeting also will focus a great deal on complications of diabetes, including the well-studied cardiovascular disease, neuropathy, nephropathy, retinopathy, and fatty liver disease as well as others that typically receive less attention, such as gastrointestinal problems and cardiomyopathy.

Another debate will address the question “Is it time to reclassify diabetes complications because microvascular and macrovascular classification is no longer sufficient?” And, the Camillo Golgi Lecture will cover “Diabetes Complications: From Classical to Emerging.”

As always, there’s much more on the agenda including pregnancy and diabetes, cystic fibrosis–derived diabetes, mental health in diabetes, COVID-19 and diabetes, hypoglycemia, and hypoglycemia unawareness.  

According to Dr. Vilsbøll, “Clinicians should come and enjoy all the great science we have, interact, and be inspired.”

Dr. Vilsbøll has served on scientific advisory panels, been part of speaker bureaus, and served as a consultant to and/or received research support from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Mundipharma, Novo Nordisk, Sanofi, and Sun Pharmaceuticals. Dr. Mathieu serves or has served on the advisory panel for Novo Nordisk, Sanofi, Merck Sharp and Dohme Ltd., Eli Lilly and Company, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, Medtronic, ActoBio Therapeutics, Pfizer, Imcyse, Insulet, Zealand Pharma, Avotres, Mannkind, Sandoz, and Vertex. She has served on the speakers bureau for Novo Nordisk, Sanofi, Eli Lilly and Company, Boehringer Ingelheim, AstraZeneca, and Novartis. Financial compensation for these activities has been received by KU Leuven.
 

A version of this article appeared on Medscape.com.

This year’s annual meeting of the European Association for the Study of Diabetes offers an in-depth look into “disease-modifying and disrupting therapies” in both type 1 and type 2 diabetes.

Noteworthy at the meeting, taking place Oct. 3-6, in Hamburg, Germany, will be final detailed data from the SURMOUNT-4 trial of the “twincretin” tirzepatide (Mounjaro, Lilly) on obesity. The top-line results, announced by the company in July, showed an average 21.1% weight loss at 36 weeks with tirzepatide injections once weekly among adults with overweight or obesity. The drug is approved in the United States and Europe for treating type 2 diabetes, and approval for obesity is expected in the United States later this year.

In addition, a symposium will present a new EASD/American Diabetes Association (ADA) consensus report, Hyperglycaemic Crisis in Adult Patients with Diabetes, scheduled to be simultaneously published in Diabetologia and Diabetes Care on Oct. 6.  

Aside from those, much of the EASD meeting content will feature smaller studies on both type 2 and type 1 diabetes, along with award lectures, symposia, debates, and lots of discussion on hot topics in diabetes and clinical challenges including complications. In essence, it will provide a forum for in-depth follow-up to the jam-packed clinical trial–filled agenda at the ADA meeting in June, said EASD Honorary Secretary Tina Vilsbøll, MD, clinical professor and head of clinic at the Steno Diabetes Center, Copenhagen.

“There were so many large trials at ADA that we just took them in without really having a chance to discuss them. ... There’s so much to discuss with all these new treatments, how do we place them in obesity and diabetes? ... All the data that we have from ADA will make good discussions at EASD,” Dr. Vilsbøll said in an interview.

Indeed, said EASD President Chantal Mathieu, MD, PhD, chair of endocrinology at University Hospital Gasthuisberg Leuven, Belgium, “We always come after ADA. That puts us in a position where we can take deeper dives into the data. ... EASD is a calmer meeting where you can really look at the details.”
 

Type 2 diabetes: Disease modifying in many ways

Dr. Mathieu told this news organization that a unifying theme for much of the EASD meeting’s content is “We are now entering the era of disease-modifying and disease-disrupting therapies” in both diabetes types.

In type 2, this means “getting to the root, which is obesity, so you’ll see a lot of presentations on the incretin system, but you also don’t get type 2 diabetes if you have an iron-clad beta cell. ... So, we also gave a lot of attention to basic translational research that helps us to understand the role of the beta cell in type 2 diabetes.”

In addition to SURMOUNT-4, there will be oral abstract sessions with follow-up data from the SURPASS series of studies of tirzepatide in type 2 diabetes, other abstract sessions, symposia about incretins and obesity, and an oral abstract session on beta cell function in both diabetes types.

Three debates will address controversial questions in the type 2 diabetes arena. In one, speakers will take opposite sides on “Initial combined therapy for type 2 diabetes: Should diabetes follow hypertension?”

In another, speakers will argue over “Is lasting remission of type 2 diabetes feasible in the real-world setting?” That’s an important question, Dr. Vilsbøll said.

“A person might be able to have a remission but go back if they regain the weight. Do we really have remission? How do we define it? Now, suddenly, we have tools to help people go in the right direction. Now we’re in a place where we can actually help our patients with their cravings and their body weight and all that. It’s more fun to discuss when we have the tools.”

A third debate will tackle the question of whether all people with type 2 diabetes and chronic kidney disease should be on [sodium-glucose co-transporter 2] (SGLT2) inhibitors “by default.”

The Minkowski Prize Lecture will address the regulation of energy and glucose metabolism by the dual incretin receptor agonists, while the EASD-Lilly Anniversary Prize Lecture will be about the role of ectopic lipid in insulin resistance and cardiometabolic disease.
 

Type 1 diabetes: Both disease modifying and disruptive

For type 1 diabetes, “disease-modifying” and “disruptive” approaches on the meeting agenda include new data on immune modulation for people in early stages in order to prevent or delay insulin dependence, islet transplantation including the use of stem cell–derived beta cells, and the latest in technology including automated insulin delivery systems, also known colloquially as the “artificial pancreas.”

Prize lectures about type 1 diabetes will include the Claude Bernard Lecture, on etiologies of autoimmune diabetes, the Albert Renold Lecture, on “disrupted RNA editing as a path to type 1 diabetes,” and the EASD/Novo Nordisk Foundation Diabetes Prize for Excellence Lecture on automated insulin delivery.

Focus on complications: The known and the emerging

The meeting also will focus a great deal on complications of diabetes, including the well-studied cardiovascular disease, neuropathy, nephropathy, retinopathy, and fatty liver disease as well as others that typically receive less attention, such as gastrointestinal problems and cardiomyopathy.

Another debate will address the question “Is it time to reclassify diabetes complications because microvascular and macrovascular classification is no longer sufficient?” And, the Camillo Golgi Lecture will cover “Diabetes Complications: From Classical to Emerging.”

As always, there’s much more on the agenda including pregnancy and diabetes, cystic fibrosis–derived diabetes, mental health in diabetes, COVID-19 and diabetes, hypoglycemia, and hypoglycemia unawareness.  

According to Dr. Vilsbøll, “Clinicians should come and enjoy all the great science we have, interact, and be inspired.”

Dr. Vilsbøll has served on scientific advisory panels, been part of speaker bureaus, and served as a consultant to and/or received research support from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Mundipharma, Novo Nordisk, Sanofi, and Sun Pharmaceuticals. Dr. Mathieu serves or has served on the advisory panel for Novo Nordisk, Sanofi, Merck Sharp and Dohme Ltd., Eli Lilly and Company, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, Medtronic, ActoBio Therapeutics, Pfizer, Imcyse, Insulet, Zealand Pharma, Avotres, Mannkind, Sandoz, and Vertex. She has served on the speakers bureau for Novo Nordisk, Sanofi, Eli Lilly and Company, Boehringer Ingelheim, AstraZeneca, and Novartis. Financial compensation for these activities has been received by KU Leuven.
 

A version of this article appeared on Medscape.com.

This year’s annual meeting of the European Association for the Study of Diabetes offers an in-depth look into “disease-modifying and disrupting therapies” in both type 1 and type 2 diabetes.

Noteworthy at the meeting, taking place Oct. 3-6, in Hamburg, Germany, will be final detailed data from the SURMOUNT-4 trial of the “twincretin” tirzepatide (Mounjaro, Lilly) on obesity. The top-line results, announced by the company in July, showed an average 21.1% weight loss at 36 weeks with tirzepatide injections once weekly among adults with overweight or obesity. The drug is approved in the United States and Europe for treating type 2 diabetes, and approval for obesity is expected in the United States later this year.

In addition, a symposium will present a new EASD/American Diabetes Association (ADA) consensus report, Hyperglycaemic Crisis in Adult Patients with Diabetes, scheduled to be simultaneously published in Diabetologia and Diabetes Care on Oct. 6.  

Aside from those, much of the EASD meeting content will feature smaller studies on both type 2 and type 1 diabetes, along with award lectures, symposia, debates, and lots of discussion on hot topics in diabetes and clinical challenges including complications. In essence, it will provide a forum for in-depth follow-up to the jam-packed clinical trial–filled agenda at the ADA meeting in June, said EASD Honorary Secretary Tina Vilsbøll, MD, clinical professor and head of clinic at the Steno Diabetes Center, Copenhagen.

“There were so many large trials at ADA that we just took them in without really having a chance to discuss them. ... There’s so much to discuss with all these new treatments, how do we place them in obesity and diabetes? ... All the data that we have from ADA will make good discussions at EASD,” Dr. Vilsbøll said in an interview.

Indeed, said EASD President Chantal Mathieu, MD, PhD, chair of endocrinology at University Hospital Gasthuisberg Leuven, Belgium, “We always come after ADA. That puts us in a position where we can take deeper dives into the data. ... EASD is a calmer meeting where you can really look at the details.”
 

Type 2 diabetes: Disease modifying in many ways

Dr. Mathieu told this news organization that a unifying theme for much of the EASD meeting’s content is “We are now entering the era of disease-modifying and disease-disrupting therapies” in both diabetes types.

In type 2, this means “getting to the root, which is obesity, so you’ll see a lot of presentations on the incretin system, but you also don’t get type 2 diabetes if you have an iron-clad beta cell. ... So, we also gave a lot of attention to basic translational research that helps us to understand the role of the beta cell in type 2 diabetes.”

In addition to SURMOUNT-4, there will be oral abstract sessions with follow-up data from the SURPASS series of studies of tirzepatide in type 2 diabetes, other abstract sessions, symposia about incretins and obesity, and an oral abstract session on beta cell function in both diabetes types.

Three debates will address controversial questions in the type 2 diabetes arena. In one, speakers will take opposite sides on “Initial combined therapy for type 2 diabetes: Should diabetes follow hypertension?”

In another, speakers will argue over “Is lasting remission of type 2 diabetes feasible in the real-world setting?” That’s an important question, Dr. Vilsbøll said.

“A person might be able to have a remission but go back if they regain the weight. Do we really have remission? How do we define it? Now, suddenly, we have tools to help people go in the right direction. Now we’re in a place where we can actually help our patients with their cravings and their body weight and all that. It’s more fun to discuss when we have the tools.”

A third debate will tackle the question of whether all people with type 2 diabetes and chronic kidney disease should be on [sodium-glucose co-transporter 2] (SGLT2) inhibitors “by default.”

The Minkowski Prize Lecture will address the regulation of energy and glucose metabolism by the dual incretin receptor agonists, while the EASD-Lilly Anniversary Prize Lecture will be about the role of ectopic lipid in insulin resistance and cardiometabolic disease.
 

Type 1 diabetes: Both disease modifying and disruptive

For type 1 diabetes, “disease-modifying” and “disruptive” approaches on the meeting agenda include new data on immune modulation for people in early stages in order to prevent or delay insulin dependence, islet transplantation including the use of stem cell–derived beta cells, and the latest in technology including automated insulin delivery systems, also known colloquially as the “artificial pancreas.”

Prize lectures about type 1 diabetes will include the Claude Bernard Lecture, on etiologies of autoimmune diabetes, the Albert Renold Lecture, on “disrupted RNA editing as a path to type 1 diabetes,” and the EASD/Novo Nordisk Foundation Diabetes Prize for Excellence Lecture on automated insulin delivery.

Focus on complications: The known and the emerging

The meeting also will focus a great deal on complications of diabetes, including the well-studied cardiovascular disease, neuropathy, nephropathy, retinopathy, and fatty liver disease as well as others that typically receive less attention, such as gastrointestinal problems and cardiomyopathy.

Another debate will address the question “Is it time to reclassify diabetes complications because microvascular and macrovascular classification is no longer sufficient?” And, the Camillo Golgi Lecture will cover “Diabetes Complications: From Classical to Emerging.”

As always, there’s much more on the agenda including pregnancy and diabetes, cystic fibrosis–derived diabetes, mental health in diabetes, COVID-19 and diabetes, hypoglycemia, and hypoglycemia unawareness.  

According to Dr. Vilsbøll, “Clinicians should come and enjoy all the great science we have, interact, and be inspired.”

Dr. Vilsbøll has served on scientific advisory panels, been part of speaker bureaus, and served as a consultant to and/or received research support from Amgen, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Gilead, GSK, Mundipharma, Novo Nordisk, Sanofi, and Sun Pharmaceuticals. Dr. Mathieu serves or has served on the advisory panel for Novo Nordisk, Sanofi, Merck Sharp and Dohme Ltd., Eli Lilly and Company, Novartis, AstraZeneca, Boehringer Ingelheim, Roche, Medtronic, ActoBio Therapeutics, Pfizer, Imcyse, Insulet, Zealand Pharma, Avotres, Mannkind, Sandoz, and Vertex. She has served on the speakers bureau for Novo Nordisk, Sanofi, Eli Lilly and Company, Boehringer Ingelheim, AstraZeneca, and Novartis. Financial compensation for these activities has been received by KU Leuven.
 

A version of this article appeared on Medscape.com.

SAN DIEGO – The use of absorbable threads to improve skin laxity is safe and effective, but their long-term aesthetic effects remain unclear, according to Catherine M. DiGiorgio, MD, MS.

In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from a hybrid of poly-l-lactic acid (PLLA) and polyglycolide/l-lactide (PLGA), and from polydioxanone (PDO) has led to renewed interest in thread lift procedures.

Dr. DiGiorgio

While a surgical facelift remains the gold standard, “we have some options to offer patients for noninvasive tightening,” Dr. DiGiorgio said. “We have devices that provide minimal downtime and are less costly, but results are inconsistent. Thread lifts, or suspension sutures, also have minimal downtime and are less costly, but the [results are] subtle and not long lasting.”

PLGA/PLLA threads consist of an 18% PLGA and 82% PLLA monofilament with bidirectional cones that shift the tissue. They are available in 8, 12, or 16 cones spaced 5-8 mm apart on either side of a 2-cm central cone-free area. “There is a 12-cm, 23-gauge needle on either side of the thread, to allow for insertion,” she explained. “These cones stimulate types I and II collagen, which results in collagenesis. The skin encapsulates the cones, resulting in lasting volume and contour.”

PDO threads, meanwhile, are biodegradable by hydrolysis over 4-8 months. They are inserted with a cannula or a needle and vary based on length, diameter, twined vs. braided, coned vs. barbed, and twisted vs. smooth. “The barbed PDO threads are what I use the most,” Dr. DiGiorgio said. “They provide slight tissue repositioning by anchoring and gripping.”

In 2019, researchers in Korea published results of a study that evaluated the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model. They found that while both PDO and PLLA induced granulomatous reactions and collagen formation, PDO resulted in slightly more collagen formation than PLLA.

Dr. DiGiorgio, who transitioned to using PDO threads after first using the PLLA/PLGA threads, said that both are effective. “I find PDO threads to be easier. They’re less costly for me, they’re less costly for the patient, and the results are about equivalent.”

Absorbable threads are indicated for the cheek, jawline, neck, lips, forehead, and brow. She finds them most useful “for the lower face, below the nasolabial fold down to the jawline, for improvement of the jowls,” she said. “I don’t think they really work on the neck.”

As with any cosmetic procedure, patient selection is key. According to Dr. DiGiorgio, the patient should have specific and segmental areas of facial laxity amenable to lifting and recontouring along a straight-line vector, adequate dermal thickness, and appropriate expectations for the level of correction. “I like to re-volumize with filler before performing thread lifts to make sure that volume is restored, because you can’t really provide lift to someone with significant volume loss,” she said.
 

Procedural tips

Prior to the procedure, Dr. DiGiorgio marks the area to be treated while the patient is seated upright and holding a mirror. Then, she pulls back the amount of skin laxity the thread is going to correct. The plane of insertion for barbed threads is at the superficial musculoaponeurotic system (SMAS), and she typically uses 3-4 threads on each side of the face.

“How do you know you’re in the right plane?” If the patient is experiencing significant pain, “you’re too deep, and it’s not going to work,” she said. “You can see if the thread is too superficial as you do more of these.”

After the procedure she asks the patient to sit up prior to trimming the threads. “I take a look in the mirror with them and have them smile and make funny faces to see if there is any dimpling or crimpling, which is probably the most common side effect,” she said. “If I see that, I will pull the thread immediately, so we don’t have a problem. It’s a little uncomfortable to pull the thread but not more uncomfortable than the procedure itself, but I think it’s worth doing to avoid having a dimple or a crimple that can last up to a year.”

In her clinical experience, thread lifts last about 8-10 months. “I find that my patients will come in about once a year for this procedure, and the treated area feels tight afterward,” Dr. DiGiorgio said. “I think that sensation of feeling tight also provides satisfaction to the patient. Results are very subtle. It’s tissue repositioning; it is not a facelift. There’s not really any downtime, but further studies are required to see if threads are safe and effective in the long-term.”

In an interview after the meeting, she noted that the learning curve for thread lifts is variable, as with any new procedure a physician chooses to add to his or her practice. “It’s important to see these patients in follow-up 2 weeks after the procedure consistently, especially when someone first starts performing the procedure,” she recommended. “These patients are usually coming in to see me for other treatments, so I see them at regular 3-month intervals regardless. You begin to get a feel for what angles work and why and how to optimize the results. As with any procedure, the more experience you have performing the procedure will result in improved outcomes and improved management.”

Dr. DiGiorgio disclosed that she has been an advisory board member for Quthero and she holds stock options in the company. She is a consultant for Revelle and has received equipment from Acclaro.

SAN DIEGO – The use of absorbable threads to improve skin laxity is safe and effective, but their long-term aesthetic effects remain unclear, according to Catherine M. DiGiorgio, MD, MS.

In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from a hybrid of poly-l-lactic acid (PLLA) and polyglycolide/l-lactide (PLGA), and from polydioxanone (PDO) has led to renewed interest in thread lift procedures.

Dr. DiGiorgio

While a surgical facelift remains the gold standard, “we have some options to offer patients for noninvasive tightening,” Dr. DiGiorgio said. “We have devices that provide minimal downtime and are less costly, but results are inconsistent. Thread lifts, or suspension sutures, also have minimal downtime and are less costly, but the [results are] subtle and not long lasting.”

PLGA/PLLA threads consist of an 18% PLGA and 82% PLLA monofilament with bidirectional cones that shift the tissue. They are available in 8, 12, or 16 cones spaced 5-8 mm apart on either side of a 2-cm central cone-free area. “There is a 12-cm, 23-gauge needle on either side of the thread, to allow for insertion,” she explained. “These cones stimulate types I and II collagen, which results in collagenesis. The skin encapsulates the cones, resulting in lasting volume and contour.”

PDO threads, meanwhile, are biodegradable by hydrolysis over 4-8 months. They are inserted with a cannula or a needle and vary based on length, diameter, twined vs. braided, coned vs. barbed, and twisted vs. smooth. “The barbed PDO threads are what I use the most,” Dr. DiGiorgio said. “They provide slight tissue repositioning by anchoring and gripping.”

In 2019, researchers in Korea published results of a study that evaluated the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model. They found that while both PDO and PLLA induced granulomatous reactions and collagen formation, PDO resulted in slightly more collagen formation than PLLA.

Dr. DiGiorgio, who transitioned to using PDO threads after first using the PLLA/PLGA threads, said that both are effective. “I find PDO threads to be easier. They’re less costly for me, they’re less costly for the patient, and the results are about equivalent.”

Absorbable threads are indicated for the cheek, jawline, neck, lips, forehead, and brow. She finds them most useful “for the lower face, below the nasolabial fold down to the jawline, for improvement of the jowls,” she said. “I don’t think they really work on the neck.”

As with any cosmetic procedure, patient selection is key. According to Dr. DiGiorgio, the patient should have specific and segmental areas of facial laxity amenable to lifting and recontouring along a straight-line vector, adequate dermal thickness, and appropriate expectations for the level of correction. “I like to re-volumize with filler before performing thread lifts to make sure that volume is restored, because you can’t really provide lift to someone with significant volume loss,” she said.
 

Procedural tips

Prior to the procedure, Dr. DiGiorgio marks the area to be treated while the patient is seated upright and holding a mirror. Then, she pulls back the amount of skin laxity the thread is going to correct. The plane of insertion for barbed threads is at the superficial musculoaponeurotic system (SMAS), and she typically uses 3-4 threads on each side of the face.

“How do you know you’re in the right plane?” If the patient is experiencing significant pain, “you’re too deep, and it’s not going to work,” she said. “You can see if the thread is too superficial as you do more of these.”

After the procedure she asks the patient to sit up prior to trimming the threads. “I take a look in the mirror with them and have them smile and make funny faces to see if there is any dimpling or crimpling, which is probably the most common side effect,” she said. “If I see that, I will pull the thread immediately, so we don’t have a problem. It’s a little uncomfortable to pull the thread but not more uncomfortable than the procedure itself, but I think it’s worth doing to avoid having a dimple or a crimple that can last up to a year.”

In her clinical experience, thread lifts last about 8-10 months. “I find that my patients will come in about once a year for this procedure, and the treated area feels tight afterward,” Dr. DiGiorgio said. “I think that sensation of feeling tight also provides satisfaction to the patient. Results are very subtle. It’s tissue repositioning; it is not a facelift. There’s not really any downtime, but further studies are required to see if threads are safe and effective in the long-term.”

In an interview after the meeting, she noted that the learning curve for thread lifts is variable, as with any new procedure a physician chooses to add to his or her practice. “It’s important to see these patients in follow-up 2 weeks after the procedure consistently, especially when someone first starts performing the procedure,” she recommended. “These patients are usually coming in to see me for other treatments, so I see them at regular 3-month intervals regardless. You begin to get a feel for what angles work and why and how to optimize the results. As with any procedure, the more experience you have performing the procedure will result in improved outcomes and improved management.”

Dr. DiGiorgio disclosed that she has been an advisory board member for Quthero and she holds stock options in the company. She is a consultant for Revelle and has received equipment from Acclaro.

SAN DIEGO – The use of absorbable threads to improve skin laxity is safe and effective, but their long-term aesthetic effects remain unclear, according to Catherine M. DiGiorgio, MD, MS.

In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain, Dr. DiGiorgio, a laser and cosmetic dermatologist who practices in Boston, said at the annual Masters of Aesthetics Symposium. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from a hybrid of poly-l-lactic acid (PLLA) and polyglycolide/l-lactide (PLGA), and from polydioxanone (PDO) has led to renewed interest in thread lift procedures.

Dr. DiGiorgio

While a surgical facelift remains the gold standard, “we have some options to offer patients for noninvasive tightening,” Dr. DiGiorgio said. “We have devices that provide minimal downtime and are less costly, but results are inconsistent. Thread lifts, or suspension sutures, also have minimal downtime and are less costly, but the [results are] subtle and not long lasting.”

PLGA/PLLA threads consist of an 18% PLGA and 82% PLLA monofilament with bidirectional cones that shift the tissue. They are available in 8, 12, or 16 cones spaced 5-8 mm apart on either side of a 2-cm central cone-free area. “There is a 12-cm, 23-gauge needle on either side of the thread, to allow for insertion,” she explained. “These cones stimulate types I and II collagen, which results in collagenesis. The skin encapsulates the cones, resulting in lasting volume and contour.”

PDO threads, meanwhile, are biodegradable by hydrolysis over 4-8 months. They are inserted with a cannula or a needle and vary based on length, diameter, twined vs. braided, coned vs. barbed, and twisted vs. smooth. “The barbed PDO threads are what I use the most,” Dr. DiGiorgio said. “They provide slight tissue repositioning by anchoring and gripping.”

In 2019, researchers in Korea published results of a study that evaluated the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model. They found that while both PDO and PLLA induced granulomatous reactions and collagen formation, PDO resulted in slightly more collagen formation than PLLA.

Dr. DiGiorgio, who transitioned to using PDO threads after first using the PLLA/PLGA threads, said that both are effective. “I find PDO threads to be easier. They’re less costly for me, they’re less costly for the patient, and the results are about equivalent.”

Absorbable threads are indicated for the cheek, jawline, neck, lips, forehead, and brow. She finds them most useful “for the lower face, below the nasolabial fold down to the jawline, for improvement of the jowls,” she said. “I don’t think they really work on the neck.”

As with any cosmetic procedure, patient selection is key. According to Dr. DiGiorgio, the patient should have specific and segmental areas of facial laxity amenable to lifting and recontouring along a straight-line vector, adequate dermal thickness, and appropriate expectations for the level of correction. “I like to re-volumize with filler before performing thread lifts to make sure that volume is restored, because you can’t really provide lift to someone with significant volume loss,” she said.
 

Procedural tips

Prior to the procedure, Dr. DiGiorgio marks the area to be treated while the patient is seated upright and holding a mirror. Then, she pulls back the amount of skin laxity the thread is going to correct. The plane of insertion for barbed threads is at the superficial musculoaponeurotic system (SMAS), and she typically uses 3-4 threads on each side of the face.

“How do you know you’re in the right plane?” If the patient is experiencing significant pain, “you’re too deep, and it’s not going to work,” she said. “You can see if the thread is too superficial as you do more of these.”

After the procedure she asks the patient to sit up prior to trimming the threads. “I take a look in the mirror with them and have them smile and make funny faces to see if there is any dimpling or crimpling, which is probably the most common side effect,” she said. “If I see that, I will pull the thread immediately, so we don’t have a problem. It’s a little uncomfortable to pull the thread but not more uncomfortable than the procedure itself, but I think it’s worth doing to avoid having a dimple or a crimple that can last up to a year.”

In her clinical experience, thread lifts last about 8-10 months. “I find that my patients will come in about once a year for this procedure, and the treated area feels tight afterward,” Dr. DiGiorgio said. “I think that sensation of feeling tight also provides satisfaction to the patient. Results are very subtle. It’s tissue repositioning; it is not a facelift. There’s not really any downtime, but further studies are required to see if threads are safe and effective in the long-term.”

In an interview after the meeting, she noted that the learning curve for thread lifts is variable, as with any new procedure a physician chooses to add to his or her practice. “It’s important to see these patients in follow-up 2 weeks after the procedure consistently, especially when someone first starts performing the procedure,” she recommended. “These patients are usually coming in to see me for other treatments, so I see them at regular 3-month intervals regardless. You begin to get a feel for what angles work and why and how to optimize the results. As with any procedure, the more experience you have performing the procedure will result in improved outcomes and improved management.”

Dr. DiGiorgio disclosed that she has been an advisory board member for Quthero and she holds stock options in the company. She is a consultant for Revelle and has received equipment from Acclaro.

Antidiabetic drug tirzepatide (Mounjaro) shows superiority over semaglutide (Ozempic, Wegovy, and Rybelsus) in controlling blood glucose as well as in the amount of weight lost, results from a meta-analysis of 22 randomized controlled trials show.

“The results indicate tirzepatide’s superior performance over subcutaneous semaglutide in managing blood sugar and achieving weight loss, making it a promising option in the pharmaceutical management of type 2 diabetes,” first author Thomas Karagiannis, MD, PhD, Aristotle University of Thessaloniki, Greece, said in an interview.

“In clinical context, the most potent doses of each drug revealed a clear difference regarding weight loss, with tirzepatide resulting in an average weight reduction that exceeded that of semaglutide by 5.7 kg (12.6 pounds),” he said.

The study is scheduled to be presented at the annual meeting of the European Association for the Study of Diabetes (EASD) in early October.

While a multitude of studies have been conducted for tirzepatide, a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 (GLP-1) receptor agonist, and semaglutide, a selective GLP-1 agonist, studies comparing the two drugs directly are lacking.

For a more comprehensive understanding of how the drugs compare, Dr. Karagiannis and colleagues conducted the meta-analysis of 22 trials, including two direct comparisons, the SURPASS-2 trial and a smaller trial, and 20 other studies comparing either semaglutide or tirzepatide with a common comparator, such as placebo, basal insulin, or other GLP-RA-1 drugs.

Overall, 18,472 participants were included in the studies.

All included studies had assessed a maintenance dose of tirzepatide of either 5, 10, or 15 mg once weekly or semaglutide at doses of 0.5, 1.0, or 2.0 mg once weekly for at least 12 weeks. All comparisons were for subcutaneous injection formulations (semaglutide can also be taken orally).
 

Blood glucose reduction

Tirzepatide at 15 mg was found to have the highest efficacy in the reduction of A1c compared with placebo, with a mean difference of –2.00%, followed by tirzepatide 10 mg (–1.86%) and semaglutide 2.0 mg (–1.62%).

All three of the tirzepatide doses had greater reductions in A1c compared with the respective low, medium, and high doses of semaglutide.

Dr. Karagiannis noted that the differences are significant: “An A1c reduction even by 0.5% is often deemed clinically important,” he said.
 

Body weight reduction comparisons

The reductions in body weight across the three drug doses were greater with tirzepatide (–10.96 kg [24.2 pounds], –8.75 kg [19.3 pounds], and –6.16 kg [13.6 pounds] for 15, 10, and 5 mg, respectively) compared with semaglutide (–5.24 kg [11.6 pounds], –4.44 kg [9.8 pounds], and –2.72 kg [6 pounds] for semaglutide 2.0, 1.0, and 0.5 mg, respectively).

In terms of drug-to-drug comparisons, tirzepatide 15 mg had a mean of 5.72 kg (12.6 pounds) greater reduction in body weight vs. semaglutide 2.0 mg; tirzepatide 10 mg had a mean of 3.52 kg (7.8 pounds) reduction vs. semaglutide 2.0 mg; and tirzepatide 5 mg had a mean of a 1.72 kg (3.8 pounds) greater reduction vs. semaglutide 1.0 mg.
 

Adverse events: Increased GI events with highest tirzepatide dose

Regarding the gastrointestinal adverse events associated with the drugs, tirzepatide 15 mg had the highest rate of the two drugs at their various doses, with a risk ratio (RR) of 3.57 compared with placebo for nausea, an RR of 4.35 for vomiting, and 2.04 for diarrhea.

There were no significant differences between the two drugs for the gastrointestinal events, with the exception of the highest dose of tirzepatide, 15 mg, which had a higher risk of vomiting vs. semaglutide 1.0 (RR 1.39) and semaglutide 0.5 mg (RR 1.85).

In addition, tirzepatide 15 mg had a higher risk vs. semaglutide 0.5 mg for nausea (RR 1.45).

There were no significant differences between the two drugs and placebo in the risk of serious adverse events.
 

Real-world applications, comparisons

Dr. Karagiannis noted that the results indicate that benefits of the efficacy of the higher tirzepatide dose need to be balanced with those potential side effects.

“Although the efficacy of the high tirzepatide dose might make it a favorable choice, its real-world application can be affected on an individual’s ability to tolerate these side effects in case they occur,” he explained.

Ultimately, “some patients may prioritize tolerability over enhanced efficacy,” he added.

Furthermore, while all three maintenance doses of tirzepatide analyzed have received marketing authorization, “to get a clearer picture of the real-world tolerance to these doses outside the context of randomized controlled trials, well-designed observational studies would be necessary,” Dr. Karagiannis said.

Among other issues of comparison with the two drugs is cost.

In a recent analysis, the cost per 1% of body weight reduction was reported to be $1,197 for high-dose tirzepatide (15 mg) vs. $1,511 for semaglutide 2.4 mg, with an overall cost of 72 weeks of therapy with tirzepatide at $17,527 compared with $22,878 for semaglutide.

Overall, patients and clinicians should consider the full range of differences and similarities between the medications, “from [their] efficacy and side effects to cost-effectiveness, long-term safety, and cardiovascular profile,” Dr. Karagiannis said.

Semaglutide is currently approved by the Food and Drug Administration for treatment of type 2 diabetes and obesity/weight loss management.

Tirzepatide has also received approval for the treatment of type 2 diabetes and its manufacturers have submitted applications for its approval for obesity/weight loss management.

Dr. Karagiannis reports no relevant financial relationships.

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

Antidiabetic drug tirzepatide (Mounjaro) shows superiority over semaglutide (Ozempic, Wegovy, and Rybelsus) in controlling blood glucose as well as in the amount of weight lost, results from a meta-analysis of 22 randomized controlled trials show.

“The results indicate tirzepatide’s superior performance over subcutaneous semaglutide in managing blood sugar and achieving weight loss, making it a promising option in the pharmaceutical management of type 2 diabetes,” first author Thomas Karagiannis, MD, PhD, Aristotle University of Thessaloniki, Greece, said in an interview.

“In clinical context, the most potent doses of each drug revealed a clear difference regarding weight loss, with tirzepatide resulting in an average weight reduction that exceeded that of semaglutide by 5.7 kg (12.6 pounds),” he said.

The study is scheduled to be presented at the annual meeting of the European Association for the Study of Diabetes (EASD) in early October.

While a multitude of studies have been conducted for tirzepatide, a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 (GLP-1) receptor agonist, and semaglutide, a selective GLP-1 agonist, studies comparing the two drugs directly are lacking.

For a more comprehensive understanding of how the drugs compare, Dr. Karagiannis and colleagues conducted the meta-analysis of 22 trials, including two direct comparisons, the SURPASS-2 trial and a smaller trial, and 20 other studies comparing either semaglutide or tirzepatide with a common comparator, such as placebo, basal insulin, or other GLP-RA-1 drugs.

Overall, 18,472 participants were included in the studies.

All included studies had assessed a maintenance dose of tirzepatide of either 5, 10, or 15 mg once weekly or semaglutide at doses of 0.5, 1.0, or 2.0 mg once weekly for at least 12 weeks. All comparisons were for subcutaneous injection formulations (semaglutide can also be taken orally).
 

Blood glucose reduction

Tirzepatide at 15 mg was found to have the highest efficacy in the reduction of A1c compared with placebo, with a mean difference of –2.00%, followed by tirzepatide 10 mg (–1.86%) and semaglutide 2.0 mg (–1.62%).

All three of the tirzepatide doses had greater reductions in A1c compared with the respective low, medium, and high doses of semaglutide.

Dr. Karagiannis noted that the differences are significant: “An A1c reduction even by 0.5% is often deemed clinically important,” he said.
 

Body weight reduction comparisons

The reductions in body weight across the three drug doses were greater with tirzepatide (–10.96 kg [24.2 pounds], –8.75 kg [19.3 pounds], and –6.16 kg [13.6 pounds] for 15, 10, and 5 mg, respectively) compared with semaglutide (–5.24 kg [11.6 pounds], –4.44 kg [9.8 pounds], and –2.72 kg [6 pounds] for semaglutide 2.0, 1.0, and 0.5 mg, respectively).

In terms of drug-to-drug comparisons, tirzepatide 15 mg had a mean of 5.72 kg (12.6 pounds) greater reduction in body weight vs. semaglutide 2.0 mg; tirzepatide 10 mg had a mean of 3.52 kg (7.8 pounds) reduction vs. semaglutide 2.0 mg; and tirzepatide 5 mg had a mean of a 1.72 kg (3.8 pounds) greater reduction vs. semaglutide 1.0 mg.
 

Adverse events: Increased GI events with highest tirzepatide dose

Regarding the gastrointestinal adverse events associated with the drugs, tirzepatide 15 mg had the highest rate of the two drugs at their various doses, with a risk ratio (RR) of 3.57 compared with placebo for nausea, an RR of 4.35 for vomiting, and 2.04 for diarrhea.

There were no significant differences between the two drugs for the gastrointestinal events, with the exception of the highest dose of tirzepatide, 15 mg, which had a higher risk of vomiting vs. semaglutide 1.0 (RR 1.39) and semaglutide 0.5 mg (RR 1.85).

In addition, tirzepatide 15 mg had a higher risk vs. semaglutide 0.5 mg for nausea (RR 1.45).

There were no significant differences between the two drugs and placebo in the risk of serious adverse events.
 

Real-world applications, comparisons

Dr. Karagiannis noted that the results indicate that benefits of the efficacy of the higher tirzepatide dose need to be balanced with those potential side effects.

“Although the efficacy of the high tirzepatide dose might make it a favorable choice, its real-world application can be affected on an individual’s ability to tolerate these side effects in case they occur,” he explained.

Ultimately, “some patients may prioritize tolerability over enhanced efficacy,” he added.

Furthermore, while all three maintenance doses of tirzepatide analyzed have received marketing authorization, “to get a clearer picture of the real-world tolerance to these doses outside the context of randomized controlled trials, well-designed observational studies would be necessary,” Dr. Karagiannis said.

Among other issues of comparison with the two drugs is cost.

In a recent analysis, the cost per 1% of body weight reduction was reported to be $1,197 for high-dose tirzepatide (15 mg) vs. $1,511 for semaglutide 2.4 mg, with an overall cost of 72 weeks of therapy with tirzepatide at $17,527 compared with $22,878 for semaglutide.

Overall, patients and clinicians should consider the full range of differences and similarities between the medications, “from [their] efficacy and side effects to cost-effectiveness, long-term safety, and cardiovascular profile,” Dr. Karagiannis said.

Semaglutide is currently approved by the Food and Drug Administration for treatment of type 2 diabetes and obesity/weight loss management.

Tirzepatide has also received approval for the treatment of type 2 diabetes and its manufacturers have submitted applications for its approval for obesity/weight loss management.

Dr. Karagiannis reports no relevant financial relationships.

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

Antidiabetic drug tirzepatide (Mounjaro) shows superiority over semaglutide (Ozempic, Wegovy, and Rybelsus) in controlling blood glucose as well as in the amount of weight lost, results from a meta-analysis of 22 randomized controlled trials show.

“The results indicate tirzepatide’s superior performance over subcutaneous semaglutide in managing blood sugar and achieving weight loss, making it a promising option in the pharmaceutical management of type 2 diabetes,” first author Thomas Karagiannis, MD, PhD, Aristotle University of Thessaloniki, Greece, said in an interview.

“In clinical context, the most potent doses of each drug revealed a clear difference regarding weight loss, with tirzepatide resulting in an average weight reduction that exceeded that of semaglutide by 5.7 kg (12.6 pounds),” he said.

The study is scheduled to be presented at the annual meeting of the European Association for the Study of Diabetes (EASD) in early October.

While a multitude of studies have been conducted for tirzepatide, a dual glucose-dependent insulinotropic polypeptide and glucagon-like peptide-1 (GLP-1) receptor agonist, and semaglutide, a selective GLP-1 agonist, studies comparing the two drugs directly are lacking.

For a more comprehensive understanding of how the drugs compare, Dr. Karagiannis and colleagues conducted the meta-analysis of 22 trials, including two direct comparisons, the SURPASS-2 trial and a smaller trial, and 20 other studies comparing either semaglutide or tirzepatide with a common comparator, such as placebo, basal insulin, or other GLP-RA-1 drugs.

Overall, 18,472 participants were included in the studies.

All included studies had assessed a maintenance dose of tirzepatide of either 5, 10, or 15 mg once weekly or semaglutide at doses of 0.5, 1.0, or 2.0 mg once weekly for at least 12 weeks. All comparisons were for subcutaneous injection formulations (semaglutide can also be taken orally).
 

Blood glucose reduction

Tirzepatide at 15 mg was found to have the highest efficacy in the reduction of A1c compared with placebo, with a mean difference of –2.00%, followed by tirzepatide 10 mg (–1.86%) and semaglutide 2.0 mg (–1.62%).

All three of the tirzepatide doses had greater reductions in A1c compared with the respective low, medium, and high doses of semaglutide.

Dr. Karagiannis noted that the differences are significant: “An A1c reduction even by 0.5% is often deemed clinically important,” he said.
 

Body weight reduction comparisons

The reductions in body weight across the three drug doses were greater with tirzepatide (–10.96 kg [24.2 pounds], –8.75 kg [19.3 pounds], and –6.16 kg [13.6 pounds] for 15, 10, and 5 mg, respectively) compared with semaglutide (–5.24 kg [11.6 pounds], –4.44 kg [9.8 pounds], and –2.72 kg [6 pounds] for semaglutide 2.0, 1.0, and 0.5 mg, respectively).

In terms of drug-to-drug comparisons, tirzepatide 15 mg had a mean of 5.72 kg (12.6 pounds) greater reduction in body weight vs. semaglutide 2.0 mg; tirzepatide 10 mg had a mean of 3.52 kg (7.8 pounds) reduction vs. semaglutide 2.0 mg; and tirzepatide 5 mg had a mean of a 1.72 kg (3.8 pounds) greater reduction vs. semaglutide 1.0 mg.
 

Adverse events: Increased GI events with highest tirzepatide dose

Regarding the gastrointestinal adverse events associated with the drugs, tirzepatide 15 mg had the highest rate of the two drugs at their various doses, with a risk ratio (RR) of 3.57 compared with placebo for nausea, an RR of 4.35 for vomiting, and 2.04 for diarrhea.

There were no significant differences between the two drugs for the gastrointestinal events, with the exception of the highest dose of tirzepatide, 15 mg, which had a higher risk of vomiting vs. semaglutide 1.0 (RR 1.39) and semaglutide 0.5 mg (RR 1.85).

In addition, tirzepatide 15 mg had a higher risk vs. semaglutide 0.5 mg for nausea (RR 1.45).

There were no significant differences between the two drugs and placebo in the risk of serious adverse events.
 

Real-world applications, comparisons

Dr. Karagiannis noted that the results indicate that benefits of the efficacy of the higher tirzepatide dose need to be balanced with those potential side effects.

“Although the efficacy of the high tirzepatide dose might make it a favorable choice, its real-world application can be affected on an individual’s ability to tolerate these side effects in case they occur,” he explained.

Ultimately, “some patients may prioritize tolerability over enhanced efficacy,” he added.

Furthermore, while all three maintenance doses of tirzepatide analyzed have received marketing authorization, “to get a clearer picture of the real-world tolerance to these doses outside the context of randomized controlled trials, well-designed observational studies would be necessary,” Dr. Karagiannis said.

Among other issues of comparison with the two drugs is cost.

In a recent analysis, the cost per 1% of body weight reduction was reported to be $1,197 for high-dose tirzepatide (15 mg) vs. $1,511 for semaglutide 2.4 mg, with an overall cost of 72 weeks of therapy with tirzepatide at $17,527 compared with $22,878 for semaglutide.

Overall, patients and clinicians should consider the full range of differences and similarities between the medications, “from [their] efficacy and side effects to cost-effectiveness, long-term safety, and cardiovascular profile,” Dr. Karagiannis said.

Semaglutide is currently approved by the Food and Drug Administration for treatment of type 2 diabetes and obesity/weight loss management.

Tirzepatide has also received approval for the treatment of type 2 diabetes and its manufacturers have submitted applications for its approval for obesity/weight loss management.

Dr. Karagiannis reports no relevant financial relationships.

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

LEIPZIG, GERMANY – With age comes illness: Cancer, cardiovascular and neurodegenerative diseases, increased infections, and autoimmune diseases such as rheumatism become more common. This is because the immune system also ages. In the case of autoimmune diseases, this aging happens particularly quickly.

“There is this phenomenon of premature aging of the immune system,” said Cornelia Weyand, PhD, director of Stanford (Calif.) University’s Center for Translational Medicine at the German Rheumatology Congress 2023. In healthy people, the immune system begins to age at age 20. From that point on, the thymus gland, which reaches peak function at 14-15 years old, plays an increasingly minor role. “At age 50 years, the aging process of the immune system gains momentum.”

“What’s good about this is that the T and B cells age together, but all a little differently, each system by itself,” said Thomas Dörner, MD, PhD, head of consultation hours for clinical hemostaseology at the Charité University Hospitals in Berlin.

While the reduced formation of naive T cells can be attributed to the regression of the thymus gland, the naive B cells are a consequence of age-related, fatty bone marrow degeneration. The influence of adipocyte-derived tumor necrosis factor (TNF)–alpha also causes the bone marrow to develop B cells more and more weakly and slowly. “Through this [process], the preimmune range of B-cells decreases and becomes less healthy than in a young person.”
 

‘Inflamm-aging’

“In the periphery, we have identified a process we call “inflamm-aging,” where the cytokines interferon-gamma, interleukin (IL)–10, and IL-17 play a predominant role. This also alters the primary and secondary immune response,” said Dr. Dörner. Here, decreasing stimulation via the B-cell receptor by aging T-lymphocytes makes a difference.

As we age, the immune system restructures itself completely. “Protective immunity regresses and the inferior immunity emerges,” explained Dr. Weyand. Wounds heal more poorly, the protective action against infections and above all malignancies, as well as the immune response to vaccinations, decreases.

The increased occurrence of neurodegenerative, cardiovascular, and autoimmune diseases is not because of a loss of function, but rather to newly gained, undesired functions. These are associated with inflammatory changes. Hence, the term inflamm-aging.

With the B cells, functional germinal centers in the lymphoid organs and protective antibodies become rarer, and age-associated B cells accumulate. As Dr. Dörner emphasized, these cells are not under the command of the B-cell receptor and are independent of the cytokine BAFF (B-cell activating factor). Instead, they react to signals that are sent from the toll-like receptors 7 and 9.

This potentially also explains the increased development of autoantibodies in older people and the association of viral and autoimmune diseases. This means that age-associated B cells develop more frequently, such as with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus. “There are good data that show that they are triggered by infections and that they are specialized to form autoantibodies,” Dr. Weyand said about the age-associated B cells.
 

‘Bad old T cells’

Under the influence of genetic stop-and-go signals, the composition of the T-cell population also changes over the course of our lives. It becomes less diverse. T-helper cells become less common, and as a result, terminally differentiated effector memory T cells become more common. According to Dr. Weyand, herein lies the problem. “These cells are not just lazy, old cells that sit around. Unfortunately, they are also malicious. What we see in both the T- and B-cell systems is that they become increasingly innate with age,” he said. “They are not quite so precise or good.”

In turn, myeloid cells are less active in old age because of phagocytosis and antigen presentation, and they get more mutations. They are released more often from the bone marrow, produce more cytokines, and essentially contribute to inflamm-aging.
 

Power sources fail

In her cellular and microbiological investigations, Dr. Weyand has devoted a lot of time to studying why T cells age prematurely in patients with RA. The key was in the cellular microbiology. “We learned how the T-cell aging process translates into metabolic reprogramming of the T cells – how a good, strong, and protective T cell transforms into a disease-inducing T cell.”

At the center of premature T-cell aging in RA are disrupted mitochondrial function and insufficient communication of the mitochondria with the lysosomes and the endoplasmic reticulum.

T cells of RA patients (RA T cells) contain less MRE11A, compared with those in healthy people. This is a nuclease that allows the repair of breaks in DNA. If MRE11A is inhibited, then senescent T cells accumulate and form proinflammatory cytokines such as IL-B, IL-6, and TNF. “This is the trio that we rheumatologists are always concerned with.”

Since mitochondrial DNA repair is essential for maintaining mitochondrial fitness, the cellular power sources in patients with RA cannot provide as much energy in the form of adenosine triphosphate as in healthy people. Metabolically, they are not so fit, Dr. Weyand said.
 

Inflammatory cell death

In fact, all metabolic pathways in the T cells are reduced. The bioenergetic failure has consequences. “Unfortunately, as the mitochondrion ages, its DNA leaks into the cytosol,” explained Dr. Weyand. “Cells do not like this.” This is because DNA activates inflammasomes in the cytosol via caspase-1. This process results in a highly inflammatory cell death: pyroptosis. Subsequently, there is no trace of the cells in the tissue. “RA patients’ synovial tissue is a graveyard of dying T cells.”

In the lysosomes, the cells’ “intestine,” problems arise because patients with RA can no longer activate the adenosine monophosphate–activated protein kinase enzyme. It does not receive the lipid tail it needs to take its position as energy sensor on the lysosomal membrane. As a result, its antagonist, mTOR – both usually keep each other in check – gains the upper hand. According to Dr. Weyand, “mTOR has a party.” It activates and stresses the cells.

Additional changes affect the endoplasmic reticulum (ER). “This is where all of your proteins are synthesized and packaged to migrate from within to outside the cell, or to the cell membrane.” Compared with healthy T cells, RA T cells have around 50% more ER. “The less that mitochondria work, the larger the ER. It gets really fat.”

Mitochondria communicate with the ER via aspartate, oxaloacetate, and malate. In so doing, they control their size. RA T cells appear to be aspartate deficient. In animal models, amino acids had an anti-inflammatory effect.

When sequencing the mRNA bound to the ER, Dr. Weyand and her colleagues encountered the building blocks for TNF. “There is more than three times as much mRNA as TNF. It transforms these T cells into TNF superproducers,” said the rheumatologist. “No wonder this kind of cell is proinflammatory – it forms precisely that cytokine on which you focus every day.”

This article was translated from Medscape’s German edition. A version of this article first appeared on Medscape.com.

LEIPZIG, GERMANY – With age comes illness: Cancer, cardiovascular and neurodegenerative diseases, increased infections, and autoimmune diseases such as rheumatism become more common. This is because the immune system also ages. In the case of autoimmune diseases, this aging happens particularly quickly.

“There is this phenomenon of premature aging of the immune system,” said Cornelia Weyand, PhD, director of Stanford (Calif.) University’s Center for Translational Medicine at the German Rheumatology Congress 2023. In healthy people, the immune system begins to age at age 20. From that point on, the thymus gland, which reaches peak function at 14-15 years old, plays an increasingly minor role. “At age 50 years, the aging process of the immune system gains momentum.”

“What’s good about this is that the T and B cells age together, but all a little differently, each system by itself,” said Thomas Dörner, MD, PhD, head of consultation hours for clinical hemostaseology at the Charité University Hospitals in Berlin.

While the reduced formation of naive T cells can be attributed to the regression of the thymus gland, the naive B cells are a consequence of age-related, fatty bone marrow degeneration. The influence of adipocyte-derived tumor necrosis factor (TNF)–alpha also causes the bone marrow to develop B cells more and more weakly and slowly. “Through this [process], the preimmune range of B-cells decreases and becomes less healthy than in a young person.”
 

‘Inflamm-aging’

“In the periphery, we have identified a process we call “inflamm-aging,” where the cytokines interferon-gamma, interleukin (IL)–10, and IL-17 play a predominant role. This also alters the primary and secondary immune response,” said Dr. Dörner. Here, decreasing stimulation via the B-cell receptor by aging T-lymphocytes makes a difference.

As we age, the immune system restructures itself completely. “Protective immunity regresses and the inferior immunity emerges,” explained Dr. Weyand. Wounds heal more poorly, the protective action against infections and above all malignancies, as well as the immune response to vaccinations, decreases.

The increased occurrence of neurodegenerative, cardiovascular, and autoimmune diseases is not because of a loss of function, but rather to newly gained, undesired functions. These are associated with inflammatory changes. Hence, the term inflamm-aging.

With the B cells, functional germinal centers in the lymphoid organs and protective antibodies become rarer, and age-associated B cells accumulate. As Dr. Dörner emphasized, these cells are not under the command of the B-cell receptor and are independent of the cytokine BAFF (B-cell activating factor). Instead, they react to signals that are sent from the toll-like receptors 7 and 9.

This potentially also explains the increased development of autoantibodies in older people and the association of viral and autoimmune diseases. This means that age-associated B cells develop more frequently, such as with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus. “There are good data that show that they are triggered by infections and that they are specialized to form autoantibodies,” Dr. Weyand said about the age-associated B cells.
 

‘Bad old T cells’

Under the influence of genetic stop-and-go signals, the composition of the T-cell population also changes over the course of our lives. It becomes less diverse. T-helper cells become less common, and as a result, terminally differentiated effector memory T cells become more common. According to Dr. Weyand, herein lies the problem. “These cells are not just lazy, old cells that sit around. Unfortunately, they are also malicious. What we see in both the T- and B-cell systems is that they become increasingly innate with age,” he said. “They are not quite so precise or good.”

In turn, myeloid cells are less active in old age because of phagocytosis and antigen presentation, and they get more mutations. They are released more often from the bone marrow, produce more cytokines, and essentially contribute to inflamm-aging.
 

Power sources fail

In her cellular and microbiological investigations, Dr. Weyand has devoted a lot of time to studying why T cells age prematurely in patients with RA. The key was in the cellular microbiology. “We learned how the T-cell aging process translates into metabolic reprogramming of the T cells – how a good, strong, and protective T cell transforms into a disease-inducing T cell.”

At the center of premature T-cell aging in RA are disrupted mitochondrial function and insufficient communication of the mitochondria with the lysosomes and the endoplasmic reticulum.

T cells of RA patients (RA T cells) contain less MRE11A, compared with those in healthy people. This is a nuclease that allows the repair of breaks in DNA. If MRE11A is inhibited, then senescent T cells accumulate and form proinflammatory cytokines such as IL-B, IL-6, and TNF. “This is the trio that we rheumatologists are always concerned with.”

Since mitochondrial DNA repair is essential for maintaining mitochondrial fitness, the cellular power sources in patients with RA cannot provide as much energy in the form of adenosine triphosphate as in healthy people. Metabolically, they are not so fit, Dr. Weyand said.
 

Inflammatory cell death

In fact, all metabolic pathways in the T cells are reduced. The bioenergetic failure has consequences. “Unfortunately, as the mitochondrion ages, its DNA leaks into the cytosol,” explained Dr. Weyand. “Cells do not like this.” This is because DNA activates inflammasomes in the cytosol via caspase-1. This process results in a highly inflammatory cell death: pyroptosis. Subsequently, there is no trace of the cells in the tissue. “RA patients’ synovial tissue is a graveyard of dying T cells.”

In the lysosomes, the cells’ “intestine,” problems arise because patients with RA can no longer activate the adenosine monophosphate–activated protein kinase enzyme. It does not receive the lipid tail it needs to take its position as energy sensor on the lysosomal membrane. As a result, its antagonist, mTOR – both usually keep each other in check – gains the upper hand. According to Dr. Weyand, “mTOR has a party.” It activates and stresses the cells.

Additional changes affect the endoplasmic reticulum (ER). “This is where all of your proteins are synthesized and packaged to migrate from within to outside the cell, or to the cell membrane.” Compared with healthy T cells, RA T cells have around 50% more ER. “The less that mitochondria work, the larger the ER. It gets really fat.”

Mitochondria communicate with the ER via aspartate, oxaloacetate, and malate. In so doing, they control their size. RA T cells appear to be aspartate deficient. In animal models, amino acids had an anti-inflammatory effect.

When sequencing the mRNA bound to the ER, Dr. Weyand and her colleagues encountered the building blocks for TNF. “There is more than three times as much mRNA as TNF. It transforms these T cells into TNF superproducers,” said the rheumatologist. “No wonder this kind of cell is proinflammatory – it forms precisely that cytokine on which you focus every day.”

This article was translated from Medscape’s German edition. A version of this article first appeared on Medscape.com.

LEIPZIG, GERMANY – With age comes illness: Cancer, cardiovascular and neurodegenerative diseases, increased infections, and autoimmune diseases such as rheumatism become more common. This is because the immune system also ages. In the case of autoimmune diseases, this aging happens particularly quickly.

“There is this phenomenon of premature aging of the immune system,” said Cornelia Weyand, PhD, director of Stanford (Calif.) University’s Center for Translational Medicine at the German Rheumatology Congress 2023. In healthy people, the immune system begins to age at age 20. From that point on, the thymus gland, which reaches peak function at 14-15 years old, plays an increasingly minor role. “At age 50 years, the aging process of the immune system gains momentum.”

“What’s good about this is that the T and B cells age together, but all a little differently, each system by itself,” said Thomas Dörner, MD, PhD, head of consultation hours for clinical hemostaseology at the Charité University Hospitals in Berlin.

While the reduced formation of naive T cells can be attributed to the regression of the thymus gland, the naive B cells are a consequence of age-related, fatty bone marrow degeneration. The influence of adipocyte-derived tumor necrosis factor (TNF)–alpha also causes the bone marrow to develop B cells more and more weakly and slowly. “Through this [process], the preimmune range of B-cells decreases and becomes less healthy than in a young person.”
 

‘Inflamm-aging’

“In the periphery, we have identified a process we call “inflamm-aging,” where the cytokines interferon-gamma, interleukin (IL)–10, and IL-17 play a predominant role. This also alters the primary and secondary immune response,” said Dr. Dörner. Here, decreasing stimulation via the B-cell receptor by aging T-lymphocytes makes a difference.

As we age, the immune system restructures itself completely. “Protective immunity regresses and the inferior immunity emerges,” explained Dr. Weyand. Wounds heal more poorly, the protective action against infections and above all malignancies, as well as the immune response to vaccinations, decreases.

The increased occurrence of neurodegenerative, cardiovascular, and autoimmune diseases is not because of a loss of function, but rather to newly gained, undesired functions. These are associated with inflammatory changes. Hence, the term inflamm-aging.

With the B cells, functional germinal centers in the lymphoid organs and protective antibodies become rarer, and age-associated B cells accumulate. As Dr. Dörner emphasized, these cells are not under the command of the B-cell receptor and are independent of the cytokine BAFF (B-cell activating factor). Instead, they react to signals that are sent from the toll-like receptors 7 and 9.

This potentially also explains the increased development of autoantibodies in older people and the association of viral and autoimmune diseases. This means that age-associated B cells develop more frequently, such as with rheumatoid arthritis, scleroderma, and systemic lupus erythematosus. “There are good data that show that they are triggered by infections and that they are specialized to form autoantibodies,” Dr. Weyand said about the age-associated B cells.
 

‘Bad old T cells’

Under the influence of genetic stop-and-go signals, the composition of the T-cell population also changes over the course of our lives. It becomes less diverse. T-helper cells become less common, and as a result, terminally differentiated effector memory T cells become more common. According to Dr. Weyand, herein lies the problem. “These cells are not just lazy, old cells that sit around. Unfortunately, they are also malicious. What we see in both the T- and B-cell systems is that they become increasingly innate with age,” he said. “They are not quite so precise or good.”

In turn, myeloid cells are less active in old age because of phagocytosis and antigen presentation, and they get more mutations. They are released more often from the bone marrow, produce more cytokines, and essentially contribute to inflamm-aging.
 

Power sources fail

In her cellular and microbiological investigations, Dr. Weyand has devoted a lot of time to studying why T cells age prematurely in patients with RA. The key was in the cellular microbiology. “We learned how the T-cell aging process translates into metabolic reprogramming of the T cells – how a good, strong, and protective T cell transforms into a disease-inducing T cell.”

At the center of premature T-cell aging in RA are disrupted mitochondrial function and insufficient communication of the mitochondria with the lysosomes and the endoplasmic reticulum.

T cells of RA patients (RA T cells) contain less MRE11A, compared with those in healthy people. This is a nuclease that allows the repair of breaks in DNA. If MRE11A is inhibited, then senescent T cells accumulate and form proinflammatory cytokines such as IL-B, IL-6, and TNF. “This is the trio that we rheumatologists are always concerned with.”

Since mitochondrial DNA repair is essential for maintaining mitochondrial fitness, the cellular power sources in patients with RA cannot provide as much energy in the form of adenosine triphosphate as in healthy people. Metabolically, they are not so fit, Dr. Weyand said.
 

Inflammatory cell death

In fact, all metabolic pathways in the T cells are reduced. The bioenergetic failure has consequences. “Unfortunately, as the mitochondrion ages, its DNA leaks into the cytosol,” explained Dr. Weyand. “Cells do not like this.” This is because DNA activates inflammasomes in the cytosol via caspase-1. This process results in a highly inflammatory cell death: pyroptosis. Subsequently, there is no trace of the cells in the tissue. “RA patients’ synovial tissue is a graveyard of dying T cells.”

In the lysosomes, the cells’ “intestine,” problems arise because patients with RA can no longer activate the adenosine monophosphate–activated protein kinase enzyme. It does not receive the lipid tail it needs to take its position as energy sensor on the lysosomal membrane. As a result, its antagonist, mTOR – both usually keep each other in check – gains the upper hand. According to Dr. Weyand, “mTOR has a party.” It activates and stresses the cells.

Additional changes affect the endoplasmic reticulum (ER). “This is where all of your proteins are synthesized and packaged to migrate from within to outside the cell, or to the cell membrane.” Compared with healthy T cells, RA T cells have around 50% more ER. “The less that mitochondria work, the larger the ER. It gets really fat.”

Mitochondria communicate with the ER via aspartate, oxaloacetate, and malate. In so doing, they control their size. RA T cells appear to be aspartate deficient. In animal models, amino acids had an anti-inflammatory effect.

When sequencing the mRNA bound to the ER, Dr. Weyand and her colleagues encountered the building blocks for TNF. “There is more than three times as much mRNA as TNF. It transforms these T cells into TNF superproducers,” said the rheumatologist. “No wonder this kind of cell is proinflammatory – it forms precisely that cytokine on which you focus every day.”

This article was translated from Medscape’s German edition. A version of this article first appeared on Medscape.com.

AMSTERDAM – Calculating a patient’s myocardial performance index (MPI) and adding it to a standard risk-prediction model significantly increased prognostic accuracy for major adverse cardiovascular events (MACE), especially heart failure, in people with type 1 but not type 2 diabetes, an analysis of data from about 2,000 Danish patients shows.

“MPI provides incremental prognostic information” in people with type 1 diabetes that “may enhance risk prediction” for their future risk of all-cause death, acute coronary syndrome, heart failure, or stroke, Hashmat S.Z. Bahrami, MD, said at the annual congress of the European Society of Cardiology.

The primary analysis he reported showed a significantly elevated adjusted hazard ratio of 1.2 among people with either type 1 or type 2 diabetes and an elevated MPI, compared with those with diabetes but a lower MPI value.

Further analysis divided the study cohort into the 1,093 people with type 1 diabetes and the 1,030 with type 2 diabetes and showed that the significant association of elevated MPI with increased MACE was entirely confined to the type 1 diabetes subgroup, again with a hazard ratio of 1.2, but without any significant association among those with type 2 diabetes, said Dr. Bahrami, a cardiology researcher at Copenhagen University Hospital.
 

‘Trying to figure out’ the type 1 diabetes link

“We’re still trying to figure out” the explanation for this difference based on diabetes type, Dr. Bahrami said. He speculated that it might relate to a higher incidence of heart failure among those with type 1 diabetes, or to longer duration of diabetes in the type 1 subgroup.

The ability of elevated MPI to predict an increased risk specifically for heart failure was apparent in another analysis he presented that divided MACE events into the individual components of this composite. Elevated MPI significantly linked with a 1.3-fold elevated risk for heart failure in those with type 1 diabetes, but high MPI had no significant association with any of the other event types included in the MACE composite.

The researchers also assessed the incremental impact from adding MPI data to an established cardiovascular disease (CVD) risk calculator for people with type 1 diabetes, the Steno Type 1 Risk Engine, which includes nine parameters such as age, sex, blood pressure, diabetes duration, and two different measures of renal function.

This analysis showed that adding MPI significantly boosted the attributable CVD risk from an area-under-the-curve of 0.77 to an AUC of 0.79. Including MPI also boosted the AUC for risk of future heart failure from 0.77 with the existing Steno Type 1 Risk Engine to 0.83, also a significant increase.

Simultaneously with his talk at the Congress, a report on the findings was published online in the European Heart Journal Cardiovascular Imaging.
 

MPI reflects left ventricular function

MPI is calculated by adding a person’s isovolumic cardiac relaxation time to their isovolumic cardiac contraction time and dividing this by their ejection time. These time measurements come from examination with tissue Doppler M-mode echocardiography, Dr. Bahrami explained, and when assessed together reflect left ventricular function during both systolic and diastolic phases.

“MPI has been around for many years, but our technique is rather novel” and has high intra- and inter-observer reproducibility, he said. “It’s highly reproducible and feasible.”

The study included data collected prospectively from Danish adults without any known CVD enrolled in the Thousand & 1 study of people with type 1 diabetes and the Thousand & 2 study of people with type 2 diabetes. The analyses that Dr. Bahrami reported included CVD events during a median 5.3 years of follow-up.

The study received funding from Novo Nordisk. Dr. Bahrami has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

AMSTERDAM – Calculating a patient’s myocardial performance index (MPI) and adding it to a standard risk-prediction model significantly increased prognostic accuracy for major adverse cardiovascular events (MACE), especially heart failure, in people with type 1 but not type 2 diabetes, an analysis of data from about 2,000 Danish patients shows.

“MPI provides incremental prognostic information” in people with type 1 diabetes that “may enhance risk prediction” for their future risk of all-cause death, acute coronary syndrome, heart failure, or stroke, Hashmat S.Z. Bahrami, MD, said at the annual congress of the European Society of Cardiology.

The primary analysis he reported showed a significantly elevated adjusted hazard ratio of 1.2 among people with either type 1 or type 2 diabetes and an elevated MPI, compared with those with diabetes but a lower MPI value.

Further analysis divided the study cohort into the 1,093 people with type 1 diabetes and the 1,030 with type 2 diabetes and showed that the significant association of elevated MPI with increased MACE was entirely confined to the type 1 diabetes subgroup, again with a hazard ratio of 1.2, but without any significant association among those with type 2 diabetes, said Dr. Bahrami, a cardiology researcher at Copenhagen University Hospital.
 

‘Trying to figure out’ the type 1 diabetes link

“We’re still trying to figure out” the explanation for this difference based on diabetes type, Dr. Bahrami said. He speculated that it might relate to a higher incidence of heart failure among those with type 1 diabetes, or to longer duration of diabetes in the type 1 subgroup.

The ability of elevated MPI to predict an increased risk specifically for heart failure was apparent in another analysis he presented that divided MACE events into the individual components of this composite. Elevated MPI significantly linked with a 1.3-fold elevated risk for heart failure in those with type 1 diabetes, but high MPI had no significant association with any of the other event types included in the MACE composite.

The researchers also assessed the incremental impact from adding MPI data to an established cardiovascular disease (CVD) risk calculator for people with type 1 diabetes, the Steno Type 1 Risk Engine, which includes nine parameters such as age, sex, blood pressure, diabetes duration, and two different measures of renal function.

This analysis showed that adding MPI significantly boosted the attributable CVD risk from an area-under-the-curve of 0.77 to an AUC of 0.79. Including MPI also boosted the AUC for risk of future heart failure from 0.77 with the existing Steno Type 1 Risk Engine to 0.83, also a significant increase.

Simultaneously with his talk at the Congress, a report on the findings was published online in the European Heart Journal Cardiovascular Imaging.
 

MPI reflects left ventricular function

MPI is calculated by adding a person’s isovolumic cardiac relaxation time to their isovolumic cardiac contraction time and dividing this by their ejection time. These time measurements come from examination with tissue Doppler M-mode echocardiography, Dr. Bahrami explained, and when assessed together reflect left ventricular function during both systolic and diastolic phases.

“MPI has been around for many years, but our technique is rather novel” and has high intra- and inter-observer reproducibility, he said. “It’s highly reproducible and feasible.”

The study included data collected prospectively from Danish adults without any known CVD enrolled in the Thousand & 1 study of people with type 1 diabetes and the Thousand & 2 study of people with type 2 diabetes. The analyses that Dr. Bahrami reported included CVD events during a median 5.3 years of follow-up.

The study received funding from Novo Nordisk. Dr. Bahrami has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

AMSTERDAM – Calculating a patient’s myocardial performance index (MPI) and adding it to a standard risk-prediction model significantly increased prognostic accuracy for major adverse cardiovascular events (MACE), especially heart failure, in people with type 1 but not type 2 diabetes, an analysis of data from about 2,000 Danish patients shows.

“MPI provides incremental prognostic information” in people with type 1 diabetes that “may enhance risk prediction” for their future risk of all-cause death, acute coronary syndrome, heart failure, or stroke, Hashmat S.Z. Bahrami, MD, said at the annual congress of the European Society of Cardiology.

The primary analysis he reported showed a significantly elevated adjusted hazard ratio of 1.2 among people with either type 1 or type 2 diabetes and an elevated MPI, compared with those with diabetes but a lower MPI value.

Further analysis divided the study cohort into the 1,093 people with type 1 diabetes and the 1,030 with type 2 diabetes and showed that the significant association of elevated MPI with increased MACE was entirely confined to the type 1 diabetes subgroup, again with a hazard ratio of 1.2, but without any significant association among those with type 2 diabetes, said Dr. Bahrami, a cardiology researcher at Copenhagen University Hospital.
 

‘Trying to figure out’ the type 1 diabetes link

“We’re still trying to figure out” the explanation for this difference based on diabetes type, Dr. Bahrami said. He speculated that it might relate to a higher incidence of heart failure among those with type 1 diabetes, or to longer duration of diabetes in the type 1 subgroup.

The ability of elevated MPI to predict an increased risk specifically for heart failure was apparent in another analysis he presented that divided MACE events into the individual components of this composite. Elevated MPI significantly linked with a 1.3-fold elevated risk for heart failure in those with type 1 diabetes, but high MPI had no significant association with any of the other event types included in the MACE composite.

The researchers also assessed the incremental impact from adding MPI data to an established cardiovascular disease (CVD) risk calculator for people with type 1 diabetes, the Steno Type 1 Risk Engine, which includes nine parameters such as age, sex, blood pressure, diabetes duration, and two different measures of renal function.

This analysis showed that adding MPI significantly boosted the attributable CVD risk from an area-under-the-curve of 0.77 to an AUC of 0.79. Including MPI also boosted the AUC for risk of future heart failure from 0.77 with the existing Steno Type 1 Risk Engine to 0.83, also a significant increase.

Simultaneously with his talk at the Congress, a report on the findings was published online in the European Heart Journal Cardiovascular Imaging.
 

MPI reflects left ventricular function

MPI is calculated by adding a person’s isovolumic cardiac relaxation time to their isovolumic cardiac contraction time and dividing this by their ejection time. These time measurements come from examination with tissue Doppler M-mode echocardiography, Dr. Bahrami explained, and when assessed together reflect left ventricular function during both systolic and diastolic phases.

“MPI has been around for many years, but our technique is rather novel” and has high intra- and inter-observer reproducibility, he said. “It’s highly reproducible and feasible.”

The study included data collected prospectively from Danish adults without any known CVD enrolled in the Thousand & 1 study of people with type 1 diabetes and the Thousand & 2 study of people with type 2 diabetes. The analyses that Dr. Bahrami reported included CVD events during a median 5.3 years of follow-up.

The study received funding from Novo Nordisk. Dr. Bahrami has disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.

What’s in the toolbox?

Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.

“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.

Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.

“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
 

A pivotal starting point

One of the primary challenges faced by pulmonologists in the management of PPF is determining the appropriate timing for initiating treatment, a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.

Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
 

Choosing the right approach

Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.

Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.

“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
 

The role of supportive care

Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.

Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.

The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.

In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.

Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.

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

MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.

What’s in the toolbox?

Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.

“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.

Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.

“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
 

A pivotal starting point

One of the primary challenges faced by pulmonologists in the management of PPF is determining the appropriate timing for initiating treatment, a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.

Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
 

Choosing the right approach

Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.

Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.

“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
 

The role of supportive care

Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.

Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.

The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.

In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.

Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.

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

MILAN – Numerous unresolved questions surround progressive pulmonary fibrosis (PPF) treatment, according to Elisabeth Bendstrup, MD, PhD, a researcher and clinical professor in the department of clinical medicine – department of respiratory diseases and allergy, Aarhus (Denmark) University, Denmark. These questions regard the optimal timing for treatment initiation, the role of available medications, either as monotherapy or in combination, and nonpharmacologic support options.

What’s in the toolbox?

Pulmonologists who manage PPF have a range of treatment options at their disposal. This includes careful patient observation, with treatment initiation based on clinical necessity. The therapeutic arsenal comprises immunomodulatory treatments, antifibrotic agents, palliative and supportive care, and, for a minority of patients, lung transplantation.

“Once a patient is diagnosed with PPF, it is important to remember that the diagnostic criteria from the guidelines are not exactly the same of those accepted for the reimbursement of antifibrotic treatments in different countries,” Dr. Bendstrup said, suggesting that nonclinical considerations could also potentially influence the treatment choice. She spoke at the annual congress of the European Respiratory Society.

Michael Kreuter, MD, director of the Lung Center at the University Hospital in Mainz, Germany, provided insight into the introduction of antifibrotic drugs for the treatment of PPF. Drawing from nearly a decade ago when the first antifibrotic medication was approved for idiopathic pulmonary fibrosis (IPF), Dr. Kreuter noted its effectiveness in slowing disease progression, although it does not reverse it. Subsequently, the discovery that non-IPF diseases, such as rheumatoid arthritis, exhibited IPF-like behavior led to the exploration of the use of the same drugs for similar conditions, even if not IPF.

“That’s how antifibrotic treatments came into place. Now we have more trials and data to be discussed in the future,” Dr. Kreuter added. He highlighted that antifibrotic drugs are effective for several diseases. Most of those diseases are treated with different anti-inflammatory drugs, which makes it difficult to decide when to start antifibrotic therapy and how to eventually combine it with different pharmacologic approaches.
 

A pivotal starting point

One of the primary challenges faced by pulmonologists in the management of PPF is determining the appropriate timing for initiating treatment, a question only partially addressed by existing guidelines. Dr. Bendstrup advocated for a comprehensive baseline evaluation. Factors to be considered include symptom burden, the severity of lung decline, radiologic characteristics, signs of alveolar inflammation, progression risk factors, quality of life, patient preferences, and medical history. “All these should be best discussed in a multidisciplinary team, including pulmonologists, nurses, experts in palliative care, occupational physicians, and more,” she said.

Current guidelines recommend nintedanib for PPF treatment for patients who have failed standard management for fibrotic interstitial lung disease (ILD) other than IPF. However, the definition of “standard management” remains a topic of debate, and it is acknowledged that evidence-based guidance for a standard of care varies among patients. Dr. Bendstrup pointed out the limited guidance clinicians receive from these guidelines. “As clinicians, we are not left with very much help from here.”
 

Choosing the right approach

Dr. Bendstrup delved into the factors influencing the choice between antifibrotic and anti-inflammatory therapies. This decision hinges on whether the patient presents with a predominantly inflammatory or a fibrotic progressive phenotype. Certain clinical characteristics contribute to the decision. Factors such as younger age, female gender, and the presence of connective tissue disease lean toward an inflammatory phenotype. Radiologic patterns, such as organized pneumonia, hypersensitivity pneumonia, or usual interstitial pneumonia–like patterns also provide valuable clues. Additionally, genetics plays a role, with shorter telomeres indicating a more fibrotic phenotype and an increased risk of immunomodulatory treatment side effects in non-IPF ILDs.

Bendstrup referred to a recent position paper on treatment recommendations and many other studies that support the use of different treatments for patients with PPF. The authors highlighted limited evidence for immunomodulation in fibrotic ILD, though such treatment is generally used except for ILD associated with systemic sclerosis. Moreover, the guidelines conditionally recommend nintedanib and call for further research on pirfenidone in PPF.

“We need intelligent, well-designed trials looking at subgroups of patients at higher risk, maybe based on molecular identification. We also need to have good biomarkers to better classify our patients based on disease behavior and treatment response. There’s a lot of discussion of biomarkers for progression, much less – if any – on biomarkers for the response to treatment. And we need them as well,” Dr. Bendstrup said in an interview.
 

The role of supportive care

Effective PPF treatment extends beyond pharmacologic interventions. It encompasses symptom management, patient education on vaccination and smoking cessation, and fostering social support networks. Psychological support, supplemental oxygen therapy, and pulmonary rehabilitation are integral components of care.

Elisabeth Robertson, a PPF patient representative from the United Kingdom, emphasized the importance of palliative care, not just in end-of-life scenarios but throughout the patient’s journey. Palliative care encompasses symptom alleviation, enabling patients to stay at home when possible, addressing mental health, and preparing for the end of life. Such holistic care can significantly enhance the patient’s quality of life.

The cochair of the session, Marlies S. Wijsenbeek, MD, PhD, pulmonary physician and head of the ILD Centre at the Erasmus University Medical Centre, Rotterdam, the Netherlands, underscored that palliative care begins at diagnosis and involves managing symptom burdens. “Supportive care also includes nurses, as they are precious for the patients while answering their questions and can help save time for the doctors,” she said in an interview.

In the discussion on treatment decisions, experts agreed on the pivotal role of patients in decision-making. However, Dr. Kreuter highlighted two critical factors that influence successful patient-doctor interactions: the cultural backgrounds of patients and their relatives, and the attitudes of health care providers.

Dr. Bendstrup has received honoraria or consultation fees from Boehringer Ingelheim, Roche, Astra Zeneca, Chiesi, and Daiichi Sankyo. Ms. Robertson disclosed no relevant financial relationships.

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