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Dr. Tadataka “Tachi” Yamada dies at 76
Dr. Yamada had a storied career as a GI leader, educator, and mentor before his work as a biotech pharma research chief and a global health advocate with the Bill and Melinda Gates Foundation.
AGA President John Inadomi, MD, tweeted “We lost a mentor, sponsor, role model and true pioneer in gastroenterology – Honor his legacy.” You can share your remembrances on the AGA Community.
Over the years, Tachi made enormous contributions to AGA. He served on multiple committees, too numerous to list. He served on the AGA Governing Board multiple times and as president.
He was awarded the association’s highest honor, the Julius Friedenwald Medal, in 2003. At that time, Chung Owyang, MD, wrote a bio of Tachi and noted his critical role in shaping AGA and Digestive Disease Week® (DDW). He was the founding chair of the AGA Council working hard to reformat DDW into a major international event for our subspecialty. He was also among the group of AGA leaders who proposed the establishment of the AGA Foundation.
In 1996, Tachi assumed the presidency of AGA during a time of great turbulence in health care, where not only the practice but also the education and research missions of gastroenterology were threatened by change. Tachi took on the challenge with exemplary vision, energy, and intelligence.
Dan Podolsky, MD, a former AGA president commented at the time of Tachi’s Friedenwald Medal that “Tachi applied characteristic creativity and energy to all AGA activities. An inspirational leader, he was especially effective in promoting the AGA’s commitment to the career development of young gastroenterologists, promoting digestive diseases research, and as a tireless advocate for the field of gastroenterology.”
“Tachi has not only led our field, but he has been a global leader helping pharma rethink their role in global health, and helping the Gates Foundation save so many lives. He was soft-spoken but his worldwide contributions and vision will carry on. Heartfelt condolences to his family and friends,” said Bishr Omary, MD, PhD, past president of AGA Institute.
Dr. Yamada had a storied career as a GI leader, educator, and mentor before his work as a biotech pharma research chief and a global health advocate with the Bill and Melinda Gates Foundation.
AGA President John Inadomi, MD, tweeted “We lost a mentor, sponsor, role model and true pioneer in gastroenterology – Honor his legacy.” You can share your remembrances on the AGA Community.
Over the years, Tachi made enormous contributions to AGA. He served on multiple committees, too numerous to list. He served on the AGA Governing Board multiple times and as president.
He was awarded the association’s highest honor, the Julius Friedenwald Medal, in 2003. At that time, Chung Owyang, MD, wrote a bio of Tachi and noted his critical role in shaping AGA and Digestive Disease Week® (DDW). He was the founding chair of the AGA Council working hard to reformat DDW into a major international event for our subspecialty. He was also among the group of AGA leaders who proposed the establishment of the AGA Foundation.
In 1996, Tachi assumed the presidency of AGA during a time of great turbulence in health care, where not only the practice but also the education and research missions of gastroenterology were threatened by change. Tachi took on the challenge with exemplary vision, energy, and intelligence.
Dan Podolsky, MD, a former AGA president commented at the time of Tachi’s Friedenwald Medal that “Tachi applied characteristic creativity and energy to all AGA activities. An inspirational leader, he was especially effective in promoting the AGA’s commitment to the career development of young gastroenterologists, promoting digestive diseases research, and as a tireless advocate for the field of gastroenterology.”
“Tachi has not only led our field, but he has been a global leader helping pharma rethink their role in global health, and helping the Gates Foundation save so many lives. He was soft-spoken but his worldwide contributions and vision will carry on. Heartfelt condolences to his family and friends,” said Bishr Omary, MD, PhD, past president of AGA Institute.
Dr. Yamada had a storied career as a GI leader, educator, and mentor before his work as a biotech pharma research chief and a global health advocate with the Bill and Melinda Gates Foundation.
AGA President John Inadomi, MD, tweeted “We lost a mentor, sponsor, role model and true pioneer in gastroenterology – Honor his legacy.” You can share your remembrances on the AGA Community.
Over the years, Tachi made enormous contributions to AGA. He served on multiple committees, too numerous to list. He served on the AGA Governing Board multiple times and as president.
He was awarded the association’s highest honor, the Julius Friedenwald Medal, in 2003. At that time, Chung Owyang, MD, wrote a bio of Tachi and noted his critical role in shaping AGA and Digestive Disease Week® (DDW). He was the founding chair of the AGA Council working hard to reformat DDW into a major international event for our subspecialty. He was also among the group of AGA leaders who proposed the establishment of the AGA Foundation.
In 1996, Tachi assumed the presidency of AGA during a time of great turbulence in health care, where not only the practice but also the education and research missions of gastroenterology were threatened by change. Tachi took on the challenge with exemplary vision, energy, and intelligence.
Dan Podolsky, MD, a former AGA president commented at the time of Tachi’s Friedenwald Medal that “Tachi applied characteristic creativity and energy to all AGA activities. An inspirational leader, he was especially effective in promoting the AGA’s commitment to the career development of young gastroenterologists, promoting digestive diseases research, and as a tireless advocate for the field of gastroenterology.”
“Tachi has not only led our field, but he has been a global leader helping pharma rethink their role in global health, and helping the Gates Foundation save so many lives. He was soft-spoken but his worldwide contributions and vision will carry on. Heartfelt condolences to his family and friends,” said Bishr Omary, MD, PhD, past president of AGA Institute.
Should the starting age for CRC screening be lowered to 45?
Dear colleagues and friends,
The start age for colorectal cancer (CRC) screening in average-risk individuals has been relatively uncontroversial and unchallenged, until recent guidelines that recommended decreasing the start age from 50 to 45 years. In this edition of Perspectives, two renowned experts, Dr. Patel and Dr. Rabeneck, debate the pros and cons of this paradigm change. This will be my final Perspectives contribution as associate editor for GI & Hep News. Thank you very much for your support and feedback, and I hope you have all enjoyed and learned from the Perspectives debates as much as I have. As always, your feedback and suggestions for future topics are welcome and can be sent to [email protected].
Charles J. Kahi, MD, MS, AGAF, is professor of medicine at Indiana University, Indianapolis.
45 is the new 50
BY SWATI G. PATEL, MD, MS
The incidence and mortality rates of CRC in individuals under the age of 50 years, or early age–onset CRC, is increasing in the United States.1 We do not fully understand the cause of this trend; however, it has been observed in multiple Westernized countries, consistent with a birth cohort effect in which generation-specific risk factors are likely responsible.1 To address this rising burden of early age–onset CRC, multiple professional societies, including the United States Preventive Services Task Force,2 now recommend decreasing the starting age for CRC screening in average-risk individuals from 50 to 45 years. These recommendations are supported by the fact that CRC incidence in 45- to 49-year-olds is now the same as that of populations already eligible for screening; the yield of screening appears to be similar among those aged 45-49 years, compared to those aged 50-59 years; and modeling studies show that the benefits outweigh the risks and costs. These factors, along with the unique benefits of early detection and prevention in young patients, support that 45 is the new 50 when it comes to CRC screening.
CRC incidence rates among 45- to 49-year-olds now match populations that are already eligible for CRC screening. The rates among 45- to 49-year-olds now is similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed. Overall incidence rates in 45- to 49-year-olds now match incidence rates observed in 45- to 49-year-old African Americans, a population in which the American College of Gastroenterology and the U.S. Multi-Society Task Force have recommended average-risk screening beginning at age 45.
Advanced colorectal neoplasia rates in 45- to 49-year-olds are similar to rates observed in 50- to 59-year-olds. One study found that advanced colorectal neoplasia rates (including advanced colorectal polyps and adenocarcinoma) in average risk–equivalent 45- to 49-year-olds are similar rates of 50- to 54-year-old average-risk individuals.3 Similarly, a recent systematic review and meta-analysis of 17 international studies including average-risk individuals undergoing colonoscopy found no significant difference between advanced colorectal neoplasia rates in 45- to 49-years-olds compared to 50- to 59-year-olds.4 These data suggest that expanding screening to average-risk individuals aged 45-49 years will have yield similar to that of those aged 50-59.
Modeling studies show that the benefits of screening outweigh the potential harms and costs. A recent cost-effectiveness analysis showed that starting average-risk screening at age 45 years with colonoscopy would cost $33,900 per quality-adjusted life-year (QALY) or $7,700 per QALY if annual FIT is selected as the screening modality.5 These costs are less than the widely accepted willingness to pay threshold of $50,000 per QALY and less than currently accepted average-risk screening, such as annual or biennial mammograms for breast cancer screening.
Expanding screening to 45- to 49-year-olds can improve early detection of CRC and prevention of CRC. Offering screening before age 50 years provides the opportunity to detect cancers at earlier stages, which can improve overall survival. Recent data have shown an increase in CRC incidence among 50- to 54-year-olds.1 Although the etiology of the rise in this age group is likely multifactorial (low screening rates or generational risk that individuals carry with them through the birth-cohort effect), diagnosis and removal of advanced colorectal polyps among 45- to 49-year-olds can have a positive impact on reversing this trend in 50- to 54-year-olds. Furthermore, initiating conversations about CRC screening at age 45 can improve uptake of screening among 50- to 54-year-olds who may have delayed screening when first offered at age 50.
There are unique benefits of early detection and prevention of CRC in young patients. Although the absolute incidence and mortality rates associated with CRC in those aged 45-49 are significantly lower than the rates observed in those over age 50, young individuals are more likely to be in the prime of their earning and fertility potential and are more likely to be caregivers to younger and older generations. They are more likely to face material, psychological, and behavioral financial hardships, such as difficulty paying bills. Absolute incidence rates and modeling studies that do not account for these intangible effects on survivorship also do not fully reflect the societal benefit of early detection and CRC prevention in those aged 45-49 years.
There are certainly many unanswered questions about the effects of expanding CRC screening to those age 45 and older. Ongoing studies are needed to determine the cause of rising incidence, whether screening test selection and intervals should be customized for those under age 50, and how best to ensure equitable access to screening services. Finally, expanding screening to younger individuals should not detract from the critical importance of ongoing efforts to improve screening in those over age 50. As these issues are addressed by the scientific community, we cannot stand by idly when there is sufficient evidence to support that 45 is the new 50.
Dr. Patel is associate professor of medicine in the divisions of gastroenterology & hepatology at the University of Colorado and Rocky Mountain Regional Veterans Affairs Medical Center, both in Aurora, Colo. She disclosed financial relationships with Olympus America, ERBE USA, and Freenome.
References
1. Siegel RL et al. J Natl Cancer Inst. 2017. doi: 10.1093/jnci/djw322.
2. USPSTF et al. JAMA. 2021 May 18;325(19):1965-77.
3. Butterly LF et al. Am J Gastroenterol. 2021 Jan;116(1):171-9.
4. Kolb JM et al. Gastroenterology. 2021 Jun. doi: 10.1053/j.gastro.2021.06.006.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
50 is still 50
BY LINDA RABENECK, MD, MPH, FRCPC
CRC screening of women and men aged 50-75 years at average risk has contributed to the overall decrease in the incidence and mortality from the disease in the United States. In 2009, the American College of Gastroenterology recommended that CRC screening among African Americans begin at age 45 years, and a recent study from Kaiser Permanente reported favorable results from FIT screening in this group.1 In 2018 the American Cancer Society surprised the field by releasing an updated recommendation to begin CRC screening in all women and men at age 45 years (Qualified Recommendation). This spring the U.S. Preventive Services Task Force released its updated recommendation to begin screening at age 45 years (B recommendation).2 The rationale for these updated recommendations is based on new information on the epidemiology of the disease in the United States that was incorporated into updated modeling.
What was this new information? An evaluation of time trends in CRC incidence by age group showed that, although the incidence of colon and rectal cancer among those 50 years and older has been decreasing for more than 2 decades, the incidence has been increasing for those younger than 50 years. As important as these CRC incidence trends are to recognize and understand, this does not imply we should start screening everyone in the general population aged 45-49 years. We need to recognize that the absolute increase in CRC incidence in those younger than 50 years is small, that we lack empirical evidence to support such a major change in screening practice, and that we need to consider potential unintended impacts.
When the rise in incidence among younger Americans was first reported there was much discussion about what it meant. It appears that the rise in incidence is a birth cohort effect among people born in the 1960s and subsequent years. Birth cohort effects imply exposures occurring in early life or those experienced by younger generations. Sorting out what these exposures might be is an area of intense research activity currently. Regardless of the drivers of the relative increase in CRC incidence among younger persons, though, it is important to note that the absolute increase is small. What do we mean by this?
As reported by Holli Loomans-Kropp, PhD, MPH, and colleagues,3 for those under age 50 years, the age-adjusted incidence of colon cancer decreased by 0.9% annually from 1980 to 1996, and then increased by 1.3% annually from 1996 to 2016 (Figure 1). 
The figure shows that the age-adjusted incidence of rectal cancer among those under age 50 years increased by 2.3% annually since 1991. Figure 1 also shows declines in age-adjusted CRC incidence since 2001 for colon cancer and since 1998 for rectal cancer. However, note the differences in the scales on the Y axes between these two figures. Figure 2 shows this information plotted on the same scale (drawn by hand by author). To recap, these relative increases in incidence are real, but the absolute increases are small.
In addition, not surprisingly, we lack results from randomized controlled trials to support the change in CRC screening recommendation. We are just beginning to see results from other types of study design that seek to address this evidence gap. For example, a recent retrospective cohort study using information recorded in Florida databases evaluated the association between CRC incidence and undergoing colonoscopy at ages 45-49 versus 50-54 years. The authors reported a reduction in CRC incidence in both age groups.4
We also need to consider the resource implications. Lowering the age to start CRC screening to 45 years would expand the target population by greater than 20 million Americans, with all that this entails in terms of additional effort and resources, including colonoscopy. Modeling studies have shown that we would achieve greater clinical benefit with lower cost from directing these colonoscopy resources to those aged 50-75 years who are under/never screened and also ensuring follow-up colonoscopy among those with a positive FIT.5 For example, a study in a U.S. safety-net system reported that among 2,238 patients with a FIT+ followed over 1 year, only 55% underwent a colonoscopy.6
Finally, we need to reflect on existing disparities. If we turn our attention and resources to focus on all those aged 45-49 years in the general population, we risk worsening these disparities.
In conclusion, we need to redouble our efforts to reduce existing disparities in CRC screening participation among those aged 50-74 years and ensure colonoscopy follow-up in those with a FIT+ rather than divert our attention and resources to all those 45- to 49-year-olds who are at lower risk.
Dr. Rabeneck is professor of medicine at the University of Toronto. She has no conflicts of interest.
References
1. Levin TR et al. Gastroenterology. 2020 Nov;159(5):1695-704.e1.
2. U.S. Preventive Services Task Force et al. JAMA. 2021 May 18;325(19):1965-77.
3. Loomans-Kropp HA et al. J Cancer Epidemiol. 2019 Nov 11;2019:9841295.
4. Sehgal M et al. Gastroenterology. 2021 May;160(6):2018-28.e13.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
6. Issaka RB et al. Am J Gastroenterol. 2017 Feb;112(2):375-82.
Dear colleagues and friends,
The start age for colorectal cancer (CRC) screening in average-risk individuals has been relatively uncontroversial and unchallenged, until recent guidelines that recommended decreasing the start age from 50 to 45 years. In this edition of Perspectives, two renowned experts, Dr. Patel and Dr. Rabeneck, debate the pros and cons of this paradigm change. This will be my final Perspectives contribution as associate editor for GI & Hep News. Thank you very much for your support and feedback, and I hope you have all enjoyed and learned from the Perspectives debates as much as I have. As always, your feedback and suggestions for future topics are welcome and can be sent to [email protected].
Charles J. Kahi, MD, MS, AGAF, is professor of medicine at Indiana University, Indianapolis.
45 is the new 50
BY SWATI G. PATEL, MD, MS
The incidence and mortality rates of CRC in individuals under the age of 50 years, or early age–onset CRC, is increasing in the United States.1 We do not fully understand the cause of this trend; however, it has been observed in multiple Westernized countries, consistent with a birth cohort effect in which generation-specific risk factors are likely responsible.1 To address this rising burden of early age–onset CRC, multiple professional societies, including the United States Preventive Services Task Force,2 now recommend decreasing the starting age for CRC screening in average-risk individuals from 50 to 45 years. These recommendations are supported by the fact that CRC incidence in 45- to 49-year-olds is now the same as that of populations already eligible for screening; the yield of screening appears to be similar among those aged 45-49 years, compared to those aged 50-59 years; and modeling studies show that the benefits outweigh the risks and costs. These factors, along with the unique benefits of early detection and prevention in young patients, support that 45 is the new 50 when it comes to CRC screening.
CRC incidence rates among 45- to 49-year-olds now match populations that are already eligible for CRC screening. The rates among 45- to 49-year-olds now is similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed. Overall incidence rates in 45- to 49-year-olds now match incidence rates observed in 45- to 49-year-old African Americans, a population in which the American College of Gastroenterology and the U.S. Multi-Society Task Force have recommended average-risk screening beginning at age 45.
Advanced colorectal neoplasia rates in 45- to 49-year-olds are similar to rates observed in 50- to 59-year-olds. One study found that advanced colorectal neoplasia rates (including advanced colorectal polyps and adenocarcinoma) in average risk–equivalent 45- to 49-year-olds are similar rates of 50- to 54-year-old average-risk individuals.3 Similarly, a recent systematic review and meta-analysis of 17 international studies including average-risk individuals undergoing colonoscopy found no significant difference between advanced colorectal neoplasia rates in 45- to 49-years-olds compared to 50- to 59-year-olds.4 These data suggest that expanding screening to average-risk individuals aged 45-49 years will have yield similar to that of those aged 50-59.
Modeling studies show that the benefits of screening outweigh the potential harms and costs. A recent cost-effectiveness analysis showed that starting average-risk screening at age 45 years with colonoscopy would cost $33,900 per quality-adjusted life-year (QALY) or $7,700 per QALY if annual FIT is selected as the screening modality.5 These costs are less than the widely accepted willingness to pay threshold of $50,000 per QALY and less than currently accepted average-risk screening, such as annual or biennial mammograms for breast cancer screening.
Expanding screening to 45- to 49-year-olds can improve early detection of CRC and prevention of CRC. Offering screening before age 50 years provides the opportunity to detect cancers at earlier stages, which can improve overall survival. Recent data have shown an increase in CRC incidence among 50- to 54-year-olds.1 Although the etiology of the rise in this age group is likely multifactorial (low screening rates or generational risk that individuals carry with them through the birth-cohort effect), diagnosis and removal of advanced colorectal polyps among 45- to 49-year-olds can have a positive impact on reversing this trend in 50- to 54-year-olds. Furthermore, initiating conversations about CRC screening at age 45 can improve uptake of screening among 50- to 54-year-olds who may have delayed screening when first offered at age 50.
There are unique benefits of early detection and prevention of CRC in young patients. Although the absolute incidence and mortality rates associated with CRC in those aged 45-49 are significantly lower than the rates observed in those over age 50, young individuals are more likely to be in the prime of their earning and fertility potential and are more likely to be caregivers to younger and older generations. They are more likely to face material, psychological, and behavioral financial hardships, such as difficulty paying bills. Absolute incidence rates and modeling studies that do not account for these intangible effects on survivorship also do not fully reflect the societal benefit of early detection and CRC prevention in those aged 45-49 years.
There are certainly many unanswered questions about the effects of expanding CRC screening to those age 45 and older. Ongoing studies are needed to determine the cause of rising incidence, whether screening test selection and intervals should be customized for those under age 50, and how best to ensure equitable access to screening services. Finally, expanding screening to younger individuals should not detract from the critical importance of ongoing efforts to improve screening in those over age 50. As these issues are addressed by the scientific community, we cannot stand by idly when there is sufficient evidence to support that 45 is the new 50.
Dr. Patel is associate professor of medicine in the divisions of gastroenterology & hepatology at the University of Colorado and Rocky Mountain Regional Veterans Affairs Medical Center, both in Aurora, Colo. She disclosed financial relationships with Olympus America, ERBE USA, and Freenome.
References
1. Siegel RL et al. J Natl Cancer Inst. 2017. doi: 10.1093/jnci/djw322.
2. USPSTF et al. JAMA. 2021 May 18;325(19):1965-77.
3. Butterly LF et al. Am J Gastroenterol. 2021 Jan;116(1):171-9.
4. Kolb JM et al. Gastroenterology. 2021 Jun. doi: 10.1053/j.gastro.2021.06.006.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
50 is still 50
BY LINDA RABENECK, MD, MPH, FRCPC
CRC screening of women and men aged 50-75 years at average risk has contributed to the overall decrease in the incidence and mortality from the disease in the United States. In 2009, the American College of Gastroenterology recommended that CRC screening among African Americans begin at age 45 years, and a recent study from Kaiser Permanente reported favorable results from FIT screening in this group.1 In 2018 the American Cancer Society surprised the field by releasing an updated recommendation to begin CRC screening in all women and men at age 45 years (Qualified Recommendation). This spring the U.S. Preventive Services Task Force released its updated recommendation to begin screening at age 45 years (B recommendation).2 The rationale for these updated recommendations is based on new information on the epidemiology of the disease in the United States that was incorporated into updated modeling.
What was this new information? An evaluation of time trends in CRC incidence by age group showed that, although the incidence of colon and rectal cancer among those 50 years and older has been decreasing for more than 2 decades, the incidence has been increasing for those younger than 50 years. As important as these CRC incidence trends are to recognize and understand, this does not imply we should start screening everyone in the general population aged 45-49 years. We need to recognize that the absolute increase in CRC incidence in those younger than 50 years is small, that we lack empirical evidence to support such a major change in screening practice, and that we need to consider potential unintended impacts.
When the rise in incidence among younger Americans was first reported there was much discussion about what it meant. It appears that the rise in incidence is a birth cohort effect among people born in the 1960s and subsequent years. Birth cohort effects imply exposures occurring in early life or those experienced by younger generations. Sorting out what these exposures might be is an area of intense research activity currently. Regardless of the drivers of the relative increase in CRC incidence among younger persons, though, it is important to note that the absolute increase is small. What do we mean by this?
As reported by Holli Loomans-Kropp, PhD, MPH, and colleagues,3 for those under age 50 years, the age-adjusted incidence of colon cancer decreased by 0.9% annually from 1980 to 1996, and then increased by 1.3% annually from 1996 to 2016 (Figure 1).
The figure shows that the age-adjusted incidence of rectal cancer among those under age 50 years increased by 2.3% annually since 1991. Figure 1 also shows declines in age-adjusted CRC incidence since 2001 for colon cancer and since 1998 for rectal cancer. However, note the differences in the scales on the Y axes between these two figures. Figure 2 shows this information plotted on the same scale (drawn by hand by author). To recap, these relative increases in incidence are real, but the absolute increases are small.
In addition, not surprisingly, we lack results from randomized controlled trials to support the change in CRC screening recommendation. We are just beginning to see results from other types of study design that seek to address this evidence gap. For example, a recent retrospective cohort study using information recorded in Florida databases evaluated the association between CRC incidence and undergoing colonoscopy at ages 45-49 versus 50-54 years. The authors reported a reduction in CRC incidence in both age groups.4
We also need to consider the resource implications. Lowering the age to start CRC screening to 45 years would expand the target population by greater than 20 million Americans, with all that this entails in terms of additional effort and resources, including colonoscopy. Modeling studies have shown that we would achieve greater clinical benefit with lower cost from directing these colonoscopy resources to those aged 50-75 years who are under/never screened and also ensuring follow-up colonoscopy among those with a positive FIT.5 For example, a study in a U.S. safety-net system reported that among 2,238 patients with a FIT+ followed over 1 year, only 55% underwent a colonoscopy.6
Finally, we need to reflect on existing disparities. If we turn our attention and resources to focus on all those aged 45-49 years in the general population, we risk worsening these disparities.
In conclusion, we need to redouble our efforts to reduce existing disparities in CRC screening participation among those aged 50-74 years and ensure colonoscopy follow-up in those with a FIT+ rather than divert our attention and resources to all those 45- to 49-year-olds who are at lower risk.
Dr. Rabeneck is professor of medicine at the University of Toronto. She has no conflicts of interest.
References
1. Levin TR et al. Gastroenterology. 2020 Nov;159(5):1695-704.e1.
2. U.S. Preventive Services Task Force et al. JAMA. 2021 May 18;325(19):1965-77.
3. Loomans-Kropp HA et al. J Cancer Epidemiol. 2019 Nov 11;2019:9841295.
4. Sehgal M et al. Gastroenterology. 2021 May;160(6):2018-28.e13.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
6. Issaka RB et al. Am J Gastroenterol. 2017 Feb;112(2):375-82.
Dear colleagues and friends,
The start age for colorectal cancer (CRC) screening in average-risk individuals has been relatively uncontroversial and unchallenged, until recent guidelines that recommended decreasing the start age from 50 to 45 years. In this edition of Perspectives, two renowned experts, Dr. Patel and Dr. Rabeneck, debate the pros and cons of this paradigm change. This will be my final Perspectives contribution as associate editor for GI & Hep News. Thank you very much for your support and feedback, and I hope you have all enjoyed and learned from the Perspectives debates as much as I have. As always, your feedback and suggestions for future topics are welcome and can be sent to [email protected].
Charles J. Kahi, MD, MS, AGAF, is professor of medicine at Indiana University, Indianapolis.
45 is the new 50
BY SWATI G. PATEL, MD, MS
The incidence and mortality rates of CRC in individuals under the age of 50 years, or early age–onset CRC, is increasing in the United States.1 We do not fully understand the cause of this trend; however, it has been observed in multiple Westernized countries, consistent with a birth cohort effect in which generation-specific risk factors are likely responsible.1 To address this rising burden of early age–onset CRC, multiple professional societies, including the United States Preventive Services Task Force,2 now recommend decreasing the starting age for CRC screening in average-risk individuals from 50 to 45 years. These recommendations are supported by the fact that CRC incidence in 45- to 49-year-olds is now the same as that of populations already eligible for screening; the yield of screening appears to be similar among those aged 45-49 years, compared to those aged 50-59 years; and modeling studies show that the benefits outweigh the risks and costs. These factors, along with the unique benefits of early detection and prevention in young patients, support that 45 is the new 50 when it comes to CRC screening.
CRC incidence rates among 45- to 49-year-olds now match populations that are already eligible for CRC screening. The rates among 45- to 49-year-olds now is similar to the incidence rates observed in 50-year-olds in 1992, before widespread CRC screening was performed. Overall incidence rates in 45- to 49-year-olds now match incidence rates observed in 45- to 49-year-old African Americans, a population in which the American College of Gastroenterology and the U.S. Multi-Society Task Force have recommended average-risk screening beginning at age 45.
Advanced colorectal neoplasia rates in 45- to 49-year-olds are similar to rates observed in 50- to 59-year-olds. One study found that advanced colorectal neoplasia rates (including advanced colorectal polyps and adenocarcinoma) in average risk–equivalent 45- to 49-year-olds are similar rates of 50- to 54-year-old average-risk individuals.3 Similarly, a recent systematic review and meta-analysis of 17 international studies including average-risk individuals undergoing colonoscopy found no significant difference between advanced colorectal neoplasia rates in 45- to 49-years-olds compared to 50- to 59-year-olds.4 These data suggest that expanding screening to average-risk individuals aged 45-49 years will have yield similar to that of those aged 50-59.
Modeling studies show that the benefits of screening outweigh the potential harms and costs. A recent cost-effectiveness analysis showed that starting average-risk screening at age 45 years with colonoscopy would cost $33,900 per quality-adjusted life-year (QALY) or $7,700 per QALY if annual FIT is selected as the screening modality.5 These costs are less than the widely accepted willingness to pay threshold of $50,000 per QALY and less than currently accepted average-risk screening, such as annual or biennial mammograms for breast cancer screening.
Expanding screening to 45- to 49-year-olds can improve early detection of CRC and prevention of CRC. Offering screening before age 50 years provides the opportunity to detect cancers at earlier stages, which can improve overall survival. Recent data have shown an increase in CRC incidence among 50- to 54-year-olds.1 Although the etiology of the rise in this age group is likely multifactorial (low screening rates or generational risk that individuals carry with them through the birth-cohort effect), diagnosis and removal of advanced colorectal polyps among 45- to 49-year-olds can have a positive impact on reversing this trend in 50- to 54-year-olds. Furthermore, initiating conversations about CRC screening at age 45 can improve uptake of screening among 50- to 54-year-olds who may have delayed screening when first offered at age 50.
There are unique benefits of early detection and prevention of CRC in young patients. Although the absolute incidence and mortality rates associated with CRC in those aged 45-49 are significantly lower than the rates observed in those over age 50, young individuals are more likely to be in the prime of their earning and fertility potential and are more likely to be caregivers to younger and older generations. They are more likely to face material, psychological, and behavioral financial hardships, such as difficulty paying bills. Absolute incidence rates and modeling studies that do not account for these intangible effects on survivorship also do not fully reflect the societal benefit of early detection and CRC prevention in those aged 45-49 years.
There are certainly many unanswered questions about the effects of expanding CRC screening to those age 45 and older. Ongoing studies are needed to determine the cause of rising incidence, whether screening test selection and intervals should be customized for those under age 50, and how best to ensure equitable access to screening services. Finally, expanding screening to younger individuals should not detract from the critical importance of ongoing efforts to improve screening in those over age 50. As these issues are addressed by the scientific community, we cannot stand by idly when there is sufficient evidence to support that 45 is the new 50.
Dr. Patel is associate professor of medicine in the divisions of gastroenterology & hepatology at the University of Colorado and Rocky Mountain Regional Veterans Affairs Medical Center, both in Aurora, Colo. She disclosed financial relationships with Olympus America, ERBE USA, and Freenome.
References
1. Siegel RL et al. J Natl Cancer Inst. 2017. doi: 10.1093/jnci/djw322.
2. USPSTF et al. JAMA. 2021 May 18;325(19):1965-77.
3. Butterly LF et al. Am J Gastroenterol. 2021 Jan;116(1):171-9.
4. Kolb JM et al. Gastroenterology. 2021 Jun. doi: 10.1053/j.gastro.2021.06.006.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
50 is still 50
BY LINDA RABENECK, MD, MPH, FRCPC
CRC screening of women and men aged 50-75 years at average risk has contributed to the overall decrease in the incidence and mortality from the disease in the United States. In 2009, the American College of Gastroenterology recommended that CRC screening among African Americans begin at age 45 years, and a recent study from Kaiser Permanente reported favorable results from FIT screening in this group.1 In 2018 the American Cancer Society surprised the field by releasing an updated recommendation to begin CRC screening in all women and men at age 45 years (Qualified Recommendation). This spring the U.S. Preventive Services Task Force released its updated recommendation to begin screening at age 45 years (B recommendation).2 The rationale for these updated recommendations is based on new information on the epidemiology of the disease in the United States that was incorporated into updated modeling.
What was this new information? An evaluation of time trends in CRC incidence by age group showed that, although the incidence of colon and rectal cancer among those 50 years and older has been decreasing for more than 2 decades, the incidence has been increasing for those younger than 50 years. As important as these CRC incidence trends are to recognize and understand, this does not imply we should start screening everyone in the general population aged 45-49 years. We need to recognize that the absolute increase in CRC incidence in those younger than 50 years is small, that we lack empirical evidence to support such a major change in screening practice, and that we need to consider potential unintended impacts.
When the rise in incidence among younger Americans was first reported there was much discussion about what it meant. It appears that the rise in incidence is a birth cohort effect among people born in the 1960s and subsequent years. Birth cohort effects imply exposures occurring in early life or those experienced by younger generations. Sorting out what these exposures might be is an area of intense research activity currently. Regardless of the drivers of the relative increase in CRC incidence among younger persons, though, it is important to note that the absolute increase is small. What do we mean by this?
As reported by Holli Loomans-Kropp, PhD, MPH, and colleagues,3 for those under age 50 years, the age-adjusted incidence of colon cancer decreased by 0.9% annually from 1980 to 1996, and then increased by 1.3% annually from 1996 to 2016 (Figure 1).
The figure shows that the age-adjusted incidence of rectal cancer among those under age 50 years increased by 2.3% annually since 1991. Figure 1 also shows declines in age-adjusted CRC incidence since 2001 for colon cancer and since 1998 for rectal cancer. However, note the differences in the scales on the Y axes between these two figures. Figure 2 shows this information plotted on the same scale (drawn by hand by author). To recap, these relative increases in incidence are real, but the absolute increases are small.
In addition, not surprisingly, we lack results from randomized controlled trials to support the change in CRC screening recommendation. We are just beginning to see results from other types of study design that seek to address this evidence gap. For example, a recent retrospective cohort study using information recorded in Florida databases evaluated the association between CRC incidence and undergoing colonoscopy at ages 45-49 versus 50-54 years. The authors reported a reduction in CRC incidence in both age groups.4
We also need to consider the resource implications. Lowering the age to start CRC screening to 45 years would expand the target population by greater than 20 million Americans, with all that this entails in terms of additional effort and resources, including colonoscopy. Modeling studies have shown that we would achieve greater clinical benefit with lower cost from directing these colonoscopy resources to those aged 50-75 years who are under/never screened and also ensuring follow-up colonoscopy among those with a positive FIT.5 For example, a study in a U.S. safety-net system reported that among 2,238 patients with a FIT+ followed over 1 year, only 55% underwent a colonoscopy.6
Finally, we need to reflect on existing disparities. If we turn our attention and resources to focus on all those aged 45-49 years in the general population, we risk worsening these disparities.
In conclusion, we need to redouble our efforts to reduce existing disparities in CRC screening participation among those aged 50-74 years and ensure colonoscopy follow-up in those with a FIT+ rather than divert our attention and resources to all those 45- to 49-year-olds who are at lower risk.
Dr. Rabeneck is professor of medicine at the University of Toronto. She has no conflicts of interest.
References
1. Levin TR et al. Gastroenterology. 2020 Nov;159(5):1695-704.e1.
2. U.S. Preventive Services Task Force et al. JAMA. 2021 May 18;325(19):1965-77.
3. Loomans-Kropp HA et al. J Cancer Epidemiol. 2019 Nov 11;2019:9841295.
4. Sehgal M et al. Gastroenterology. 2021 May;160(6):2018-28.e13.
5. Ladabaum U et al. Gastroenterology. 2019 Jul;157(1):137-48.
6. Issaka RB et al. Am J Gastroenterol. 2017 Feb;112(2):375-82.
AGA Advocacy Day
Whether you’re a clinician or researcher,
Help us elevate the GI perspective by participating in AGA Advocacy Day on Thursday, Sept. 23, 2021, from 9 a.m. to 4 p.m. EDT. This is a unique opportunity for you to virtually meet with federal legislators to share your experiences and show how supporting the needs of GIs and our patients impacts the community they represent.
No prior advocacy experience needed! AGA staff will supply key talking points on a variety of health care policies and provide plenty of training to help you tell your story in a way that inspires and influences policymakers.
Your participation on this day – no matter how long – is vital to our success. If you can’t attend meetings the entire day, then share your availability during registration and we’ll arrange meetings around your busy schedule.
Save your spot.
Whether you’re a clinician or researcher,
Help us elevate the GI perspective by participating in AGA Advocacy Day on Thursday, Sept. 23, 2021, from 9 a.m. to 4 p.m. EDT. This is a unique opportunity for you to virtually meet with federal legislators to share your experiences and show how supporting the needs of GIs and our patients impacts the community they represent.
No prior advocacy experience needed! AGA staff will supply key talking points on a variety of health care policies and provide plenty of training to help you tell your story in a way that inspires and influences policymakers.
Your participation on this day – no matter how long – is vital to our success. If you can’t attend meetings the entire day, then share your availability during registration and we’ll arrange meetings around your busy schedule.
Save your spot.
Whether you’re a clinician or researcher,
Help us elevate the GI perspective by participating in AGA Advocacy Day on Thursday, Sept. 23, 2021, from 9 a.m. to 4 p.m. EDT. This is a unique opportunity for you to virtually meet with federal legislators to share your experiences and show how supporting the needs of GIs and our patients impacts the community they represent.
No prior advocacy experience needed! AGA staff will supply key talking points on a variety of health care policies and provide plenty of training to help you tell your story in a way that inspires and influences policymakers.
Your participation on this day – no matter how long – is vital to our success. If you can’t attend meetings the entire day, then share your availability during registration and we’ll arrange meetings around your busy schedule.
Save your spot.
Confronting the NASH epidemic together
. The recommendations from this meeting have been copublished in Gastroenterology along with three other leading journals: Diabetes Care, Metabolism: Clinical and Experimental, and Obesity: The Journal of the Obesity Society.
Key findings from this special report include the following:
- Patients with obesity or type 2 diabetes are at a higher risk of developing NAFLD/NASH with diabetes being a major risk factor for worse disease severity and progression to cirrhosis (permanent damage to the liver).
- Primary care providers are critical to managing this growing epidemic. They should be the first line for screening patients at risk, stratifying patients based on their risk for advanced fibrosis, and providing effective management and referrals.
- The guiding principle for risk stratification is to rule out advanced fibrosis by simple, noninvasive fibrosis scores (such as NAFLD fibrosis score or Fibrosis-4 Index). Patients at intermediate or high risk may require further assessment with a second-line test – evaluation with elastography or by serum marker test with direct measures of fibrogenesis.
- Because NAFLD is not an isolated disease but a component of cardiometabolic abnormalities typically associated with obesity, insulin resistance, and type 2 diabetes, the cornerstone of therapy is lifestyle-based therapies (altered diet – such as reduced-calorie or Mediterranean diets – and regular, moderate physical activity), as well as replacing obesogenic medications, to decrease body weight and improve cardiometabolic health. Patients with diabetes who also have NASH may benefit from certain antidiabetic medications (such as pioglitazone and semaglutide) that treat not only their diabetes but also reverse steatohepatitis and improve cardiometabolic health.
- Optimal care of patients with NAFLD and NASH requires collaboration among primary care providers, endocrinologists, diabetologists, obesity medicine specialists, gastroenterologists, and hepatologists to tackle both the liver manifestations of the disease and the comorbid metabolic syndrome and cardiovascular risk, as well as screening and treating other comorbid conditions (such as obstructive sleep apnea).
. The recommendations from this meeting have been copublished in Gastroenterology along with three other leading journals: Diabetes Care, Metabolism: Clinical and Experimental, and Obesity: The Journal of the Obesity Society.
Key findings from this special report include the following:
- Patients with obesity or type 2 diabetes are at a higher risk of developing NAFLD/NASH with diabetes being a major risk factor for worse disease severity and progression to cirrhosis (permanent damage to the liver).
- Primary care providers are critical to managing this growing epidemic. They should be the first line for screening patients at risk, stratifying patients based on their risk for advanced fibrosis, and providing effective management and referrals.
- The guiding principle for risk stratification is to rule out advanced fibrosis by simple, noninvasive fibrosis scores (such as NAFLD fibrosis score or Fibrosis-4 Index). Patients at intermediate or high risk may require further assessment with a second-line test – evaluation with elastography or by serum marker test with direct measures of fibrogenesis.
- Because NAFLD is not an isolated disease but a component of cardiometabolic abnormalities typically associated with obesity, insulin resistance, and type 2 diabetes, the cornerstone of therapy is lifestyle-based therapies (altered diet – such as reduced-calorie or Mediterranean diets – and regular, moderate physical activity), as well as replacing obesogenic medications, to decrease body weight and improve cardiometabolic health. Patients with diabetes who also have NASH may benefit from certain antidiabetic medications (such as pioglitazone and semaglutide) that treat not only their diabetes but also reverse steatohepatitis and improve cardiometabolic health.
- Optimal care of patients with NAFLD and NASH requires collaboration among primary care providers, endocrinologists, diabetologists, obesity medicine specialists, gastroenterologists, and hepatologists to tackle both the liver manifestations of the disease and the comorbid metabolic syndrome and cardiovascular risk, as well as screening and treating other comorbid conditions (such as obstructive sleep apnea).
. The recommendations from this meeting have been copublished in Gastroenterology along with three other leading journals: Diabetes Care, Metabolism: Clinical and Experimental, and Obesity: The Journal of the Obesity Society.
Key findings from this special report include the following:
- Patients with obesity or type 2 diabetes are at a higher risk of developing NAFLD/NASH with diabetes being a major risk factor for worse disease severity and progression to cirrhosis (permanent damage to the liver).
- Primary care providers are critical to managing this growing epidemic. They should be the first line for screening patients at risk, stratifying patients based on their risk for advanced fibrosis, and providing effective management and referrals.
- The guiding principle for risk stratification is to rule out advanced fibrosis by simple, noninvasive fibrosis scores (such as NAFLD fibrosis score or Fibrosis-4 Index). Patients at intermediate or high risk may require further assessment with a second-line test – evaluation with elastography or by serum marker test with direct measures of fibrogenesis.
- Because NAFLD is not an isolated disease but a component of cardiometabolic abnormalities typically associated with obesity, insulin resistance, and type 2 diabetes, the cornerstone of therapy is lifestyle-based therapies (altered diet – such as reduced-calorie or Mediterranean diets – and regular, moderate physical activity), as well as replacing obesogenic medications, to decrease body weight and improve cardiometabolic health. Patients with diabetes who also have NASH may benefit from certain antidiabetic medications (such as pioglitazone and semaglutide) that treat not only their diabetes but also reverse steatohepatitis and improve cardiometabolic health.
- Optimal care of patients with NAFLD and NASH requires collaboration among primary care providers, endocrinologists, diabetologists, obesity medicine specialists, gastroenterologists, and hepatologists to tackle both the liver manifestations of the disease and the comorbid metabolic syndrome and cardiovascular risk, as well as screening and treating other comorbid conditions (such as obstructive sleep apnea).
Politics or protection? What’s behind the push for boosters?
That plan, which was first announced on Aug. 18, has raised eyebrows because it comes in advance of regulatory reviews by the Food and Drug Administration and recommendations from the Centers for Disease Control and Prevention. Those reviews are needed to determine whether third doses of these vaccines are effective or even safe. The move could have important legal ramifications for doctors and patients, too.
On Aug. 31, two high-level officials in the FDA’s Office of Vaccines Research and Review abruptly resigned amid reports that they were angry that the Biden administration was making decisions that should be left up to that agency.
So far, data show that the vaccines are highly effective at preventing the most severe consequences of COVID-19 – hospitalization and death – even regarding the Delta variant. The World Health Organization has urged wealthy nations such as the United States not to offer boosters so that the limited supply of vaccines can be directed to countries with fewer resources.
White House supports boosters
In a recent press briefing, Jeff Zients, the White House COVID-19 response coordinator, defended the move.
“You know, the booster decision, which you referenced ... was made by and announced by the nation’s leading public health officials, including Dr. Walensky; Dr. Fauci; Surgeon General Vivek Murthy; Dr. Janet Woodcock; the FDA acting commissioner, Dr. Francis Collins; Dr. Kessler; and others,” Mr. Zients said.
“And as our medical experts laid out, having reviewed all of the available data, it is in their clinical judgment that it is time to prepare Americans for a booster shot.”
He said a target date of Sept. 20 was announced so as to give states and practitioners time to prepare. He also said the move to give boosters was meant to help the United States stay ahead of a rapidly changing virus. Mr. Zients added that whether boosters will be administered starting on Sept. 20 depends on the FDA’s and CDC’s giving the go-ahead.
“Booster doses are going to be handled the same way all vaccines are handled,” said Kristen Nordlund, a CDC spokesperson. “Companies will have to provide data to FDA. FDA will have to make a decision and authorize the use of those, and ACIP [the Advisory Committee on Immunization Practices] will have to look at the evidence as well and make recommendations on top of FDA’s regulatory action,” she said.
Ms. Nordlund agreed that the planned Sept. 20 start date for boosters was something to which they aspired and was not necessarily set.
Historically, the FDA has needed at least 4 months to review a change to a vaccine’s approval, even on an accelerated schedule. Reviewers use that time to assess data regarding individual patients in a study, to review raw data, and essentially to check a drug company’s math and conclusions. The Biden administration’s timeline would shorten that review period from months to just a few weeks.
‘FDA in a very difficult position’
After the FDA approves, the ACIP of the CDC must meet to review the evidence and make recommendations on the use of the boosters in the United States.
Pfizer says it completed its submission for a supplemental biologics license application to the FDA on Aug. 27. To meet a Sept. 20 timeline, the entire process would have to be completed within 3 weeks.
“I don’t think that was handled, you know, ideally,” said Peter Lurie, MD, president of the Center for Science in the Public Interest and former associate commissioner of public health strategy and analysis at the FDA.
“It puts FDA in a very difficult position,” Dr. Lurie said. “It’s almost as if the decision has been made and they’re just checking a box, and that is, you know, contrary to the what FDA – at least the internal people at FDA – have been trying to do for ages.”
He said the agency took great pains with the emergency use authorizations and the full approvals of the vaccines to work as rapidly but thoroughly as possible. They did not skip steps.
“I think all of that reflected very well on the agency,” Dr. Lurie said. “And I think it worked out well in terms of trust in the vaccines.”
Although additional doses of vaccine are expected to be safe, little is known about side effects or adverse events after a third dose.
“It’s critical to wait for additional data and regulatory allowance for booster doses,” Sara Oliver, MD, a member of the CDC’s epidemic intelligence service, said in an Aug. 30 presentation to the ACIP, which is charged with making recommendations for use of all vaccines in the United States.
Boosters already being given
But after the White House announced that boosters were on the way, many people are not waiting.
Many health care practitioners and pharmacies have already been giving people third doses of vaccines, even if they are not among the immunocompromised – the group for which the shots are currently approved.
“You can walk into a pharmacy and ask for a third dose. Depending on which pharmacy you go to, you may get it,” said Helen Talbot, MD, associate professor of medicine at Vanderbilt University, Nashville, Tenn., and a member of the ACIP.
She says she has a friend who recently went for a checkup and was offered a third dose. His physician is already giving extra doses to everyone who is older than 65.
Dr. Talbot said that in fairness, pharmacies in the United States are throwing away doses of vaccine because they are expiring before they get used.
“Many of us may or may not be ready to give a third dose but would rather give someone a third dose than throw a vaccine away,” she said.
Consequences of a third shot
But giving or getting a third dose before approval by the FDA may have legal consequences.
In the ACIP meeting on Aug. 30, Demetre Daskalakis, MD, who leads vaccine equity efforts at the CDC, cautioned that physicians who give extra doses of the vaccine before the FDA and CDC have signed off may be in violation of practitioner agreements with the federal government and might not be covered by the federal PREP Act. The PREP Act provides immunity from lawsuits for people who administer COVID-19 vaccines and compensates patients in the event of injury. Patients who get a vaccine and suffer a rare but serious side effect may lose the ability to claim compensation offered by the act.
“Many of us gasped when he said that,” Dr. Talbot said, “because that’s a big deal.”
The ACIP signaled that it is considering recommending boosters for a much narrower slice of the American population than the Biden administration has suggested.
They said that so far, the data point only to the need for boosters for seniors, who are the patients most likely to experience breakthrough infections that require hospitalization, and health care workers, who are needed now more than ever and cannot work if they’re sick.
In a White House news briefing Aug. 31, CDC Director Rochelle Walensky, MD, was asked about the ACIP’s conclusions and whether she believed there were enough data to recommend booster shots for most Americans 8 months after their last dose.
“The ACIP did not review international data that actually has led us to be even more concerned about increased risk of vaccine effectiveness waning against hospitalization, severe disease, and death. They will be reviewing that as well,” she said.
A version of this article first appeared on Medscape.com.
That plan, which was first announced on Aug. 18, has raised eyebrows because it comes in advance of regulatory reviews by the Food and Drug Administration and recommendations from the Centers for Disease Control and Prevention. Those reviews are needed to determine whether third doses of these vaccines are effective or even safe. The move could have important legal ramifications for doctors and patients, too.
On Aug. 31, two high-level officials in the FDA’s Office of Vaccines Research and Review abruptly resigned amid reports that they were angry that the Biden administration was making decisions that should be left up to that agency.
So far, data show that the vaccines are highly effective at preventing the most severe consequences of COVID-19 – hospitalization and death – even regarding the Delta variant. The World Health Organization has urged wealthy nations such as the United States not to offer boosters so that the limited supply of vaccines can be directed to countries with fewer resources.
White House supports boosters
In a recent press briefing, Jeff Zients, the White House COVID-19 response coordinator, defended the move.
“You know, the booster decision, which you referenced ... was made by and announced by the nation’s leading public health officials, including Dr. Walensky; Dr. Fauci; Surgeon General Vivek Murthy; Dr. Janet Woodcock; the FDA acting commissioner, Dr. Francis Collins; Dr. Kessler; and others,” Mr. Zients said.
“And as our medical experts laid out, having reviewed all of the available data, it is in their clinical judgment that it is time to prepare Americans for a booster shot.”
He said a target date of Sept. 20 was announced so as to give states and practitioners time to prepare. He also said the move to give boosters was meant to help the United States stay ahead of a rapidly changing virus. Mr. Zients added that whether boosters will be administered starting on Sept. 20 depends on the FDA’s and CDC’s giving the go-ahead.
“Booster doses are going to be handled the same way all vaccines are handled,” said Kristen Nordlund, a CDC spokesperson. “Companies will have to provide data to FDA. FDA will have to make a decision and authorize the use of those, and ACIP [the Advisory Committee on Immunization Practices] will have to look at the evidence as well and make recommendations on top of FDA’s regulatory action,” she said.
Ms. Nordlund agreed that the planned Sept. 20 start date for boosters was something to which they aspired and was not necessarily set.
Historically, the FDA has needed at least 4 months to review a change to a vaccine’s approval, even on an accelerated schedule. Reviewers use that time to assess data regarding individual patients in a study, to review raw data, and essentially to check a drug company’s math and conclusions. The Biden administration’s timeline would shorten that review period from months to just a few weeks.
‘FDA in a very difficult position’
After the FDA approves, the ACIP of the CDC must meet to review the evidence and make recommendations on the use of the boosters in the United States.
Pfizer says it completed its submission for a supplemental biologics license application to the FDA on Aug. 27. To meet a Sept. 20 timeline, the entire process would have to be completed within 3 weeks.
“I don’t think that was handled, you know, ideally,” said Peter Lurie, MD, president of the Center for Science in the Public Interest and former associate commissioner of public health strategy and analysis at the FDA.
“It puts FDA in a very difficult position,” Dr. Lurie said. “It’s almost as if the decision has been made and they’re just checking a box, and that is, you know, contrary to the what FDA – at least the internal people at FDA – have been trying to do for ages.”
He said the agency took great pains with the emergency use authorizations and the full approvals of the vaccines to work as rapidly but thoroughly as possible. They did not skip steps.
“I think all of that reflected very well on the agency,” Dr. Lurie said. “And I think it worked out well in terms of trust in the vaccines.”
Although additional doses of vaccine are expected to be safe, little is known about side effects or adverse events after a third dose.
“It’s critical to wait for additional data and regulatory allowance for booster doses,” Sara Oliver, MD, a member of the CDC’s epidemic intelligence service, said in an Aug. 30 presentation to the ACIP, which is charged with making recommendations for use of all vaccines in the United States.
Boosters already being given
But after the White House announced that boosters were on the way, many people are not waiting.
Many health care practitioners and pharmacies have already been giving people third doses of vaccines, even if they are not among the immunocompromised – the group for which the shots are currently approved.
“You can walk into a pharmacy and ask for a third dose. Depending on which pharmacy you go to, you may get it,” said Helen Talbot, MD, associate professor of medicine at Vanderbilt University, Nashville, Tenn., and a member of the ACIP.
She says she has a friend who recently went for a checkup and was offered a third dose. His physician is already giving extra doses to everyone who is older than 65.
Dr. Talbot said that in fairness, pharmacies in the United States are throwing away doses of vaccine because they are expiring before they get used.
“Many of us may or may not be ready to give a third dose but would rather give someone a third dose than throw a vaccine away,” she said.
Consequences of a third shot
But giving or getting a third dose before approval by the FDA may have legal consequences.
In the ACIP meeting on Aug. 30, Demetre Daskalakis, MD, who leads vaccine equity efforts at the CDC, cautioned that physicians who give extra doses of the vaccine before the FDA and CDC have signed off may be in violation of practitioner agreements with the federal government and might not be covered by the federal PREP Act. The PREP Act provides immunity from lawsuits for people who administer COVID-19 vaccines and compensates patients in the event of injury. Patients who get a vaccine and suffer a rare but serious side effect may lose the ability to claim compensation offered by the act.
“Many of us gasped when he said that,” Dr. Talbot said, “because that’s a big deal.”
The ACIP signaled that it is considering recommending boosters for a much narrower slice of the American population than the Biden administration has suggested.
They said that so far, the data point only to the need for boosters for seniors, who are the patients most likely to experience breakthrough infections that require hospitalization, and health care workers, who are needed now more than ever and cannot work if they’re sick.
In a White House news briefing Aug. 31, CDC Director Rochelle Walensky, MD, was asked about the ACIP’s conclusions and whether she believed there were enough data to recommend booster shots for most Americans 8 months after their last dose.
“The ACIP did not review international data that actually has led us to be even more concerned about increased risk of vaccine effectiveness waning against hospitalization, severe disease, and death. They will be reviewing that as well,” she said.
A version of this article first appeared on Medscape.com.
That plan, which was first announced on Aug. 18, has raised eyebrows because it comes in advance of regulatory reviews by the Food and Drug Administration and recommendations from the Centers for Disease Control and Prevention. Those reviews are needed to determine whether third doses of these vaccines are effective or even safe. The move could have important legal ramifications for doctors and patients, too.
On Aug. 31, two high-level officials in the FDA’s Office of Vaccines Research and Review abruptly resigned amid reports that they were angry that the Biden administration was making decisions that should be left up to that agency.
So far, data show that the vaccines are highly effective at preventing the most severe consequences of COVID-19 – hospitalization and death – even regarding the Delta variant. The World Health Organization has urged wealthy nations such as the United States not to offer boosters so that the limited supply of vaccines can be directed to countries with fewer resources.
White House supports boosters
In a recent press briefing, Jeff Zients, the White House COVID-19 response coordinator, defended the move.
“You know, the booster decision, which you referenced ... was made by and announced by the nation’s leading public health officials, including Dr. Walensky; Dr. Fauci; Surgeon General Vivek Murthy; Dr. Janet Woodcock; the FDA acting commissioner, Dr. Francis Collins; Dr. Kessler; and others,” Mr. Zients said.
“And as our medical experts laid out, having reviewed all of the available data, it is in their clinical judgment that it is time to prepare Americans for a booster shot.”
He said a target date of Sept. 20 was announced so as to give states and practitioners time to prepare. He also said the move to give boosters was meant to help the United States stay ahead of a rapidly changing virus. Mr. Zients added that whether boosters will be administered starting on Sept. 20 depends on the FDA’s and CDC’s giving the go-ahead.
“Booster doses are going to be handled the same way all vaccines are handled,” said Kristen Nordlund, a CDC spokesperson. “Companies will have to provide data to FDA. FDA will have to make a decision and authorize the use of those, and ACIP [the Advisory Committee on Immunization Practices] will have to look at the evidence as well and make recommendations on top of FDA’s regulatory action,” she said.
Ms. Nordlund agreed that the planned Sept. 20 start date for boosters was something to which they aspired and was not necessarily set.
Historically, the FDA has needed at least 4 months to review a change to a vaccine’s approval, even on an accelerated schedule. Reviewers use that time to assess data regarding individual patients in a study, to review raw data, and essentially to check a drug company’s math and conclusions. The Biden administration’s timeline would shorten that review period from months to just a few weeks.
‘FDA in a very difficult position’
After the FDA approves, the ACIP of the CDC must meet to review the evidence and make recommendations on the use of the boosters in the United States.
Pfizer says it completed its submission for a supplemental biologics license application to the FDA on Aug. 27. To meet a Sept. 20 timeline, the entire process would have to be completed within 3 weeks.
“I don’t think that was handled, you know, ideally,” said Peter Lurie, MD, president of the Center for Science in the Public Interest and former associate commissioner of public health strategy and analysis at the FDA.
“It puts FDA in a very difficult position,” Dr. Lurie said. “It’s almost as if the decision has been made and they’re just checking a box, and that is, you know, contrary to the what FDA – at least the internal people at FDA – have been trying to do for ages.”
He said the agency took great pains with the emergency use authorizations and the full approvals of the vaccines to work as rapidly but thoroughly as possible. They did not skip steps.
“I think all of that reflected very well on the agency,” Dr. Lurie said. “And I think it worked out well in terms of trust in the vaccines.”
Although additional doses of vaccine are expected to be safe, little is known about side effects or adverse events after a third dose.
“It’s critical to wait for additional data and regulatory allowance for booster doses,” Sara Oliver, MD, a member of the CDC’s epidemic intelligence service, said in an Aug. 30 presentation to the ACIP, which is charged with making recommendations for use of all vaccines in the United States.
Boosters already being given
But after the White House announced that boosters were on the way, many people are not waiting.
Many health care practitioners and pharmacies have already been giving people third doses of vaccines, even if they are not among the immunocompromised – the group for which the shots are currently approved.
“You can walk into a pharmacy and ask for a third dose. Depending on which pharmacy you go to, you may get it,” said Helen Talbot, MD, associate professor of medicine at Vanderbilt University, Nashville, Tenn., and a member of the ACIP.
She says she has a friend who recently went for a checkup and was offered a third dose. His physician is already giving extra doses to everyone who is older than 65.
Dr. Talbot said that in fairness, pharmacies in the United States are throwing away doses of vaccine because they are expiring before they get used.
“Many of us may or may not be ready to give a third dose but would rather give someone a third dose than throw a vaccine away,” she said.
Consequences of a third shot
But giving or getting a third dose before approval by the FDA may have legal consequences.
In the ACIP meeting on Aug. 30, Demetre Daskalakis, MD, who leads vaccine equity efforts at the CDC, cautioned that physicians who give extra doses of the vaccine before the FDA and CDC have signed off may be in violation of practitioner agreements with the federal government and might not be covered by the federal PREP Act. The PREP Act provides immunity from lawsuits for people who administer COVID-19 vaccines and compensates patients in the event of injury. Patients who get a vaccine and suffer a rare but serious side effect may lose the ability to claim compensation offered by the act.
“Many of us gasped when he said that,” Dr. Talbot said, “because that’s a big deal.”
The ACIP signaled that it is considering recommending boosters for a much narrower slice of the American population than the Biden administration has suggested.
They said that so far, the data point only to the need for boosters for seniors, who are the patients most likely to experience breakthrough infections that require hospitalization, and health care workers, who are needed now more than ever and cannot work if they’re sick.
In a White House news briefing Aug. 31, CDC Director Rochelle Walensky, MD, was asked about the ACIP’s conclusions and whether she believed there were enough data to recommend booster shots for most Americans 8 months after their last dose.
“The ACIP did not review international data that actually has led us to be even more concerned about increased risk of vaccine effectiveness waning against hospitalization, severe disease, and death. They will be reviewing that as well,” she said.
A version of this article first appeared on Medscape.com.
WHO tracking new COVID-19 variant called Mu
The variant, also known as B.1.621, was first identified in Colombia in January. It has now been detected in 43 countries and was added to the WHO’s “variant of interest” list Aug. 30.
“The Mu variant has a constellation of mutations that indicate potential properties of immune escape,” the WHO wrote in its weekly COVID-19 update on Aug 31.
Preliminary data suggests that the Mu variant may be able to evade antibodies at levels similar to the Beta variant, the WHO wrote, though more studies are needed. The Beta variant, also known as B.1.351, was first detected in South Africa and has shown some ability to evade vaccines.
As of Aug. 29, the global prevalence of the Mu variant appears to be less than 0.1%. But its prevalence in South America has “consistently increased,” the WHO wrote, now making up 39% of cases in Colombia and 13% of cases in Ecuador.
More than 4,700 cases of the Mu variant have been identified worldwide through genomic sequencing, according to Outbreak.info, an open-source database operated by Scripps Research. The United States has identified 2,011 of these cases, with 348 in California. As of Sept. 2, only one state -- Nebraska -- had not yet reported a Mu case.
“At the moment, it looks like there’s genuine cause for concern in USA, Central America, and South America, but as we saw with Delta, a potent variant can traverse the globe in the blink of an eye,” Danny Altmann, PhD, an immunologist at Imperial College London, told The Telegraph.
The WHO is monitoring nine variants with genetic mutations that could make them more transmissible, lead to more severe disease, and help them evade vaccines. The Delta variant, which is now a dominant form of the virus in the United States and worldwide, has led to a surge in cases and hospitalizations this summer.
In its report, the WHO said it would monitor the Mu variant for changes, “particularly with the co-circulation of the Delta variant.”
“Mu looks potentially good at immune evasion,” Dr. Altmann told The Telegraph. “For my taste, it’s a stark reminder that this isn’t by any means over. On a planet of 4.4 million-plus new infections per week, there are new variants popping up all the time, and little reason to feel complacent.”
A version of this article first appeared on WebMD.com.
The variant, also known as B.1.621, was first identified in Colombia in January. It has now been detected in 43 countries and was added to the WHO’s “variant of interest” list Aug. 30.
“The Mu variant has a constellation of mutations that indicate potential properties of immune escape,” the WHO wrote in its weekly COVID-19 update on Aug 31.
Preliminary data suggests that the Mu variant may be able to evade antibodies at levels similar to the Beta variant, the WHO wrote, though more studies are needed. The Beta variant, also known as B.1.351, was first detected in South Africa and has shown some ability to evade vaccines.
As of Aug. 29, the global prevalence of the Mu variant appears to be less than 0.1%. But its prevalence in South America has “consistently increased,” the WHO wrote, now making up 39% of cases in Colombia and 13% of cases in Ecuador.
More than 4,700 cases of the Mu variant have been identified worldwide through genomic sequencing, according to Outbreak.info, an open-source database operated by Scripps Research. The United States has identified 2,011 of these cases, with 348 in California. As of Sept. 2, only one state -- Nebraska -- had not yet reported a Mu case.
“At the moment, it looks like there’s genuine cause for concern in USA, Central America, and South America, but as we saw with Delta, a potent variant can traverse the globe in the blink of an eye,” Danny Altmann, PhD, an immunologist at Imperial College London, told The Telegraph.
The WHO is monitoring nine variants with genetic mutations that could make them more transmissible, lead to more severe disease, and help them evade vaccines. The Delta variant, which is now a dominant form of the virus in the United States and worldwide, has led to a surge in cases and hospitalizations this summer.
In its report, the WHO said it would monitor the Mu variant for changes, “particularly with the co-circulation of the Delta variant.”
“Mu looks potentially good at immune evasion,” Dr. Altmann told The Telegraph. “For my taste, it’s a stark reminder that this isn’t by any means over. On a planet of 4.4 million-plus new infections per week, there are new variants popping up all the time, and little reason to feel complacent.”
A version of this article first appeared on WebMD.com.
The variant, also known as B.1.621, was first identified in Colombia in January. It has now been detected in 43 countries and was added to the WHO’s “variant of interest” list Aug. 30.
“The Mu variant has a constellation of mutations that indicate potential properties of immune escape,” the WHO wrote in its weekly COVID-19 update on Aug 31.
Preliminary data suggests that the Mu variant may be able to evade antibodies at levels similar to the Beta variant, the WHO wrote, though more studies are needed. The Beta variant, also known as B.1.351, was first detected in South Africa and has shown some ability to evade vaccines.
As of Aug. 29, the global prevalence of the Mu variant appears to be less than 0.1%. But its prevalence in South America has “consistently increased,” the WHO wrote, now making up 39% of cases in Colombia and 13% of cases in Ecuador.
More than 4,700 cases of the Mu variant have been identified worldwide through genomic sequencing, according to Outbreak.info, an open-source database operated by Scripps Research. The United States has identified 2,011 of these cases, with 348 in California. As of Sept. 2, only one state -- Nebraska -- had not yet reported a Mu case.
“At the moment, it looks like there’s genuine cause for concern in USA, Central America, and South America, but as we saw with Delta, a potent variant can traverse the globe in the blink of an eye,” Danny Altmann, PhD, an immunologist at Imperial College London, told The Telegraph.
The WHO is monitoring nine variants with genetic mutations that could make them more transmissible, lead to more severe disease, and help them evade vaccines. The Delta variant, which is now a dominant form of the virus in the United States and worldwide, has led to a surge in cases and hospitalizations this summer.
In its report, the WHO said it would monitor the Mu variant for changes, “particularly with the co-circulation of the Delta variant.”
“Mu looks potentially good at immune evasion,” Dr. Altmann told The Telegraph. “For my taste, it’s a stark reminder that this isn’t by any means over. On a planet of 4.4 million-plus new infections per week, there are new variants popping up all the time, and little reason to feel complacent.”
A version of this article first appeared on WebMD.com.
A long look at long haulers
With the number of pediatric infections with SARS-CoV-2 rising it is not surprising that children with persistent symptoms are beginning to accumulate. Who are these pediatric “long haulers” and do they differ from their adult counterparts? The answer is far from clear because the terms “long COVID” and “long hauler” are not well defined. But, I suspect we will find that they will be similar in most respects.
In a recent Guest Essay in the New York Times, two medical school professors attempt to inject some common sense into the long hauler phenomenon. (“The Truth About Long Covid is Complicated. Better Treatment Isn’t,” Adam Gaffney and Zackary Berger, The New York Times, Aug. 18, 2021).
The authors divide the patients with long COVID into three categories. The first includes those who are complaining of persistent cough and fatigue for up to 3 months, a not unexpected course for patients recovering from a significant respiratory illness like pneumonia.
The second group comprises patients who developed acute respiratory distress syndrome during the course of their SARS-CoV-2 infection. These unfortunate individuals likely incurred lung damage that may have triggered renal damage and delirium and may never regain full function.
The third group of patients reports a wide variety of less specific symptoms including, but not limited to, severe fatigue, brain fog, shortness of breath, gastrointestinal symptoms, chronic pain, and palpitations.
The authors of the essay refer to several studies in which there was little if any correlation between these patients’ complaints and their antibody levels. In fact, one study of adolescents found that in a group with similar symptoms many of the individuals had no serologic evidence of SARS-CoV-2 infection.
Unfortunately, the lay public, the media, and some physicians make no distinction between these three groups and lump them all under the same long COVID umbrella. The resulting confusion seeds unwarranted anxiety among the first and third groups and may prevent some individuals from receiving the appropriate attention they deserve.
I suspect that like me, many of you see some similarities between this third group of long COVID patients and adolescents whose persistent symptoms don’t quite fit with their primary illness. Patients labeled as having post-concussion syndrome or “chronic Lyme disease” come immediately to mind. In both conditions, many of the patients had little if any evidence of severe insult from the initial event but continue to complain about a variety of symptoms including severe fatigue and brain fog.
We have done a very poor job of properly managing these patients. And there are a lot of them. A large part of the problem is labeling. In the old days one might have said these patients were having “psychosomatic” symptoms. But, while it may be an accurate description, like the term “retardation” it has been permanently tarnished. Fortunately, most of us are smart enough to avoid telling these patients that it is all in their heads.
However, convincing an individual that many of his symptoms may be the result of the psychological insult from the original disease compounded by other stresses and lifestyle factors can be a difficult sell. The task is made particularly difficult when there continue to be physicians who will miss or ignore the obvious and embark on therapeutic endeavors that are not only ineffective but can serve as a distraction from the real work of listening to and engaging these patients whose suffering may be just as real as that of those long haulers with structural damage.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
With the number of pediatric infections with SARS-CoV-2 rising it is not surprising that children with persistent symptoms are beginning to accumulate. Who are these pediatric “long haulers” and do they differ from their adult counterparts? The answer is far from clear because the terms “long COVID” and “long hauler” are not well defined. But, I suspect we will find that they will be similar in most respects.
In a recent Guest Essay in the New York Times, two medical school professors attempt to inject some common sense into the long hauler phenomenon. (“The Truth About Long Covid is Complicated. Better Treatment Isn’t,” Adam Gaffney and Zackary Berger, The New York Times, Aug. 18, 2021).
The authors divide the patients with long COVID into three categories. The first includes those who are complaining of persistent cough and fatigue for up to 3 months, a not unexpected course for patients recovering from a significant respiratory illness like pneumonia.
The second group comprises patients who developed acute respiratory distress syndrome during the course of their SARS-CoV-2 infection. These unfortunate individuals likely incurred lung damage that may have triggered renal damage and delirium and may never regain full function.
The third group of patients reports a wide variety of less specific symptoms including, but not limited to, severe fatigue, brain fog, shortness of breath, gastrointestinal symptoms, chronic pain, and palpitations.
The authors of the essay refer to several studies in which there was little if any correlation between these patients’ complaints and their antibody levels. In fact, one study of adolescents found that in a group with similar symptoms many of the individuals had no serologic evidence of SARS-CoV-2 infection.
Unfortunately, the lay public, the media, and some physicians make no distinction between these three groups and lump them all under the same long COVID umbrella. The resulting confusion seeds unwarranted anxiety among the first and third groups and may prevent some individuals from receiving the appropriate attention they deserve.
I suspect that like me, many of you see some similarities between this third group of long COVID patients and adolescents whose persistent symptoms don’t quite fit with their primary illness. Patients labeled as having post-concussion syndrome or “chronic Lyme disease” come immediately to mind. In both conditions, many of the patients had little if any evidence of severe insult from the initial event but continue to complain about a variety of symptoms including severe fatigue and brain fog.
We have done a very poor job of properly managing these patients. And there are a lot of them. A large part of the problem is labeling. In the old days one might have said these patients were having “psychosomatic” symptoms. But, while it may be an accurate description, like the term “retardation” it has been permanently tarnished. Fortunately, most of us are smart enough to avoid telling these patients that it is all in their heads.
However, convincing an individual that many of his symptoms may be the result of the psychological insult from the original disease compounded by other stresses and lifestyle factors can be a difficult sell. The task is made particularly difficult when there continue to be physicians who will miss or ignore the obvious and embark on therapeutic endeavors that are not only ineffective but can serve as a distraction from the real work of listening to and engaging these patients whose suffering may be just as real as that of those long haulers with structural damage.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
With the number of pediatric infections with SARS-CoV-2 rising it is not surprising that children with persistent symptoms are beginning to accumulate. Who are these pediatric “long haulers” and do they differ from their adult counterparts? The answer is far from clear because the terms “long COVID” and “long hauler” are not well defined. But, I suspect we will find that they will be similar in most respects.
In a recent Guest Essay in the New York Times, two medical school professors attempt to inject some common sense into the long hauler phenomenon. (“The Truth About Long Covid is Complicated. Better Treatment Isn’t,” Adam Gaffney and Zackary Berger, The New York Times, Aug. 18, 2021).
The authors divide the patients with long COVID into three categories. The first includes those who are complaining of persistent cough and fatigue for up to 3 months, a not unexpected course for patients recovering from a significant respiratory illness like pneumonia.
The second group comprises patients who developed acute respiratory distress syndrome during the course of their SARS-CoV-2 infection. These unfortunate individuals likely incurred lung damage that may have triggered renal damage and delirium and may never regain full function.
The third group of patients reports a wide variety of less specific symptoms including, but not limited to, severe fatigue, brain fog, shortness of breath, gastrointestinal symptoms, chronic pain, and palpitations.
The authors of the essay refer to several studies in which there was little if any correlation between these patients’ complaints and their antibody levels. In fact, one study of adolescents found that in a group with similar symptoms many of the individuals had no serologic evidence of SARS-CoV-2 infection.
Unfortunately, the lay public, the media, and some physicians make no distinction between these three groups and lump them all under the same long COVID umbrella. The resulting confusion seeds unwarranted anxiety among the first and third groups and may prevent some individuals from receiving the appropriate attention they deserve.
I suspect that like me, many of you see some similarities between this third group of long COVID patients and adolescents whose persistent symptoms don’t quite fit with their primary illness. Patients labeled as having post-concussion syndrome or “chronic Lyme disease” come immediately to mind. In both conditions, many of the patients had little if any evidence of severe insult from the initial event but continue to complain about a variety of symptoms including severe fatigue and brain fog.
We have done a very poor job of properly managing these patients. And there are a lot of them. A large part of the problem is labeling. In the old days one might have said these patients were having “psychosomatic” symptoms. But, while it may be an accurate description, like the term “retardation” it has been permanently tarnished. Fortunately, most of us are smart enough to avoid telling these patients that it is all in their heads.
However, convincing an individual that many of his symptoms may be the result of the psychological insult from the original disease compounded by other stresses and lifestyle factors can be a difficult sell. The task is made particularly difficult when there continue to be physicians who will miss or ignore the obvious and embark on therapeutic endeavors that are not only ineffective but can serve as a distraction from the real work of listening to and engaging these patients whose suffering may be just as real as that of those long haulers with structural damage.
Dr. Wilkoff practiced primary care pediatrics in Brunswick, Maine, for nearly 40 years. He has authored several books on behavioral pediatrics, including “How to Say No to Your Toddler.” Other than a Littman stethoscope he accepted as a first-year medical student in 1966, Dr. Wilkoff reports having nothing to disclose. Email him at [email protected].
COVID-19 disease may actually cause preeclampsia, suggests study
New evidence strongly suggests that COVID-19 disease causes an increased risk of preeclampsia and preterm birth in those who have an infection while pregnant, according to a retrospective observational study published in the American Journal of Obstetrics and Gynecology. Though the study was observational, its primary finding was a dose-response relationship between the severity of COVID-19 disease and the likelihood of preeclampsia or preterm birth, fulfilling a key criterion for establishing causality in an association.
“The fact that 43% (13/30) of the cases of preeclampsia diagnosed after SARS-Cov-2 infection were preterm preeclampsia (< 37 weeks) suggests that COVID-19 may be a cause for medically indicated preterm birth that contributes to the excess preterm birth delivery rate previously reported,” wrote Jonathan Lai, MD, of the Fetal Medicine Research Institute of King’s College Hospital, London, and colleagues. The study also found an increased likelihood of COVID-19 disease in those who had preeclampsia before their infection. “Whether preeclampsia can predispose COVID-19 some cases, or that the two conditions may co-occur because they share similar risk factors requires further investigation,” the authors wrote.
It’s also unclear whether the increased risk of pre-eclampsia is contributing to the higher preterm birth risk, according to Linda Eckert, MD, a professor of Ob.Gyn. at The University of Washington who specializes in maternal immunization.
“COVID is linked to preeclampsia in this study, and COVID is linked to preterm birth,” Dr. Eckert said in an interview. “The question of whether preeclampsia leading to preterm birth is also linked to infection is not possible to tease out in this study as all the factors are likely interrelated. There is a relationship between COVID and preterm birth absent preeclampsia.”
The researchers retrospectively examined data from 1,223 pregnant women who tested positive for SARS-CoV-2 between February 2020 and March 2021 at any of 14 National Health Service maternity hospitals in the United Kingdom. The researchers compared the severity of disease among the women with their risk of preeclampsia as a primary outcome, followed by the outcomes of preterm birth and gestational age at delivery.
COVID-19 infections were classified as asymptomatic, mild illness (lacking shortness of breath, dyspnea, or abnormal chest imaging), moderate illness (evidence of lower respiratory disease but an oxygen saturation of at least 94%), and severe illness (requiring “high dependency or intensive care secondary to respiratory impairment/failure or multiorgan dysfunction”).
The researchers adjusted their analysis of preeclampsia to account for prior risk of preeclampsia based on maternal characteristics and medical history. Analysis of preterm birth risk included adjustment for maternal age, weight, height, race, method of conception, chronic hypertension, smoking, and diabetes.
Preeclampsia occurred in 4.2% of the women, and 17.6% of the women had a preterm birth. In addition, 1.3% of the cohort had a miscarriage, and there were 10 (0.81%) fetal deaths. Since 21 cases of preeclampsia occurred before the women tested positive, the researchers removed those cases from the analysis. Among the remaining 30 cases, 13 women had preterm preeclampsia and 17 had term preeclampsia.
When the researchers compared the study population’s risk of preeclampsia with that of a separate population with similar risk factors, they found a dose-response increased risk in those with COVID-19 infections. While 1.9% of asymptomatic patients had preeclampsia, incidence was 2.2% in patients with mild disease, 5.7% in those with moderate disease, and 11.1% in those with severe disease. Women with severe COVID-19 tended to be older and to have a higher body mass index.
After adjustments, women were nearly five times more likely to develop preeclampsia if they had severe COVID-19 compared to women with asymptomatic infection (adjusted relative risk [aRR] = 4.9). Those with moderate or severe disease had triple the risk of preeclampsia compared to those with mild or asymptomatic infection (aRR = 3.3).
To investigate whether having preeclampsia predisposes women to develop COVID-19 disease, the researchers compared the women who had preeclampsia before their infection with women in the study who never developed preeclampsia. Although they found a trend toward higher risk of moderate or severe COVID-19 following preeclampsia, the association was not significant before or after adjustment.
The researchers also found a dose-response relationship in risk of preterm birth. While 11.7% of asymptomatic patients had preterm birth, the incidence was 12.8% in those with mild COVID-19, 29.9% in those with moderate disease, and 69.4% in those with severe disease. Women with severe disease were more than five times more likely to have a preterm birth than were women with an asymptomatic infection (aRR = 5.64), and the risk of preterm birth was 2.5 times greater in women with moderate disease (aRR = 2.47).
“Moreover, there was a dose-response relationship between gestational age at delivery and the severity of SARS-CoV-2 infection,” the authors reported. Mean gestational age at delivery was 38.7 weeks in asymptomatic women compared to 37.5 weeks for those with moderate disease and 33 weeks in those with severe disease (P < .001).
”The more severe the infection with SARS-CoV-2, the greater the risk of preeclampsia and preterm birth,” the authors wrote. “SARS-CoV-2 infection can lead to endothelial dysfunction, intravascular inflammation, proteinuria, activation of thrombin, and hypertension, which are all features of preeclampsia. Therefore, a causal relationship must be considered.”
A dose-response association is only one criterion for causality, however, so it’s still premature to say definitively that a causal relationship exists, Dr. Eckert said.
“More investigation in different populations across different ethnicities is needed before causality can be confidently assured,” she said.
Anthony Sciscione, DO, director of maternal-fetal medicine and the ob.gyn. residency at ChristianaCare in Delaware, agreed that the precise relationship between the two remains unresolved.
”We don’t know what causes preeclampsia,” but “we strongly suspect it has to do with a placental dysfunction, or endothelial dysfunction, and it’s really clear that women who get COVID have a much higher risk of preeclampsia,” Dr. Sciscione said in an interview. It’s possible that no real relationship exists between the two (or that greater surveillance of women with COVID-19 is picking up the relationship) but it’s more likely that one of two other situations is happening, Dr. Sciscione said. Either COVID-19 involves a syndrome that looks like preeclampsia in pregnant women, or the disease “leads to the cascade that causes preeclampsia,” he said.
One clear clinical implication of these findings is that “women who have severe COVID early in pregnancy may need to be watched more closely for signs of developing preeclampsia” and that “women with severe COVID are more likely to have preterm births,” Dr. Eckert said. “This absolutely lends support to the need for pregnant individuals to receive a COVID vaccine.”
Dr. Sciscione said his experience counseling pregnant patients about the vaccine has made it clear that patients generally want to do what’s safest for their babies and may feel uneasiness about the safety of the vaccine. “The truth is, now there’s mounting evidence that there are fetal effects, not just maternal effects” from COVID-19 disease. He added that preterm birth is associated with a variety of long-term adverse outcomes, such as cerebral palsy and learning disabilities.
“At this time it’s critically important that women be offered and get the vaccine because we know that people that are vaccinated don’t get as sick,” Dr. Sciscione said.
The research was funded by the Fetal Medicine Foundation and the National Institutes of Health. The authors and Dr. Eckert have no disclosures. Dr. Sciscione is the associate editor of the American Journal of Obstetrics and Gynecology, where the study appeared.
New evidence strongly suggests that COVID-19 disease causes an increased risk of preeclampsia and preterm birth in those who have an infection while pregnant, according to a retrospective observational study published in the American Journal of Obstetrics and Gynecology. Though the study was observational, its primary finding was a dose-response relationship between the severity of COVID-19 disease and the likelihood of preeclampsia or preterm birth, fulfilling a key criterion for establishing causality in an association.
“The fact that 43% (13/30) of the cases of preeclampsia diagnosed after SARS-Cov-2 infection were preterm preeclampsia (< 37 weeks) suggests that COVID-19 may be a cause for medically indicated preterm birth that contributes to the excess preterm birth delivery rate previously reported,” wrote Jonathan Lai, MD, of the Fetal Medicine Research Institute of King’s College Hospital, London, and colleagues. The study also found an increased likelihood of COVID-19 disease in those who had preeclampsia before their infection. “Whether preeclampsia can predispose COVID-19 some cases, or that the two conditions may co-occur because they share similar risk factors requires further investigation,” the authors wrote.
It’s also unclear whether the increased risk of pre-eclampsia is contributing to the higher preterm birth risk, according to Linda Eckert, MD, a professor of Ob.Gyn. at The University of Washington who specializes in maternal immunization.
“COVID is linked to preeclampsia in this study, and COVID is linked to preterm birth,” Dr. Eckert said in an interview. “The question of whether preeclampsia leading to preterm birth is also linked to infection is not possible to tease out in this study as all the factors are likely interrelated. There is a relationship between COVID and preterm birth absent preeclampsia.”
The researchers retrospectively examined data from 1,223 pregnant women who tested positive for SARS-CoV-2 between February 2020 and March 2021 at any of 14 National Health Service maternity hospitals in the United Kingdom. The researchers compared the severity of disease among the women with their risk of preeclampsia as a primary outcome, followed by the outcomes of preterm birth and gestational age at delivery.
COVID-19 infections were classified as asymptomatic, mild illness (lacking shortness of breath, dyspnea, or abnormal chest imaging), moderate illness (evidence of lower respiratory disease but an oxygen saturation of at least 94%), and severe illness (requiring “high dependency or intensive care secondary to respiratory impairment/failure or multiorgan dysfunction”).
The researchers adjusted their analysis of preeclampsia to account for prior risk of preeclampsia based on maternal characteristics and medical history. Analysis of preterm birth risk included adjustment for maternal age, weight, height, race, method of conception, chronic hypertension, smoking, and diabetes.
Preeclampsia occurred in 4.2% of the women, and 17.6% of the women had a preterm birth. In addition, 1.3% of the cohort had a miscarriage, and there were 10 (0.81%) fetal deaths. Since 21 cases of preeclampsia occurred before the women tested positive, the researchers removed those cases from the analysis. Among the remaining 30 cases, 13 women had preterm preeclampsia and 17 had term preeclampsia.
When the researchers compared the study population’s risk of preeclampsia with that of a separate population with similar risk factors, they found a dose-response increased risk in those with COVID-19 infections. While 1.9% of asymptomatic patients had preeclampsia, incidence was 2.2% in patients with mild disease, 5.7% in those with moderate disease, and 11.1% in those with severe disease. Women with severe COVID-19 tended to be older and to have a higher body mass index.
After adjustments, women were nearly five times more likely to develop preeclampsia if they had severe COVID-19 compared to women with asymptomatic infection (adjusted relative risk [aRR] = 4.9). Those with moderate or severe disease had triple the risk of preeclampsia compared to those with mild or asymptomatic infection (aRR = 3.3).
To investigate whether having preeclampsia predisposes women to develop COVID-19 disease, the researchers compared the women who had preeclampsia before their infection with women in the study who never developed preeclampsia. Although they found a trend toward higher risk of moderate or severe COVID-19 following preeclampsia, the association was not significant before or after adjustment.
The researchers also found a dose-response relationship in risk of preterm birth. While 11.7% of asymptomatic patients had preterm birth, the incidence was 12.8% in those with mild COVID-19, 29.9% in those with moderate disease, and 69.4% in those with severe disease. Women with severe disease were more than five times more likely to have a preterm birth than were women with an asymptomatic infection (aRR = 5.64), and the risk of preterm birth was 2.5 times greater in women with moderate disease (aRR = 2.47).
“Moreover, there was a dose-response relationship between gestational age at delivery and the severity of SARS-CoV-2 infection,” the authors reported. Mean gestational age at delivery was 38.7 weeks in asymptomatic women compared to 37.5 weeks for those with moderate disease and 33 weeks in those with severe disease (P < .001).
”The more severe the infection with SARS-CoV-2, the greater the risk of preeclampsia and preterm birth,” the authors wrote. “SARS-CoV-2 infection can lead to endothelial dysfunction, intravascular inflammation, proteinuria, activation of thrombin, and hypertension, which are all features of preeclampsia. Therefore, a causal relationship must be considered.”
A dose-response association is only one criterion for causality, however, so it’s still premature to say definitively that a causal relationship exists, Dr. Eckert said.
“More investigation in different populations across different ethnicities is needed before causality can be confidently assured,” she said.
Anthony Sciscione, DO, director of maternal-fetal medicine and the ob.gyn. residency at ChristianaCare in Delaware, agreed that the precise relationship between the two remains unresolved.
”We don’t know what causes preeclampsia,” but “we strongly suspect it has to do with a placental dysfunction, or endothelial dysfunction, and it’s really clear that women who get COVID have a much higher risk of preeclampsia,” Dr. Sciscione said in an interview. It’s possible that no real relationship exists between the two (or that greater surveillance of women with COVID-19 is picking up the relationship) but it’s more likely that one of two other situations is happening, Dr. Sciscione said. Either COVID-19 involves a syndrome that looks like preeclampsia in pregnant women, or the disease “leads to the cascade that causes preeclampsia,” he said.
One clear clinical implication of these findings is that “women who have severe COVID early in pregnancy may need to be watched more closely for signs of developing preeclampsia” and that “women with severe COVID are more likely to have preterm births,” Dr. Eckert said. “This absolutely lends support to the need for pregnant individuals to receive a COVID vaccine.”
Dr. Sciscione said his experience counseling pregnant patients about the vaccine has made it clear that patients generally want to do what’s safest for their babies and may feel uneasiness about the safety of the vaccine. “The truth is, now there’s mounting evidence that there are fetal effects, not just maternal effects” from COVID-19 disease. He added that preterm birth is associated with a variety of long-term adverse outcomes, such as cerebral palsy and learning disabilities.
“At this time it’s critically important that women be offered and get the vaccine because we know that people that are vaccinated don’t get as sick,” Dr. Sciscione said.
The research was funded by the Fetal Medicine Foundation and the National Institutes of Health. The authors and Dr. Eckert have no disclosures. Dr. Sciscione is the associate editor of the American Journal of Obstetrics and Gynecology, where the study appeared.
New evidence strongly suggests that COVID-19 disease causes an increased risk of preeclampsia and preterm birth in those who have an infection while pregnant, according to a retrospective observational study published in the American Journal of Obstetrics and Gynecology. Though the study was observational, its primary finding was a dose-response relationship between the severity of COVID-19 disease and the likelihood of preeclampsia or preterm birth, fulfilling a key criterion for establishing causality in an association.
“The fact that 43% (13/30) of the cases of preeclampsia diagnosed after SARS-Cov-2 infection were preterm preeclampsia (< 37 weeks) suggests that COVID-19 may be a cause for medically indicated preterm birth that contributes to the excess preterm birth delivery rate previously reported,” wrote Jonathan Lai, MD, of the Fetal Medicine Research Institute of King’s College Hospital, London, and colleagues. The study also found an increased likelihood of COVID-19 disease in those who had preeclampsia before their infection. “Whether preeclampsia can predispose COVID-19 some cases, or that the two conditions may co-occur because they share similar risk factors requires further investigation,” the authors wrote.
It’s also unclear whether the increased risk of pre-eclampsia is contributing to the higher preterm birth risk, according to Linda Eckert, MD, a professor of Ob.Gyn. at The University of Washington who specializes in maternal immunization.
“COVID is linked to preeclampsia in this study, and COVID is linked to preterm birth,” Dr. Eckert said in an interview. “The question of whether preeclampsia leading to preterm birth is also linked to infection is not possible to tease out in this study as all the factors are likely interrelated. There is a relationship between COVID and preterm birth absent preeclampsia.”
The researchers retrospectively examined data from 1,223 pregnant women who tested positive for SARS-CoV-2 between February 2020 and March 2021 at any of 14 National Health Service maternity hospitals in the United Kingdom. The researchers compared the severity of disease among the women with their risk of preeclampsia as a primary outcome, followed by the outcomes of preterm birth and gestational age at delivery.
COVID-19 infections were classified as asymptomatic, mild illness (lacking shortness of breath, dyspnea, or abnormal chest imaging), moderate illness (evidence of lower respiratory disease but an oxygen saturation of at least 94%), and severe illness (requiring “high dependency or intensive care secondary to respiratory impairment/failure or multiorgan dysfunction”).
The researchers adjusted their analysis of preeclampsia to account for prior risk of preeclampsia based on maternal characteristics and medical history. Analysis of preterm birth risk included adjustment for maternal age, weight, height, race, method of conception, chronic hypertension, smoking, and diabetes.
Preeclampsia occurred in 4.2% of the women, and 17.6% of the women had a preterm birth. In addition, 1.3% of the cohort had a miscarriage, and there were 10 (0.81%) fetal deaths. Since 21 cases of preeclampsia occurred before the women tested positive, the researchers removed those cases from the analysis. Among the remaining 30 cases, 13 women had preterm preeclampsia and 17 had term preeclampsia.
When the researchers compared the study population’s risk of preeclampsia with that of a separate population with similar risk factors, they found a dose-response increased risk in those with COVID-19 infections. While 1.9% of asymptomatic patients had preeclampsia, incidence was 2.2% in patients with mild disease, 5.7% in those with moderate disease, and 11.1% in those with severe disease. Women with severe COVID-19 tended to be older and to have a higher body mass index.
After adjustments, women were nearly five times more likely to develop preeclampsia if they had severe COVID-19 compared to women with asymptomatic infection (adjusted relative risk [aRR] = 4.9). Those with moderate or severe disease had triple the risk of preeclampsia compared to those with mild or asymptomatic infection (aRR = 3.3).
To investigate whether having preeclampsia predisposes women to develop COVID-19 disease, the researchers compared the women who had preeclampsia before their infection with women in the study who never developed preeclampsia. Although they found a trend toward higher risk of moderate or severe COVID-19 following preeclampsia, the association was not significant before or after adjustment.
The researchers also found a dose-response relationship in risk of preterm birth. While 11.7% of asymptomatic patients had preterm birth, the incidence was 12.8% in those with mild COVID-19, 29.9% in those with moderate disease, and 69.4% in those with severe disease. Women with severe disease were more than five times more likely to have a preterm birth than were women with an asymptomatic infection (aRR = 5.64), and the risk of preterm birth was 2.5 times greater in women with moderate disease (aRR = 2.47).
“Moreover, there was a dose-response relationship between gestational age at delivery and the severity of SARS-CoV-2 infection,” the authors reported. Mean gestational age at delivery was 38.7 weeks in asymptomatic women compared to 37.5 weeks for those with moderate disease and 33 weeks in those with severe disease (P < .001).
”The more severe the infection with SARS-CoV-2, the greater the risk of preeclampsia and preterm birth,” the authors wrote. “SARS-CoV-2 infection can lead to endothelial dysfunction, intravascular inflammation, proteinuria, activation of thrombin, and hypertension, which are all features of preeclampsia. Therefore, a causal relationship must be considered.”
A dose-response association is only one criterion for causality, however, so it’s still premature to say definitively that a causal relationship exists, Dr. Eckert said.
“More investigation in different populations across different ethnicities is needed before causality can be confidently assured,” she said.
Anthony Sciscione, DO, director of maternal-fetal medicine and the ob.gyn. residency at ChristianaCare in Delaware, agreed that the precise relationship between the two remains unresolved.
”We don’t know what causes preeclampsia,” but “we strongly suspect it has to do with a placental dysfunction, or endothelial dysfunction, and it’s really clear that women who get COVID have a much higher risk of preeclampsia,” Dr. Sciscione said in an interview. It’s possible that no real relationship exists between the two (or that greater surveillance of women with COVID-19 is picking up the relationship) but it’s more likely that one of two other situations is happening, Dr. Sciscione said. Either COVID-19 involves a syndrome that looks like preeclampsia in pregnant women, or the disease “leads to the cascade that causes preeclampsia,” he said.
One clear clinical implication of these findings is that “women who have severe COVID early in pregnancy may need to be watched more closely for signs of developing preeclampsia” and that “women with severe COVID are more likely to have preterm births,” Dr. Eckert said. “This absolutely lends support to the need for pregnant individuals to receive a COVID vaccine.”
Dr. Sciscione said his experience counseling pregnant patients about the vaccine has made it clear that patients generally want to do what’s safest for their babies and may feel uneasiness about the safety of the vaccine. “The truth is, now there’s mounting evidence that there are fetal effects, not just maternal effects” from COVID-19 disease. He added that preterm birth is associated with a variety of long-term adverse outcomes, such as cerebral palsy and learning disabilities.
“At this time it’s critically important that women be offered and get the vaccine because we know that people that are vaccinated don’t get as sick,” Dr. Sciscione said.
The research was funded by the Fetal Medicine Foundation and the National Institutes of Health. The authors and Dr. Eckert have no disclosures. Dr. Sciscione is the associate editor of the American Journal of Obstetrics and Gynecology, where the study appeared.
FROM THE JOURNAL OF OBSTETRICS AND GYNECOLOGY
Expert shares vulvovaginal candidiasis treatment pearls
that was approved in June 2021, Aruna Venkatesan, MD, recommends.
“Ibrexafungerp, an inhibitor of beta (1-3)–glucan synthase, is important for many reasons,” Dr. Venkatesan, chief of dermatology and director of the genital dermatology clinic at Santa Clara Valley Medical Center, San Jose, Calif., said during the annual meeting of the Pacific Dermatologic Association. “It’s one of the few drugs that can be used to treat Candida glabrata when C. glabrata is resistant to azoles and echinocandins. As the second-most common Candida species after C. albicans, C. glabrata is more common in immunosuppressed patients and it can cause mucosal and invasive disease, so ibrexafungerp is a welcome addition to our treatment armamentarium,” said Dr. Venkatesan, clinical professor of dermatology (affiliated) at Stanford (Calif.) Hospital and Clinics, adding that that vulvovaginal candidiasis can be tricky to diagnose. “In medical school, we learned that yeast infection in a woman presents as white, curd-like discharge, but that’s actually a minority of patients.”
For a patient who is being treated with topical steroids or estrogen for a genital condition, but is experiencing worsening itch, redness, or thick white discharge, she recommends performing a KOH exam.
“Instead of using a 15-blade scalpel, as we are used to performing on the skin for tinea, take a sterile [cotton swab], and swab the affected area. You can then apply it to a slide and perform a KOH exam as you normally would. Then look for yeast elements under the microscope. I also find it helpful to send for fungal culture to get speciation, especially in someone who’s not responding to therapy. This is because non-albicans yeast can be more resistant to azoles and require a different treatment plan.”
Often, patients with vulvovaginal candidiasis who present to her clinic are referred from an ob.gyn. and other general practitioners because they have failed a topical or oral azole. “I tend to avoid the topicals,” said Dr. Venkatesan, who is also president-elect of the North American chapter of the International Society for the Study of Vulvovaginal Disease. “If the culture shows C. albicans, I usually treat with oral fluconazole, 150 mg or 200 mg once, and consider repeat weekly dosing. Many patients come to me because they have recurrent refractory disease, so giving it once weekly for 6-8 weeks while they work on their potential risk factors such as diabetic blood sugar control is sensible.”
Non-albicans yeast can be resistant to azoles. If the fungal culture shows C. glabrata in such patients, “consider a course of intravaginal boric acid suppositories,” she advised. “These used to be difficult to give patients, because you would either have to send the prescription to a compounding pharmacy, or have the patients buy the capsules and boric acid crystals separately and make them themselves. That always made me nervous because of the chance of errors. The safety and the concern of taking it by mouth is an issue.” But now, intravaginal boric acid suppositories are available on Amazon and other web sites, and are relatively affordable, she said, adding, “just make sure the patient doesn’t take it by mouth as this is very toxic.”
Dr. Venkatesan reported having no financial disclosures.
that was approved in June 2021, Aruna Venkatesan, MD, recommends.
“Ibrexafungerp, an inhibitor of beta (1-3)–glucan synthase, is important for many reasons,” Dr. Venkatesan, chief of dermatology and director of the genital dermatology clinic at Santa Clara Valley Medical Center, San Jose, Calif., said during the annual meeting of the Pacific Dermatologic Association. “It’s one of the few drugs that can be used to treat Candida glabrata when C. glabrata is resistant to azoles and echinocandins. As the second-most common Candida species after C. albicans, C. glabrata is more common in immunosuppressed patients and it can cause mucosal and invasive disease, so ibrexafungerp is a welcome addition to our treatment armamentarium,” said Dr. Venkatesan, clinical professor of dermatology (affiliated) at Stanford (Calif.) Hospital and Clinics, adding that that vulvovaginal candidiasis can be tricky to diagnose. “In medical school, we learned that yeast infection in a woman presents as white, curd-like discharge, but that’s actually a minority of patients.”
For a patient who is being treated with topical steroids or estrogen for a genital condition, but is experiencing worsening itch, redness, or thick white discharge, she recommends performing a KOH exam.
“Instead of using a 15-blade scalpel, as we are used to performing on the skin for tinea, take a sterile [cotton swab], and swab the affected area. You can then apply it to a slide and perform a KOH exam as you normally would. Then look for yeast elements under the microscope. I also find it helpful to send for fungal culture to get speciation, especially in someone who’s not responding to therapy. This is because non-albicans yeast can be more resistant to azoles and require a different treatment plan.”
Often, patients with vulvovaginal candidiasis who present to her clinic are referred from an ob.gyn. and other general practitioners because they have failed a topical or oral azole. “I tend to avoid the topicals,” said Dr. Venkatesan, who is also president-elect of the North American chapter of the International Society for the Study of Vulvovaginal Disease. “If the culture shows C. albicans, I usually treat with oral fluconazole, 150 mg or 200 mg once, and consider repeat weekly dosing. Many patients come to me because they have recurrent refractory disease, so giving it once weekly for 6-8 weeks while they work on their potential risk factors such as diabetic blood sugar control is sensible.”
Non-albicans yeast can be resistant to azoles. If the fungal culture shows C. glabrata in such patients, “consider a course of intravaginal boric acid suppositories,” she advised. “These used to be difficult to give patients, because you would either have to send the prescription to a compounding pharmacy, or have the patients buy the capsules and boric acid crystals separately and make them themselves. That always made me nervous because of the chance of errors. The safety and the concern of taking it by mouth is an issue.” But now, intravaginal boric acid suppositories are available on Amazon and other web sites, and are relatively affordable, she said, adding, “just make sure the patient doesn’t take it by mouth as this is very toxic.”
Dr. Venkatesan reported having no financial disclosures.
that was approved in June 2021, Aruna Venkatesan, MD, recommends.
“Ibrexafungerp, an inhibitor of beta (1-3)–glucan synthase, is important for many reasons,” Dr. Venkatesan, chief of dermatology and director of the genital dermatology clinic at Santa Clara Valley Medical Center, San Jose, Calif., said during the annual meeting of the Pacific Dermatologic Association. “It’s one of the few drugs that can be used to treat Candida glabrata when C. glabrata is resistant to azoles and echinocandins. As the second-most common Candida species after C. albicans, C. glabrata is more common in immunosuppressed patients and it can cause mucosal and invasive disease, so ibrexafungerp is a welcome addition to our treatment armamentarium,” said Dr. Venkatesan, clinical professor of dermatology (affiliated) at Stanford (Calif.) Hospital and Clinics, adding that that vulvovaginal candidiasis can be tricky to diagnose. “In medical school, we learned that yeast infection in a woman presents as white, curd-like discharge, but that’s actually a minority of patients.”
For a patient who is being treated with topical steroids or estrogen for a genital condition, but is experiencing worsening itch, redness, or thick white discharge, she recommends performing a KOH exam.
“Instead of using a 15-blade scalpel, as we are used to performing on the skin for tinea, take a sterile [cotton swab], and swab the affected area. You can then apply it to a slide and perform a KOH exam as you normally would. Then look for yeast elements under the microscope. I also find it helpful to send for fungal culture to get speciation, especially in someone who’s not responding to therapy. This is because non-albicans yeast can be more resistant to azoles and require a different treatment plan.”
Often, patients with vulvovaginal candidiasis who present to her clinic are referred from an ob.gyn. and other general practitioners because they have failed a topical or oral azole. “I tend to avoid the topicals,” said Dr. Venkatesan, who is also president-elect of the North American chapter of the International Society for the Study of Vulvovaginal Disease. “If the culture shows C. albicans, I usually treat with oral fluconazole, 150 mg or 200 mg once, and consider repeat weekly dosing. Many patients come to me because they have recurrent refractory disease, so giving it once weekly for 6-8 weeks while they work on their potential risk factors such as diabetic blood sugar control is sensible.”
Non-albicans yeast can be resistant to azoles. If the fungal culture shows C. glabrata in such patients, “consider a course of intravaginal boric acid suppositories,” she advised. “These used to be difficult to give patients, because you would either have to send the prescription to a compounding pharmacy, or have the patients buy the capsules and boric acid crystals separately and make them themselves. That always made me nervous because of the chance of errors. The safety and the concern of taking it by mouth is an issue.” But now, intravaginal boric acid suppositories are available on Amazon and other web sites, and are relatively affordable, she said, adding, “just make sure the patient doesn’t take it by mouth as this is very toxic.”
Dr. Venkatesan reported having no financial disclosures.
FROM PDA 2021
Ask about itch and joint pain in pediatric psoriasis patients, expert advises
During the annual meeting of the Society for Pediatric Dermatology, Amy S. Paller, MD, MS, marveled on the remarkable advances in the treatment of inflammatory skin disorders during the past 2 decades.
“We’ve come a long way, from disease features being red, thick, and scaly and being treated with nonspecific therapy like topical steroids, keratolytics, and tar, to understanding disease pathogenesis and finding new targeted therapies for inflammatory skin disorders in children,” said Dr. Paller, professor and chair of the department of dermatology at Northwestern University, Chicago. “There are now studies moving forward with gene correction, gene replacement, the gene product replaced, or pathway inhibition to prevent the effects of genetic change.”
Technology is leading the way in generating new therapeutic advances, she continued, beyond traditional “omics” to lipidomics, metabolomics, glycomics, and kinomics. “This has enabled us to find new genetic disorders and their causes, to look at changes in gene expression patterns, and to look at changes in protein expression patterns that give us clues as to how to move forward with better therapy,” she said. “When we’re talking about new insights into pathogenesis-based therapy, we’re talking largely about understanding the pathways that lead to either inflammation or promoting cell proliferation and abnormal differentiation.”
Treating pediatric psoriasis
. “First of all, ask about itch and pain with these patients,” she advised. “Interviews have shown that 61% of children experience some itch, 39% have pain or stinging, and in the ixekizumab trials, 72% had what’s considered meaningful itch, with at least 4 out of 10 (mean intensity 5.3) on the itch numeric rating scale. Little is known about the itch associated with psoriasis and its underlying cause – unrelated to the IL-4/IL-13 pathway activation of atopic dermatitis – but it’s worth asking about. I find that itch of the scalp is especially a problem in psoriasis.”
Physicians should also ask pediatric psoriasis patients about joint pain, because about 1% of them have psoriatic arthritis, which is much less common than in adults, “but important to find and manage,” she added. Dr. Paller recommends the new R-JET rapid joint exam technique, which is accompanied by a three-question survey and body diagram that facilitates identification of true arthritis, “so you can know how quickly to refer”.
Several studies have described an increased risk of metabolic syndrome in adolescents with pediatric psoriasis and now in prepubertal children with the disease. In a recent study of 60 consecutive prepubertal children with psoriasis, 70% of whom had mild disease, 40% were overweight or obese, 53% had central obesity, 27% had high levels of the HOMA-IR (homeostasis model assessment of insulin resistance) despite generally normal levels of fasting glucose, and 30% met criteria for metabolic syndrome.
“This really struck me because our AAD [American Academy of Dermatology] guidelines did not recommend screening for type 2 diabetes in prepubertal children, even if overweight, because the risk is so small,” Dr. Paller said. “This report suggests that we may need to reconsider this recommendation in prepubertal children with psoriasis.”
Meanwhile, the number of medications approved by the Food and Drug Administration and the European Medicines Agency for children with psoriasis who are 6 years of age and above continues to expand, including tumor necrosis factor (TNF) inhibitors, interleukin (IL)-23 inhibitors, and IL-17 inhibitors. Most children can now achieve a PASI 90 within 12 weeks with the IL-23 inhibitor ustekinumab and the IL-17 inhibitors ixekizumab and secukinumab, Dr. Paller said.
In the ixekizumab trial, there are head-to-head comparison data in a European arm that involved the use of etanercept, she said. “What’s most noticeable is the significant difference in those who were able to achieve PASI 90 or above with this IL-17 inhibitor, versus etanercept,” which she added, raises the question of whether aiming for a PASI 75 is adequate, "or should we strive for PASI 90?” A pediatric psoriasis study published in 2020 found that the greatest improvement in quality of life was associated with a PASI 90 and use of systemic treatments.
Looking forward, phase 3 clinical trials are underway in pediatric patients with moderate to severe psoriasis for guselkumab, tildrakizumab, risankizumab, certolizumab, bimekizumab, and brodalumab. “The cost of all of these biologics is high, however. I remind everyone that we still have methotrexate,” she said. “The risk of side effects with our low-dose methotrexate treatment for psoriasis remains low, but methotrexate doesn’t hit these [high] PASI numbers and it’s much slower in its onset than biologics.”
Dr. Paller disclosed that she is a consultant to and/or an investigator for AbbVie, Arena, Bausch, Bristol Myers Squibb, Dermavant, Eli Lilly, Incyte, Forte, LEO Pharma, LifeMax, Pfizer, RAPT Therapeutics, Regeneron, and Sanofi.
Commentary by Robert Sidbury, MD, MPH
Dr. Paller reminds us of some essential features of pediatric psoriasis:
• It can hurt. Ask your patients if it does.
• It can itch. Look for excoriations, especially in the scalp.
• It is often associated with metabolic syndrome, so check relevant biometrics and labs, and consider coincident insulin resistance.
• Our traditional clinical trial target of PASI75, or a 75% reduction in body surface area involvement, is just not good enough. Studies have shown that the most meaningful quality-of-life gains come at PASI90 or above.
• With our newer biologics, such as IL-12/23 blockers (for instance, ustekinumab) and IL-17 blockers (for example, ixekizumab and secukinumab), PASI90 and better is a reasonable expectation, not a pipe dream.
Dr. Sidbury is chief of dermatology at Seattle Children's Hospital and professor, department of pediatrics, University of Washington, Seattle. He is a site principal investigator for dupilumab trials, for which the hospital has a contract with Regeneron.
This article was updated 6/16/22.
During the annual meeting of the Society for Pediatric Dermatology, Amy S. Paller, MD, MS, marveled on the remarkable advances in the treatment of inflammatory skin disorders during the past 2 decades.
“We’ve come a long way, from disease features being red, thick, and scaly and being treated with nonspecific therapy like topical steroids, keratolytics, and tar, to understanding disease pathogenesis and finding new targeted therapies for inflammatory skin disorders in children,” said Dr. Paller, professor and chair of the department of dermatology at Northwestern University, Chicago. “There are now studies moving forward with gene correction, gene replacement, the gene product replaced, or pathway inhibition to prevent the effects of genetic change.”
Technology is leading the way in generating new therapeutic advances, she continued, beyond traditional “omics” to lipidomics, metabolomics, glycomics, and kinomics. “This has enabled us to find new genetic disorders and their causes, to look at changes in gene expression patterns, and to look at changes in protein expression patterns that give us clues as to how to move forward with better therapy,” she said. “When we’re talking about new insights into pathogenesis-based therapy, we’re talking largely about understanding the pathways that lead to either inflammation or promoting cell proliferation and abnormal differentiation.”
Treating pediatric psoriasis
. “First of all, ask about itch and pain with these patients,” she advised. “Interviews have shown that 61% of children experience some itch, 39% have pain or stinging, and in the ixekizumab trials, 72% had what’s considered meaningful itch, with at least 4 out of 10 (mean intensity 5.3) on the itch numeric rating scale. Little is known about the itch associated with psoriasis and its underlying cause – unrelated to the IL-4/IL-13 pathway activation of atopic dermatitis – but it’s worth asking about. I find that itch of the scalp is especially a problem in psoriasis.”
Physicians should also ask pediatric psoriasis patients about joint pain, because about 1% of them have psoriatic arthritis, which is much less common than in adults, “but important to find and manage,” she added. Dr. Paller recommends the new R-JET rapid joint exam technique, which is accompanied by a three-question survey and body diagram that facilitates identification of true arthritis, “so you can know how quickly to refer”.
Several studies have described an increased risk of metabolic syndrome in adolescents with pediatric psoriasis and now in prepubertal children with the disease. In a recent study of 60 consecutive prepubertal children with psoriasis, 70% of whom had mild disease, 40% were overweight or obese, 53% had central obesity, 27% had high levels of the HOMA-IR (homeostasis model assessment of insulin resistance) despite generally normal levels of fasting glucose, and 30% met criteria for metabolic syndrome.
“This really struck me because our AAD [American Academy of Dermatology] guidelines did not recommend screening for type 2 diabetes in prepubertal children, even if overweight, because the risk is so small,” Dr. Paller said. “This report suggests that we may need to reconsider this recommendation in prepubertal children with psoriasis.”
Meanwhile, the number of medications approved by the Food and Drug Administration and the European Medicines Agency for children with psoriasis who are 6 years of age and above continues to expand, including tumor necrosis factor (TNF) inhibitors, interleukin (IL)-23 inhibitors, and IL-17 inhibitors. Most children can now achieve a PASI 90 within 12 weeks with the IL-23 inhibitor ustekinumab and the IL-17 inhibitors ixekizumab and secukinumab, Dr. Paller said.
In the ixekizumab trial, there are head-to-head comparison data in a European arm that involved the use of etanercept, she said. “What’s most noticeable is the significant difference in those who were able to achieve PASI 90 or above with this IL-17 inhibitor, versus etanercept,” which she added, raises the question of whether aiming for a PASI 75 is adequate, "or should we strive for PASI 90?” A pediatric psoriasis study published in 2020 found that the greatest improvement in quality of life was associated with a PASI 90 and use of systemic treatments.
Looking forward, phase 3 clinical trials are underway in pediatric patients with moderate to severe psoriasis for guselkumab, tildrakizumab, risankizumab, certolizumab, bimekizumab, and brodalumab. “The cost of all of these biologics is high, however. I remind everyone that we still have methotrexate,” she said. “The risk of side effects with our low-dose methotrexate treatment for psoriasis remains low, but methotrexate doesn’t hit these [high] PASI numbers and it’s much slower in its onset than biologics.”
Dr. Paller disclosed that she is a consultant to and/or an investigator for AbbVie, Arena, Bausch, Bristol Myers Squibb, Dermavant, Eli Lilly, Incyte, Forte, LEO Pharma, LifeMax, Pfizer, RAPT Therapeutics, Regeneron, and Sanofi.
Commentary by Robert Sidbury, MD, MPH
Dr. Paller reminds us of some essential features of pediatric psoriasis:
• It can hurt. Ask your patients if it does.
• It can itch. Look for excoriations, especially in the scalp.
• It is often associated with metabolic syndrome, so check relevant biometrics and labs, and consider coincident insulin resistance.
• Our traditional clinical trial target of PASI75, or a 75% reduction in body surface area involvement, is just not good enough. Studies have shown that the most meaningful quality-of-life gains come at PASI90 or above.
• With our newer biologics, such as IL-12/23 blockers (for instance, ustekinumab) and IL-17 blockers (for example, ixekizumab and secukinumab), PASI90 and better is a reasonable expectation, not a pipe dream.
Dr. Sidbury is chief of dermatology at Seattle Children's Hospital and professor, department of pediatrics, University of Washington, Seattle. He is a site principal investigator for dupilumab trials, for which the hospital has a contract with Regeneron.
This article was updated 6/16/22.
During the annual meeting of the Society for Pediatric Dermatology, Amy S. Paller, MD, MS, marveled on the remarkable advances in the treatment of inflammatory skin disorders during the past 2 decades.
“We’ve come a long way, from disease features being red, thick, and scaly and being treated with nonspecific therapy like topical steroids, keratolytics, and tar, to understanding disease pathogenesis and finding new targeted therapies for inflammatory skin disorders in children,” said Dr. Paller, professor and chair of the department of dermatology at Northwestern University, Chicago. “There are now studies moving forward with gene correction, gene replacement, the gene product replaced, or pathway inhibition to prevent the effects of genetic change.”
Technology is leading the way in generating new therapeutic advances, she continued, beyond traditional “omics” to lipidomics, metabolomics, glycomics, and kinomics. “This has enabled us to find new genetic disorders and their causes, to look at changes in gene expression patterns, and to look at changes in protein expression patterns that give us clues as to how to move forward with better therapy,” she said. “When we’re talking about new insights into pathogenesis-based therapy, we’re talking largely about understanding the pathways that lead to either inflammation or promoting cell proliferation and abnormal differentiation.”
Treating pediatric psoriasis
. “First of all, ask about itch and pain with these patients,” she advised. “Interviews have shown that 61% of children experience some itch, 39% have pain or stinging, and in the ixekizumab trials, 72% had what’s considered meaningful itch, with at least 4 out of 10 (mean intensity 5.3) on the itch numeric rating scale. Little is known about the itch associated with psoriasis and its underlying cause – unrelated to the IL-4/IL-13 pathway activation of atopic dermatitis – but it’s worth asking about. I find that itch of the scalp is especially a problem in psoriasis.”
Physicians should also ask pediatric psoriasis patients about joint pain, because about 1% of them have psoriatic arthritis, which is much less common than in adults, “but important to find and manage,” she added. Dr. Paller recommends the new R-JET rapid joint exam technique, which is accompanied by a three-question survey and body diagram that facilitates identification of true arthritis, “so you can know how quickly to refer”.
Several studies have described an increased risk of metabolic syndrome in adolescents with pediatric psoriasis and now in prepubertal children with the disease. In a recent study of 60 consecutive prepubertal children with psoriasis, 70% of whom had mild disease, 40% were overweight or obese, 53% had central obesity, 27% had high levels of the HOMA-IR (homeostasis model assessment of insulin resistance) despite generally normal levels of fasting glucose, and 30% met criteria for metabolic syndrome.
“This really struck me because our AAD [American Academy of Dermatology] guidelines did not recommend screening for type 2 diabetes in prepubertal children, even if overweight, because the risk is so small,” Dr. Paller said. “This report suggests that we may need to reconsider this recommendation in prepubertal children with psoriasis.”
Meanwhile, the number of medications approved by the Food and Drug Administration and the European Medicines Agency for children with psoriasis who are 6 years of age and above continues to expand, including tumor necrosis factor (TNF) inhibitors, interleukin (IL)-23 inhibitors, and IL-17 inhibitors. Most children can now achieve a PASI 90 within 12 weeks with the IL-23 inhibitor ustekinumab and the IL-17 inhibitors ixekizumab and secukinumab, Dr. Paller said.
In the ixekizumab trial, there are head-to-head comparison data in a European arm that involved the use of etanercept, she said. “What’s most noticeable is the significant difference in those who were able to achieve PASI 90 or above with this IL-17 inhibitor, versus etanercept,” which she added, raises the question of whether aiming for a PASI 75 is adequate, "or should we strive for PASI 90?” A pediatric psoriasis study published in 2020 found that the greatest improvement in quality of life was associated with a PASI 90 and use of systemic treatments.
Looking forward, phase 3 clinical trials are underway in pediatric patients with moderate to severe psoriasis for guselkumab, tildrakizumab, risankizumab, certolizumab, bimekizumab, and brodalumab. “The cost of all of these biologics is high, however. I remind everyone that we still have methotrexate,” she said. “The risk of side effects with our low-dose methotrexate treatment for psoriasis remains low, but methotrexate doesn’t hit these [high] PASI numbers and it’s much slower in its onset than biologics.”
Dr. Paller disclosed that she is a consultant to and/or an investigator for AbbVie, Arena, Bausch, Bristol Myers Squibb, Dermavant, Eli Lilly, Incyte, Forte, LEO Pharma, LifeMax, Pfizer, RAPT Therapeutics, Regeneron, and Sanofi.
Commentary by Robert Sidbury, MD, MPH
Dr. Paller reminds us of some essential features of pediatric psoriasis:
• It can hurt. Ask your patients if it does.
• It can itch. Look for excoriations, especially in the scalp.
• It is often associated with metabolic syndrome, so check relevant biometrics and labs, and consider coincident insulin resistance.
• Our traditional clinical trial target of PASI75, or a 75% reduction in body surface area involvement, is just not good enough. Studies have shown that the most meaningful quality-of-life gains come at PASI90 or above.
• With our newer biologics, such as IL-12/23 blockers (for instance, ustekinumab) and IL-17 blockers (for example, ixekizumab and secukinumab), PASI90 and better is a reasonable expectation, not a pipe dream.
Dr. Sidbury is chief of dermatology at Seattle Children's Hospital and professor, department of pediatrics, University of Washington, Seattle. He is a site principal investigator for dupilumab trials, for which the hospital has a contract with Regeneron.
This article was updated 6/16/22.
FROM SPD 2021