Pulmonology

A 40-year-old women is evaluated for liver abnormalities. She had elevated transaminases and alkaline phosphatase. A liver ultrasound showed multiple lesions. She underwent liver biopsy, which showed granulomas. What test results, if abnormal, would be most suggestive of sarcoidosis?

A. Erythrocyte sedimentation rate

B. C-reactive protein

C. Lymphocyte count

D. Antinuclear antibodies

The correct answer here is lymphocyte count. Sarcoidosis is in just about every differential diagnosis, as it can involve every organ system. I will share with you a few pearls I have learned over 30 years of taking care of patients with sarcoidosis. Lymphocyte counts drop with active sarcoidosis. Sarcoidosis should always be part of the differential when you see lymphopenia. El Jammal et al. studied 90 patients referred for possible granulomatous hepatitis.¹ Seventy-three patients had a final diagnosis of granulomatous hepatitis, and 38 of those patients had sarcoidosis. Lymphopenia had a high specificity (85.7%) for the diagnosis of sarcoidosis, with a specificity of 100% in the patients under 50 years old.

Morell and colleagues looked at whether low lymphocyte counts and low lymphocyte percentage were markers of active sarcoidosis.² Forty patients with biopsy-proven sarcoidosis were prospectively evaluated every 6 months. A low lymphocyte count and a low lymphocyte percentage (< 20%) were detected more frequently in patients with active sarcoidosis than in the patients with asymptomatic sarcoidosis (P < .02 and P < .0001).

Jones et al. looked at lymphopenia as a marker of sarcoidosis in patients presenting with uveitis.³ The study was a retrospective case-control study (112 patients with sarcoidosis-associated uveitis and 398 controls with other forms of uveitis). The mean lymphocyte count for patients with sarcoidosis was 1.43 vs. 2.04 for other causes of uveitis (P ≤ .0001).

Patients with sarcoidosis are at risk of hypercalciuria, hypercalcemia, and kidney stones. These are common in patients with sarcoidosis, with up to 50% of such patients having hypercalciuria. This is because in sarcoidosis patients 25(OH) vitamin D is converted in granulomas by activated macrophages to 1,25(OH)₂ vitamin D, which is the active form of vitamin D.

Several studies have looked at the diagnostic utility of 1,25(OH)₂ vitamin D levels in patients with suspected sarcoidosis. Rohmer and colleagues looked at whether 1,25(OH)₂ vitamin D levels could help with the diagnosis of sarcoidosis as the cause of uveitis.⁴ They found that the level of 25(OH) vitamin D in sarcoidosis patients with uveitis was lower than in patients with uveitis without sarcoidosis, 34 vs. 43 nmol/mL (P < .02), whereas the 1,25(OH)₂ vitamin D level was higher in patients with sarcoidosis than in those with uveitis without sarcoidosis, 132 vs. 108 pmol/L (P = .02). They looked at the 1,25(OH)₂D/25(OH)D ratio; a ratio > 3.5 was strongly associated with an abnormal chest CT-scan (OR = 5.7, P = .003) and granulomas on bronchial biopsy (OR = 14.7, P = .007).

Kavathia et al. looked at whether elevated 1,25(OH)₂ vitamin D levels predicted chronicity of sarcoidosis.⁵ A total of 59 sarcoidosis patients were recruited for the study. Higher serum 1,25(OH)₂ vitamin D levels were associated with patients requiring repeated systemic immunosuppressive therapy or > 1 year of therapy. Increasing quartiles of serum 1,25(OH)₂ vitamin D level were associated with increased odds of patients having chronic sarcoidosis (OR = 1.82; 95% CI, 1.11-2.99, P = .019).

Because of the higher activated vitamin D levels in sarcoidosis patients, they are at risk for problems with vitamin D supplementation. I have seen two patients develop large numbers of kidney stones after receiving high-dose vitamin D. Sodhi and Aldrich reported on a cohort of 196 sarcoidosis patients who had received vitamin D and compared them with 196 control patients with sarcoidosis who were not receiving vitamin D.⁶ Hypercalcemia was more frequent in the group that received vitamin D (42.3%) than in the group that did not (18.3%, P < .0001). In this study, only a minority (23%) of patients receiving vitamin D had their 1,25(OH)₂ vitamin D level checked.


Pearl: Lymphocyte count and 1,25(OH)₂ vitamin D levels can be helpful tests in assessing sarcoidosis activity. Patients with sarcoidosis who receive vitamin D should have their 1.25(OH)₂ vitamin D levels monitored.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. El Jammal et al. Sarcoidosis Vasc Diffuse Lung Dis. 2023 Sep 13;40(3):e2023031.

2. Morell F et al. Chest. 2002 Apr;121(4):1239-44.

3. Jones NP et al. Br J Ophthalmol. 2016 Oct;100(10):1393-6.

4. Rohmer J et al. Ocul Immunol Inflamm. 2020 Apr 2;28(3):341-7.

5. Kavathia D et al. Respir Med. 2010 Apr;104(4):564–70.

6. Sodhi A and Aldrich T. Am J Med Sci. 2016 Sep;352(3):252-7.

A 40-year-old women is evaluated for liver abnormalities. She had elevated transaminases and alkaline phosphatase. A liver ultrasound showed multiple lesions. She underwent liver biopsy, which showed granulomas. What test results, if abnormal, would be most suggestive of sarcoidosis?

A. Erythrocyte sedimentation rate

B. C-reactive protein

C. Lymphocyte count

D. Antinuclear antibodies

The correct answer here is lymphocyte count. Sarcoidosis is in just about every differential diagnosis, as it can involve every organ system. I will share with you a few pearls I have learned over 30 years of taking care of patients with sarcoidosis. Lymphocyte counts drop with active sarcoidosis. Sarcoidosis should always be part of the differential when you see lymphopenia. El Jammal et al. studied 90 patients referred for possible granulomatous hepatitis.¹ Seventy-three patients had a final diagnosis of granulomatous hepatitis, and 38 of those patients had sarcoidosis. Lymphopenia had a high specificity (85.7%) for the diagnosis of sarcoidosis, with a specificity of 100% in the patients under 50 years old.

Morell and colleagues looked at whether low lymphocyte counts and low lymphocyte percentage were markers of active sarcoidosis.² Forty patients with biopsy-proven sarcoidosis were prospectively evaluated every 6 months. A low lymphocyte count and a low lymphocyte percentage (< 20%) were detected more frequently in patients with active sarcoidosis than in the patients with asymptomatic sarcoidosis (P < .02 and P < .0001).

Jones et al. looked at lymphopenia as a marker of sarcoidosis in patients presenting with uveitis.³ The study was a retrospective case-control study (112 patients with sarcoidosis-associated uveitis and 398 controls with other forms of uveitis). The mean lymphocyte count for patients with sarcoidosis was 1.43 vs. 2.04 for other causes of uveitis (P ≤ .0001).

Patients with sarcoidosis are at risk of hypercalciuria, hypercalcemia, and kidney stones. These are common in patients with sarcoidosis, with up to 50% of such patients having hypercalciuria. This is because in sarcoidosis patients 25(OH) vitamin D is converted in granulomas by activated macrophages to 1,25(OH)₂ vitamin D, which is the active form of vitamin D.

Several studies have looked at the diagnostic utility of 1,25(OH)₂ vitamin D levels in patients with suspected sarcoidosis. Rohmer and colleagues looked at whether 1,25(OH)₂ vitamin D levels could help with the diagnosis of sarcoidosis as the cause of uveitis.⁴ They found that the level of 25(OH) vitamin D in sarcoidosis patients with uveitis was lower than in patients with uveitis without sarcoidosis, 34 vs. 43 nmol/mL (P < .02), whereas the 1,25(OH)₂ vitamin D level was higher in patients with sarcoidosis than in those with uveitis without sarcoidosis, 132 vs. 108 pmol/L (P = .02). They looked at the 1,25(OH)₂D/25(OH)D ratio; a ratio > 3.5 was strongly associated with an abnormal chest CT-scan (OR = 5.7, P = .003) and granulomas on bronchial biopsy (OR = 14.7, P = .007).

Kavathia et al. looked at whether elevated 1,25(OH)₂ vitamin D levels predicted chronicity of sarcoidosis.⁵ A total of 59 sarcoidosis patients were recruited for the study. Higher serum 1,25(OH)₂ vitamin D levels were associated with patients requiring repeated systemic immunosuppressive therapy or > 1 year of therapy. Increasing quartiles of serum 1,25(OH)₂ vitamin D level were associated with increased odds of patients having chronic sarcoidosis (OR = 1.82; 95% CI, 1.11-2.99, P = .019).

Because of the higher activated vitamin D levels in sarcoidosis patients, they are at risk for problems with vitamin D supplementation. I have seen two patients develop large numbers of kidney stones after receiving high-dose vitamin D. Sodhi and Aldrich reported on a cohort of 196 sarcoidosis patients who had received vitamin D and compared them with 196 control patients with sarcoidosis who were not receiving vitamin D.⁶ Hypercalcemia was more frequent in the group that received vitamin D (42.3%) than in the group that did not (18.3%, P < .0001). In this study, only a minority (23%) of patients receiving vitamin D had their 1,25(OH)₂ vitamin D level checked.


Pearl: Lymphocyte count and 1,25(OH)₂ vitamin D levels can be helpful tests in assessing sarcoidosis activity. Patients with sarcoidosis who receive vitamin D should have their 1.25(OH)₂ vitamin D levels monitored.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. El Jammal et al. Sarcoidosis Vasc Diffuse Lung Dis. 2023 Sep 13;40(3):e2023031.

2. Morell F et al. Chest. 2002 Apr;121(4):1239-44.

3. Jones NP et al. Br J Ophthalmol. 2016 Oct;100(10):1393-6.

4. Rohmer J et al. Ocul Immunol Inflamm. 2020 Apr 2;28(3):341-7.

5. Kavathia D et al. Respir Med. 2010 Apr;104(4):564–70.

6. Sodhi A and Aldrich T. Am J Med Sci. 2016 Sep;352(3):252-7.

A 40-year-old women is evaluated for liver abnormalities. She had elevated transaminases and alkaline phosphatase. A liver ultrasound showed multiple lesions. She underwent liver biopsy, which showed granulomas. What test results, if abnormal, would be most suggestive of sarcoidosis?

A. Erythrocyte sedimentation rate

B. C-reactive protein

C. Lymphocyte count

D. Antinuclear antibodies

The correct answer here is lymphocyte count. Sarcoidosis is in just about every differential diagnosis, as it can involve every organ system. I will share with you a few pearls I have learned over 30 years of taking care of patients with sarcoidosis. Lymphocyte counts drop with active sarcoidosis. Sarcoidosis should always be part of the differential when you see lymphopenia. El Jammal et al. studied 90 patients referred for possible granulomatous hepatitis.¹ Seventy-three patients had a final diagnosis of granulomatous hepatitis, and 38 of those patients had sarcoidosis. Lymphopenia had a high specificity (85.7%) for the diagnosis of sarcoidosis, with a specificity of 100% in the patients under 50 years old.

Morell and colleagues looked at whether low lymphocyte counts and low lymphocyte percentage were markers of active sarcoidosis.² Forty patients with biopsy-proven sarcoidosis were prospectively evaluated every 6 months. A low lymphocyte count and a low lymphocyte percentage (< 20%) were detected more frequently in patients with active sarcoidosis than in the patients with asymptomatic sarcoidosis (P < .02 and P < .0001).

Jones et al. looked at lymphopenia as a marker of sarcoidosis in patients presenting with uveitis.³ The study was a retrospective case-control study (112 patients with sarcoidosis-associated uveitis and 398 controls with other forms of uveitis). The mean lymphocyte count for patients with sarcoidosis was 1.43 vs. 2.04 for other causes of uveitis (P ≤ .0001).

Patients with sarcoidosis are at risk of hypercalciuria, hypercalcemia, and kidney stones. These are common in patients with sarcoidosis, with up to 50% of such patients having hypercalciuria. This is because in sarcoidosis patients 25(OH) vitamin D is converted in granulomas by activated macrophages to 1,25(OH)₂ vitamin D, which is the active form of vitamin D.

Several studies have looked at the diagnostic utility of 1,25(OH)₂ vitamin D levels in patients with suspected sarcoidosis. Rohmer and colleagues looked at whether 1,25(OH)₂ vitamin D levels could help with the diagnosis of sarcoidosis as the cause of uveitis.⁴ They found that the level of 25(OH) vitamin D in sarcoidosis patients with uveitis was lower than in patients with uveitis without sarcoidosis, 34 vs. 43 nmol/mL (P < .02), whereas the 1,25(OH)₂ vitamin D level was higher in patients with sarcoidosis than in those with uveitis without sarcoidosis, 132 vs. 108 pmol/L (P = .02). They looked at the 1,25(OH)₂D/25(OH)D ratio; a ratio > 3.5 was strongly associated with an abnormal chest CT-scan (OR = 5.7, P = .003) and granulomas on bronchial biopsy (OR = 14.7, P = .007).

Kavathia et al. looked at whether elevated 1,25(OH)₂ vitamin D levels predicted chronicity of sarcoidosis.⁵ A total of 59 sarcoidosis patients were recruited for the study. Higher serum 1,25(OH)₂ vitamin D levels were associated with patients requiring repeated systemic immunosuppressive therapy or > 1 year of therapy. Increasing quartiles of serum 1,25(OH)₂ vitamin D level were associated with increased odds of patients having chronic sarcoidosis (OR = 1.82; 95% CI, 1.11-2.99, P = .019).

Because of the higher activated vitamin D levels in sarcoidosis patients, they are at risk for problems with vitamin D supplementation. I have seen two patients develop large numbers of kidney stones after receiving high-dose vitamin D. Sodhi and Aldrich reported on a cohort of 196 sarcoidosis patients who had received vitamin D and compared them with 196 control patients with sarcoidosis who were not receiving vitamin D.⁶ Hypercalcemia was more frequent in the group that received vitamin D (42.3%) than in the group that did not (18.3%, P < .0001). In this study, only a minority (23%) of patients receiving vitamin D had their 1,25(OH)₂ vitamin D level checked.


Pearl: Lymphocyte count and 1,25(OH)₂ vitamin D levels can be helpful tests in assessing sarcoidosis activity. Patients with sarcoidosis who receive vitamin D should have their 1.25(OH)₂ vitamin D levels monitored.

Dr. Paauw is professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington. Contact Dr. Paauw at [email protected].

References

1. El Jammal et al. Sarcoidosis Vasc Diffuse Lung Dis. 2023 Sep 13;40(3):e2023031.

2. Morell F et al. Chest. 2002 Apr;121(4):1239-44.

3. Jones NP et al. Br J Ophthalmol. 2016 Oct;100(10):1393-6.

4. Rohmer J et al. Ocul Immunol Inflamm. 2020 Apr 2;28(3):341-7.

5. Kavathia D et al. Respir Med. 2010 Apr;104(4):564–70.

6. Sodhi A and Aldrich T. Am J Med Sci. 2016 Sep;352(3):252-7.

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

ANAHEIM, CALIF. – Gargling and nasal rinsing with saltwater several times a day appeared to be associated with significantly lower COVID-19 hospitalization rates in a small, randomized, double-blind, controlled study.

“The hypothesis was that interventions that target the upper respiratory tract may reduce the frequency and duration of upper respiratory symptoms associated with COVID-19,” said Sebastian Espinoza, first author of the study; he is with Trinity University, San Antonio.

Adults aged 18-65 years who tested positive for SARS-CoV-2 on polymerase chain reaction (PCR) testing between 2020 and 2022 were randomly selected to use low- or high-dose saltwater regimens for 14 days at the Harris Health System, Houston. For patients to be included in the study, 14 days had to have elapsed since the onset of any symptoms associated with COVID.

The low dose was 2.13 grams of salt dissolved in 8 ounces of warm water, and the high dose was 6 grams. Participants gargled the saltwater and used it as a nasal rinse for 5 minutes four times a day.

Primary outcomes included frequency and duration of symptoms associated with SARS-CoV-2 infection; secondary outcomes included admission to the hospital or the intensive care unit, mechanical ventilatory support, or death.

The findings were presented in a poster at the annual meeting of the American College of Allergy, Asthma, and Immunology.

Fifty-eight people were randomly assigned to either the low-saline (n = 27) or the high-saline (n = 28) group; three patients were lost to follow-up in both these groups. The reference control population consisted of 9,398 people with confirmed SARS-CoV-2 infection. Rates of vaccination were similar for all participants.

Hospitalization rates in the low- (18.5%) and high- (21.4%) saline groups were significantly lower than in the reference control population (58.8%; P < .001). No significant differences were noted in other outcomes among these groups.

The average age of patients in the control population (n = 9,398) was 45 years. The average age was similar in the low- and high-saline groups. In the low-saline group (n = 27), the average age was 39, and in the high-saline group, the average age was 41.

In all three groups, body mass index was between 29.6 and 31.7.

Exclusion criteria included chronic hypertension or participation in another interventional study.
 

‘Low risk, small potential benefit’

Allergist Zach Rubin, MD, a spokesperson for the ACAAI, said in an interview that the findings are in line with other small studies that previously reported some benefit in using nasal saline irrigation and gargling to treat a SARS-CoV-2 infection.

“This is a type of intervention that is low risk with some small potential benefit,” he said.

The researchers did not evaluate the potential reason for the saline regimen’s association with fewer hospitalizations, but Dr. Rubin said, “It may be possible that nasal saline irrigation and gargling help improve viral clearance and reduce the risk of microaspiration into the lungs, so it may be possible that this intervention could reduce the risk of pneumonia, which is a major cause of hospitalization.”

Dr. Rubin, who is an allergist at Oak Brook Allergists, Ill., said, “I generally recommend nasal saline irrigation to my patients for allergic rhinitis and viral upper respiratory infections already. It can help reduce symptoms such as nasal congestion, rhinorrhea, postnasal drip, and sinus pain and pressure.”

The intervention may be reasonable beyond an adult population, he said.

“This could be used for pediatric patients as well, if they are developmentally ready to try this intervention,” he said.

Mr. Espinoza said further study is warranted, but he said that if confirmed in later trials, the simple intervention may be particularly helpful in low-resource settings.

Mr. Espinoza and Dr. Rubin have disclosed no relevant financial relationships.

A version of this article appeared on Medscape.com.

SAN DIEGO – Patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) who start a tumor necrosis factor inhibitor (TNFi) appear to have rates of survival and respiratory-related hospitalization similar to those initiating a non-TNFi biologic disease-modifying antirheumatic drug (bDMARD) or Janus kinase inhibitor (JAKi), results from a large pharmacoepidemiologic study show.

“These results challenge some of the findings in prior literature that perhaps TNFi should be avoided in RA-ILD,” lead study investigator Bryant R. England, MD, PhD,  said in an interview. The findings were presented during a plenary session at the American College of Rheumatology annual meeting.

Dr. England, associate professor of rheumatology and immunology at the University of Nebraska Medical Center, Omaha, said that while RA-ILD carries a poor prognosis, a paucity of evidence exists on the effectiveness and safety of disease-modifying therapies in this population.

It’s a pleasant surprise “to see that the investigators were unable to demonstrate a significant difference in the risk of respiratory hospitalization or death between people with RA-ILD initiating non-TNFi/JAKi versus TNFi. Here is a unique situation where a so called ‘negative’ study contributes important information. This study provides needed safety data, as they were unable to show that TNFi results in worsening of severe RA-ILD outcomes,” Sindhu R. Johnson, MD, PhD, professor of medicine at the University of Toronto, said when asked for comment on the study.

University of Toronto

“While this study does not address the use of these medications for the treatment of RA-ILD, these data suggest that TNFi may remain a treatment option for articular disease in people with RA-ILD,” said Dr. Johnson, who was not involved with the study.

For the study, Dr. England and colleagues drew from Veterans Health Administration data between 2006 and 2018 to identify patients with RA-ILD initiating TNFi or non-TNFi biologic/JAKi for the first time. Those who received ILD-focused therapies such as mycophenolate and antifibrotics were excluded from the analysis.

The researchers used validated administrative algorithms requiring multiple RA and ILD diagnostic codes to identify RA-ILD and used 1:1 propensity score matching to compare TNFi and non-TNFi biologic/JAKi factors such as health care use, comorbidities, and several RA-ILD factors, such as pretreatment forced vital capacity, obtained from electronic health records and administrative data. The primary outcome was a composite of time to respiratory-related hospitalization or death using Cox regression models.

Dr. England reported findings from 237 TNFi initiators and 237 non-TNFi/JAKi initiators. Their mean age was 68 years and 92% were male. After matching, the mean standardized differences of variables in the propensity score model improved, but a few variables remained slightly imbalanced, such as two markers of inflammation, inhaled corticosteroid use, and body mass index. The most frequently prescribed TNFi drugs were adalimumab (51%) and etanercept (37%), and the most frequently prescribed non-TNFi/JAKi drugs were rituximab (53%) and abatacept (28%).

The researchers observed no significant difference in the primary outcome between non-TNFi/JAKi and TNFi initiators (adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 0.92-1.60). They also observed no significant differences in respiratory hospitalization, all-cause mortality, or respiratory-related death at 1 and 3 years. In sensitivity analyses with modified cohort eligibility requirements, no significant differences in outcomes were observed between non-TNFi/JAKi and TNFi initiators.

During his presentation at the meeting, Dr. England posed the question: Are TNFi drugs safe to be used in RA-ILD?

“The answer is: It’s complex,” he said. “Our findings don’t suggest that we should be systematically avoiding TNFis with every single person with RA-ILD. But that’s different than whether there are specific subpopulations of RA-ILD for which the choice of these therapies may differ. Unfortunately, we could not address that in this study. We also could not address whether TNFis have efficacy at stopping, slowing, or reversing progression of the ILD itself. This calls for us as a field to gather together and pursue clinical trials to try to generate robust evidence that can guide these important clinical decisions that we’re making with our patients.”

He acknowledged certain limitations of the analysis, including its observational design. “So, despite best efforts to minimize bias with pharmacoepidemiologic designs and approaches, there could still be confounding and selection,” he said. “Additionally, RA-ILD is a heterogeneous disease characterized by different patterns and trajectories. While we did account for several RA- and ILD-related factors, we could not account for all heterogeneity in RA-ILD.”

When asked for comment on the study, session moderator Janet Pope, MD, MPH, professor of medicine in the division of rheumatology at the University of Western Ontario, London, said that the study findings surprised her.

“Sometimes RA patients on TNFis were thought to have more new or worsening ILD vs. [those on] non-TNFi bDMARDs, but most [data were] from older studies where TNFis were used as initial bDMARD in sicker patients,” she told this news organization. “So, data were confounded previously. Even in this study, there may have been channeling bias as it was not a randomized controlled trial. We need a definitive randomized controlled trial to answer this question of what the most optimal therapy for RA-ILD is.”

Dr. England reports receiving consulting fees and research support from Boehringer Ingelheim, and several coauthors reported financial relationships from various pharmaceutical companies and medical publishers. Dr. Johnson reports no relevant financial relationships. Dr. Pope reports being a consultant for several pharmaceutical companies. She has received grant/research support from AbbVie/Abbott and Eli Lilly and is an adviser for Boehringer Ingelheim.

A version of this article appeared on Medscape.com.

SAN DIEGO – Patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) who start a tumor necrosis factor inhibitor (TNFi) appear to have rates of survival and respiratory-related hospitalization similar to those initiating a non-TNFi biologic disease-modifying antirheumatic drug (bDMARD) or Janus kinase inhibitor (JAKi), results from a large pharmacoepidemiologic study show.

“These results challenge some of the findings in prior literature that perhaps TNFi should be avoided in RA-ILD,” lead study investigator Bryant R. England, MD, PhD,  said in an interview. The findings were presented during a plenary session at the American College of Rheumatology annual meeting.

Dr. England, associate professor of rheumatology and immunology at the University of Nebraska Medical Center, Omaha, said that while RA-ILD carries a poor prognosis, a paucity of evidence exists on the effectiveness and safety of disease-modifying therapies in this population.

It’s a pleasant surprise “to see that the investigators were unable to demonstrate a significant difference in the risk of respiratory hospitalization or death between people with RA-ILD initiating non-TNFi/JAKi versus TNFi. Here is a unique situation where a so called ‘negative’ study contributes important information. This study provides needed safety data, as they were unable to show that TNFi results in worsening of severe RA-ILD outcomes,” Sindhu R. Johnson, MD, PhD, professor of medicine at the University of Toronto, said when asked for comment on the study.

University of Toronto

“While this study does not address the use of these medications for the treatment of RA-ILD, these data suggest that TNFi may remain a treatment option for articular disease in people with RA-ILD,” said Dr. Johnson, who was not involved with the study.

For the study, Dr. England and colleagues drew from Veterans Health Administration data between 2006 and 2018 to identify patients with RA-ILD initiating TNFi or non-TNFi biologic/JAKi for the first time. Those who received ILD-focused therapies such as mycophenolate and antifibrotics were excluded from the analysis.

The researchers used validated administrative algorithms requiring multiple RA and ILD diagnostic codes to identify RA-ILD and used 1:1 propensity score matching to compare TNFi and non-TNFi biologic/JAKi factors such as health care use, comorbidities, and several RA-ILD factors, such as pretreatment forced vital capacity, obtained from electronic health records and administrative data. The primary outcome was a composite of time to respiratory-related hospitalization or death using Cox regression models.

Dr. England reported findings from 237 TNFi initiators and 237 non-TNFi/JAKi initiators. Their mean age was 68 years and 92% were male. After matching, the mean standardized differences of variables in the propensity score model improved, but a few variables remained slightly imbalanced, such as two markers of inflammation, inhaled corticosteroid use, and body mass index. The most frequently prescribed TNFi drugs were adalimumab (51%) and etanercept (37%), and the most frequently prescribed non-TNFi/JAKi drugs were rituximab (53%) and abatacept (28%).

The researchers observed no significant difference in the primary outcome between non-TNFi/JAKi and TNFi initiators (adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 0.92-1.60). They also observed no significant differences in respiratory hospitalization, all-cause mortality, or respiratory-related death at 1 and 3 years. In sensitivity analyses with modified cohort eligibility requirements, no significant differences in outcomes were observed between non-TNFi/JAKi and TNFi initiators.

During his presentation at the meeting, Dr. England posed the question: Are TNFi drugs safe to be used in RA-ILD?

“The answer is: It’s complex,” he said. “Our findings don’t suggest that we should be systematically avoiding TNFis with every single person with RA-ILD. But that’s different than whether there are specific subpopulations of RA-ILD for which the choice of these therapies may differ. Unfortunately, we could not address that in this study. We also could not address whether TNFis have efficacy at stopping, slowing, or reversing progression of the ILD itself. This calls for us as a field to gather together and pursue clinical trials to try to generate robust evidence that can guide these important clinical decisions that we’re making with our patients.”

He acknowledged certain limitations of the analysis, including its observational design. “So, despite best efforts to minimize bias with pharmacoepidemiologic designs and approaches, there could still be confounding and selection,” he said. “Additionally, RA-ILD is a heterogeneous disease characterized by different patterns and trajectories. While we did account for several RA- and ILD-related factors, we could not account for all heterogeneity in RA-ILD.”

When asked for comment on the study, session moderator Janet Pope, MD, MPH, professor of medicine in the division of rheumatology at the University of Western Ontario, London, said that the study findings surprised her.

“Sometimes RA patients on TNFis were thought to have more new or worsening ILD vs. [those on] non-TNFi bDMARDs, but most [data were] from older studies where TNFis were used as initial bDMARD in sicker patients,” she told this news organization. “So, data were confounded previously. Even in this study, there may have been channeling bias as it was not a randomized controlled trial. We need a definitive randomized controlled trial to answer this question of what the most optimal therapy for RA-ILD is.”

Dr. England reports receiving consulting fees and research support from Boehringer Ingelheim, and several coauthors reported financial relationships from various pharmaceutical companies and medical publishers. Dr. Johnson reports no relevant financial relationships. Dr. Pope reports being a consultant for several pharmaceutical companies. She has received grant/research support from AbbVie/Abbott and Eli Lilly and is an adviser for Boehringer Ingelheim.

A version of this article appeared on Medscape.com.

SAN DIEGO – Patients with rheumatoid arthritis-associated interstitial lung disease (RA-ILD) who start a tumor necrosis factor inhibitor (TNFi) appear to have rates of survival and respiratory-related hospitalization similar to those initiating a non-TNFi biologic disease-modifying antirheumatic drug (bDMARD) or Janus kinase inhibitor (JAKi), results from a large pharmacoepidemiologic study show.

“These results challenge some of the findings in prior literature that perhaps TNFi should be avoided in RA-ILD,” lead study investigator Bryant R. England, MD, PhD,  said in an interview. The findings were presented during a plenary session at the American College of Rheumatology annual meeting.

Dr. England, associate professor of rheumatology and immunology at the University of Nebraska Medical Center, Omaha, said that while RA-ILD carries a poor prognosis, a paucity of evidence exists on the effectiveness and safety of disease-modifying therapies in this population.

It’s a pleasant surprise “to see that the investigators were unable to demonstrate a significant difference in the risk of respiratory hospitalization or death between people with RA-ILD initiating non-TNFi/JAKi versus TNFi. Here is a unique situation where a so called ‘negative’ study contributes important information. This study provides needed safety data, as they were unable to show that TNFi results in worsening of severe RA-ILD outcomes,” Sindhu R. Johnson, MD, PhD, professor of medicine at the University of Toronto, said when asked for comment on the study.

University of Toronto

“While this study does not address the use of these medications for the treatment of RA-ILD, these data suggest that TNFi may remain a treatment option for articular disease in people with RA-ILD,” said Dr. Johnson, who was not involved with the study.

For the study, Dr. England and colleagues drew from Veterans Health Administration data between 2006 and 2018 to identify patients with RA-ILD initiating TNFi or non-TNFi biologic/JAKi for the first time. Those who received ILD-focused therapies such as mycophenolate and antifibrotics were excluded from the analysis.

The researchers used validated administrative algorithms requiring multiple RA and ILD diagnostic codes to identify RA-ILD and used 1:1 propensity score matching to compare TNFi and non-TNFi biologic/JAKi factors such as health care use, comorbidities, and several RA-ILD factors, such as pretreatment forced vital capacity, obtained from electronic health records and administrative data. The primary outcome was a composite of time to respiratory-related hospitalization or death using Cox regression models.

Dr. England reported findings from 237 TNFi initiators and 237 non-TNFi/JAKi initiators. Their mean age was 68 years and 92% were male. After matching, the mean standardized differences of variables in the propensity score model improved, but a few variables remained slightly imbalanced, such as two markers of inflammation, inhaled corticosteroid use, and body mass index. The most frequently prescribed TNFi drugs were adalimumab (51%) and etanercept (37%), and the most frequently prescribed non-TNFi/JAKi drugs were rituximab (53%) and abatacept (28%).

The researchers observed no significant difference in the primary outcome between non-TNFi/JAKi and TNFi initiators (adjusted hazard ratio [aHR], 1.22; 95% confidence interval [CI], 0.92-1.60). They also observed no significant differences in respiratory hospitalization, all-cause mortality, or respiratory-related death at 1 and 3 years. In sensitivity analyses with modified cohort eligibility requirements, no significant differences in outcomes were observed between non-TNFi/JAKi and TNFi initiators.

During his presentation at the meeting, Dr. England posed the question: Are TNFi drugs safe to be used in RA-ILD?

“The answer is: It’s complex,” he said. “Our findings don’t suggest that we should be systematically avoiding TNFis with every single person with RA-ILD. But that’s different than whether there are specific subpopulations of RA-ILD for which the choice of these therapies may differ. Unfortunately, we could not address that in this study. We also could not address whether TNFis have efficacy at stopping, slowing, or reversing progression of the ILD itself. This calls for us as a field to gather together and pursue clinical trials to try to generate robust evidence that can guide these important clinical decisions that we’re making with our patients.”

He acknowledged certain limitations of the analysis, including its observational design. “So, despite best efforts to minimize bias with pharmacoepidemiologic designs and approaches, there could still be confounding and selection,” he said. “Additionally, RA-ILD is a heterogeneous disease characterized by different patterns and trajectories. While we did account for several RA- and ILD-related factors, we could not account for all heterogeneity in RA-ILD.”

When asked for comment on the study, session moderator Janet Pope, MD, MPH, professor of medicine in the division of rheumatology at the University of Western Ontario, London, said that the study findings surprised her.

“Sometimes RA patients on TNFis were thought to have more new or worsening ILD vs. [those on] non-TNFi bDMARDs, but most [data were] from older studies where TNFis were used as initial bDMARD in sicker patients,” she told this news organization. “So, data were confounded previously. Even in this study, there may have been channeling bias as it was not a randomized controlled trial. We need a definitive randomized controlled trial to answer this question of what the most optimal therapy for RA-ILD is.”

Dr. England reports receiving consulting fees and research support from Boehringer Ingelheim, and several coauthors reported financial relationships from various pharmaceutical companies and medical publishers. Dr. Johnson reports no relevant financial relationships. Dr. Pope reports being a consultant for several pharmaceutical companies. She has received grant/research support from AbbVie/Abbott and Eli Lilly and is an adviser for Boehringer Ingelheim.

A version of this article appeared on Medscape.com.

Evidence summary

Recent UK study shows no difference by timing

A 2022 UK prospective, randomized, multicenter trial assigned 21,104 predominantly White adults (58% men) with hypertension to take their usual antihypertensive medication either in the morning (6 am to 10 am) or evening (8 pm to midnight).¹ A computer algorithm randomized patients, but neither the patients nor the investigators were masked to allocation.

All patient baseline characteristics were equivalent between groups. If troubled by nocturia, patients in the evening group taking diuretics were told to take only the diuretic earlier (6 pm) and subsequently to change to morning if they experienced persistent bothersome symptoms. More patients in the evening administration group than in the morning administration group reported having to change the time of day that they took their diuretic (546 [5.2%] vs 71 [0.7%]; P < .0001).

The median follow-up was 5.2 years. Data were collected at regular intervals through patient completion of online questionnaires and researcher analysis of ­National Health Service data on hospitalization and death. The intention-to-treat analysis showed no difference in the primary outcome (a composite of vascular death, nonfatal myocardial infarction, or nonfatal stroke) between the evening and morning administration groups (0.69 events vs 0.72 events per 100 person-years; hazard ratio [HR] = 0.95; 95% CI, 0.83-1.10; P = .53).

The controversial Hygia Project favored evening

Prior to the UK study was the Hygia Chronotherapy Trial, a prospective, controlled, multicenter study conducted within the primary care setting in Spain. Caucasian Spanish adults (N = 19,168; mean age, 61 years; 56% men) with hypertension were randomly assigned to take all prescribed antihypertensive medication either at bedtime or upon waking.²

The Hygia Project initially sought to establish the value of ambulatory blood pressure monitoring (ABPM) compared to office blood pressure (BP) monitoring and to explore the prognostic value of sleeping BP.³ The study objectives evolved over time. The randomization process was not clearly described,^2,3 but multiple randomizations were alluded to. The authors stated that “for any of these chronotherapy trials” randomizations were done separately for “each participating center” and “randomization of participants to treatment-time regimen is done separately for each hypertension medication or combination being tested.”

A 2022 UK multicenter trial found no difference between the evening and morning administration groups in a composite outcome of vascular death, nonfatal myocardial infarction, or nonfatal stroke.

The baseline characteristics of patients in the evening and morning administration groups were similar, but statistically significant differences existed in BMI (29.6 vs 29.7; P = .030) and sleep-time systolic BP percent decline (9.3 vs 9.0; P < .001). Mean baseline 48-hour BP was 132/77 mm Hg. Hypertension was defined as an awake systolic BP ≥ 135 mm Hg or diastolic BP ≥ 85 mm Hg, or asleep systolic BP ≥ 120 mm Hg or diastolic BP ≥ 70 mm Hg. BP readings were confirmed with 48-hour ABPM. Exclusion criteria included pregnancy, a history of substance use disorder, night-shift work, and cardiovascular disease (defined as unstable angina, heart failure, life-threatening arrhythmia, atrial fibrillation, kidney failure, and grade III-IV retinopathy).

Prescribers were free to prescribe medicines from 5 classes (diuretic, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or beta-blocker) as they thought appropriate, were encouraged to use fixed-dose combination pills, and were told not to use split (eg, twice per day) dosing. Annual ­48-hour ABPM was completed, and patients’ electronic health records were analyzed by blinded investigators. Median follow-up was 6.3 years, and only 84 participants failed to complete the minimum 1-year participation requirement.

Continue to: The primary outcome...

The primary outcome—a composite of cardiovascular death, myocardial infarction, coronary revascularization, heart failure, or stroke—occurred in 1752 patients, favoring the bedtime group (HR = 0.55; 95% CI, 0.50-0.61; P < .001). The calculated number of events was 1130 in the morning administration group and 622 in the evening administration group; the authors did not explicitly report the event numbers in each group. Each component of the composite outcome also favored evening administration (P < .001 for all): cardiovascular death (HR = 0.44; 95% CI, 0.34-0.56), myocardial infarction (HR = 0.66; 95% CI, 0.52-0.84), coronary revascularization (HR = 0.60; 95% CI, 0.47-0.75), heart failure (HR = 0.58; 95% CI, 0.49-0.70), and stroke (HR = 0.51; 95% CI, 0.41-0.63).

The complicated, layered study design and randomization methods limit the ability to critically appraise the study.

Smaller Spanish study also supported evening administration

A prior, smaller, prospective randomized trial conducted by the same researchers as the Hygia Project found even greater benefits to evening BP medication administration.⁴ The 2156 Spanish patients (52% men; average age, 55 years) from multiple primary care offices were randomized 1:1 to BP medication administration either upon awakening or at bedtime. Dozens of baseline characteristics were evenly distributed except for age (55.0 vs 56.3; P = .021) and creatinine (0.96 vs 0.98; P = .028), both of which were lower in the evening group.

After a median follow-up of 5.6 years, the bedtime group had significantly lower total events (187 events in the morning group vs 68 in the evening group; relative risk [RR] = 0.39; 95% CI, 0.29-0.51; P < .001). Individual cardiovascular outcomes also dramatically favored the evening group: total deaths (12 vs 28; P = .008), cardiovascular deaths (3 vs 14; P = .006), cardiovascular disease events (30 vs 74; P < .001), stroke (7 vs 24; P = .001), and heart failure (8 vs 33; P < .001).

Limits of both the UK trial and the Hygia Project trial included single countries of study with a lack of racial and ethnic diversity, and greater nonadherence to the evening administration of the medications.

Recommendations from others

A 2022 consensus statement from the International Society of Hypertension, published before the UK trial, recommended against bedtime dosing until more high-quality data became available. They pointed to evidence showing higher medication adherence with morning dosing, risk for asleep BP dropping, and worsening daytime BP control as reasons to continue morning administration.⁵ Other reviewers have questioned the Hygia Project results due to their reported implausibly large effects on cardiovascular outcomes, noting that independent attempts to verify the methods and the data have proven challenging and are not completed.⁶

Editor’s takeaway

I confess that I was swayed by the results of the Hygia Project; for a year or so, I advised my patients to take at least 1 BP pill at night. But after the UK study came out, I needed to reconsider. I began to worry that the great outcomes of nocturnal therapy may have been a mirage. I have returned to counseling patients to take their BP medications in whichever way fosters consistency while minimizing adverse effects for them.

Evidence summary

Recent UK study shows no difference by timing

A 2022 UK prospective, randomized, multicenter trial assigned 21,104 predominantly White adults (58% men) with hypertension to take their usual antihypertensive medication either in the morning (6 am to 10 am) or evening (8 pm to midnight).¹ A computer algorithm randomized patients, but neither the patients nor the investigators were masked to allocation.

All patient baseline characteristics were equivalent between groups. If troubled by nocturia, patients in the evening group taking diuretics were told to take only the diuretic earlier (6 pm) and subsequently to change to morning if they experienced persistent bothersome symptoms. More patients in the evening administration group than in the morning administration group reported having to change the time of day that they took their diuretic (546 [5.2%] vs 71 [0.7%]; P < .0001).

The median follow-up was 5.2 years. Data were collected at regular intervals through patient completion of online questionnaires and researcher analysis of ­National Health Service data on hospitalization and death. The intention-to-treat analysis showed no difference in the primary outcome (a composite of vascular death, nonfatal myocardial infarction, or nonfatal stroke) between the evening and morning administration groups (0.69 events vs 0.72 events per 100 person-years; hazard ratio [HR] = 0.95; 95% CI, 0.83-1.10; P = .53).

The controversial Hygia Project favored evening

Prior to the UK study was the Hygia Chronotherapy Trial, a prospective, controlled, multicenter study conducted within the primary care setting in Spain. Caucasian Spanish adults (N = 19,168; mean age, 61 years; 56% men) with hypertension were randomly assigned to take all prescribed antihypertensive medication either at bedtime or upon waking.²

The Hygia Project initially sought to establish the value of ambulatory blood pressure monitoring (ABPM) compared to office blood pressure (BP) monitoring and to explore the prognostic value of sleeping BP.³ The study objectives evolved over time. The randomization process was not clearly described,^2,3 but multiple randomizations were alluded to. The authors stated that “for any of these chronotherapy trials” randomizations were done separately for “each participating center” and “randomization of participants to treatment-time regimen is done separately for each hypertension medication or combination being tested.”

A 2022 UK multicenter trial found no difference between the evening and morning administration groups in a composite outcome of vascular death, nonfatal myocardial infarction, or nonfatal stroke.

The baseline characteristics of patients in the evening and morning administration groups were similar, but statistically significant differences existed in BMI (29.6 vs 29.7; P = .030) and sleep-time systolic BP percent decline (9.3 vs 9.0; P < .001). Mean baseline 48-hour BP was 132/77 mm Hg. Hypertension was defined as an awake systolic BP ≥ 135 mm Hg or diastolic BP ≥ 85 mm Hg, or asleep systolic BP ≥ 120 mm Hg or diastolic BP ≥ 70 mm Hg. BP readings were confirmed with 48-hour ABPM. Exclusion criteria included pregnancy, a history of substance use disorder, night-shift work, and cardiovascular disease (defined as unstable angina, heart failure, life-threatening arrhythmia, atrial fibrillation, kidney failure, and grade III-IV retinopathy).

Prescribers were free to prescribe medicines from 5 classes (diuretic, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or beta-blocker) as they thought appropriate, were encouraged to use fixed-dose combination pills, and were told not to use split (eg, twice per day) dosing. Annual ­48-hour ABPM was completed, and patients’ electronic health records were analyzed by blinded investigators. Median follow-up was 6.3 years, and only 84 participants failed to complete the minimum 1-year participation requirement.

Continue to: The primary outcome...

The primary outcome—a composite of cardiovascular death, myocardial infarction, coronary revascularization, heart failure, or stroke—occurred in 1752 patients, favoring the bedtime group (HR = 0.55; 95% CI, 0.50-0.61; P < .001). The calculated number of events was 1130 in the morning administration group and 622 in the evening administration group; the authors did not explicitly report the event numbers in each group. Each component of the composite outcome also favored evening administration (P < .001 for all): cardiovascular death (HR = 0.44; 95% CI, 0.34-0.56), myocardial infarction (HR = 0.66; 95% CI, 0.52-0.84), coronary revascularization (HR = 0.60; 95% CI, 0.47-0.75), heart failure (HR = 0.58; 95% CI, 0.49-0.70), and stroke (HR = 0.51; 95% CI, 0.41-0.63).

The complicated, layered study design and randomization methods limit the ability to critically appraise the study.

Smaller Spanish study also supported evening administration

A prior, smaller, prospective randomized trial conducted by the same researchers as the Hygia Project found even greater benefits to evening BP medication administration.⁴ The 2156 Spanish patients (52% men; average age, 55 years) from multiple primary care offices were randomized 1:1 to BP medication administration either upon awakening or at bedtime. Dozens of baseline characteristics were evenly distributed except for age (55.0 vs 56.3; P = .021) and creatinine (0.96 vs 0.98; P = .028), both of which were lower in the evening group.

After a median follow-up of 5.6 years, the bedtime group had significantly lower total events (187 events in the morning group vs 68 in the evening group; relative risk [RR] = 0.39; 95% CI, 0.29-0.51; P < .001). Individual cardiovascular outcomes also dramatically favored the evening group: total deaths (12 vs 28; P = .008), cardiovascular deaths (3 vs 14; P = .006), cardiovascular disease events (30 vs 74; P < .001), stroke (7 vs 24; P = .001), and heart failure (8 vs 33; P < .001).

Limits of both the UK trial and the Hygia Project trial included single countries of study with a lack of racial and ethnic diversity, and greater nonadherence to the evening administration of the medications.

Recommendations from others

A 2022 consensus statement from the International Society of Hypertension, published before the UK trial, recommended against bedtime dosing until more high-quality data became available. They pointed to evidence showing higher medication adherence with morning dosing, risk for asleep BP dropping, and worsening daytime BP control as reasons to continue morning administration.⁵ Other reviewers have questioned the Hygia Project results due to their reported implausibly large effects on cardiovascular outcomes, noting that independent attempts to verify the methods and the data have proven challenging and are not completed.⁶

Editor’s takeaway

I confess that I was swayed by the results of the Hygia Project; for a year or so, I advised my patients to take at least 1 BP pill at night. But after the UK study came out, I needed to reconsider. I began to worry that the great outcomes of nocturnal therapy may have been a mirage. I have returned to counseling patients to take their BP medications in whichever way fosters consistency while minimizing adverse effects for them.

Evidence summary

Recent UK study shows no difference by timing

A 2022 UK prospective, randomized, multicenter trial assigned 21,104 predominantly White adults (58% men) with hypertension to take their usual antihypertensive medication either in the morning (6 am to 10 am) or evening (8 pm to midnight).¹ A computer algorithm randomized patients, but neither the patients nor the investigators were masked to allocation.

All patient baseline characteristics were equivalent between groups. If troubled by nocturia, patients in the evening group taking diuretics were told to take only the diuretic earlier (6 pm) and subsequently to change to morning if they experienced persistent bothersome symptoms. More patients in the evening administration group than in the morning administration group reported having to change the time of day that they took their diuretic (546 [5.2%] vs 71 [0.7%]; P < .0001).

The median follow-up was 5.2 years. Data were collected at regular intervals through patient completion of online questionnaires and researcher analysis of ­National Health Service data on hospitalization and death. The intention-to-treat analysis showed no difference in the primary outcome (a composite of vascular death, nonfatal myocardial infarction, or nonfatal stroke) between the evening and morning administration groups (0.69 events vs 0.72 events per 100 person-years; hazard ratio [HR] = 0.95; 95% CI, 0.83-1.10; P = .53).

The controversial Hygia Project favored evening

Prior to the UK study was the Hygia Chronotherapy Trial, a prospective, controlled, multicenter study conducted within the primary care setting in Spain. Caucasian Spanish adults (N = 19,168; mean age, 61 years; 56% men) with hypertension were randomly assigned to take all prescribed antihypertensive medication either at bedtime or upon waking.²

The Hygia Project initially sought to establish the value of ambulatory blood pressure monitoring (ABPM) compared to office blood pressure (BP) monitoring and to explore the prognostic value of sleeping BP.³ The study objectives evolved over time. The randomization process was not clearly described,^2,3 but multiple randomizations were alluded to. The authors stated that “for any of these chronotherapy trials” randomizations were done separately for “each participating center” and “randomization of participants to treatment-time regimen is done separately for each hypertension medication or combination being tested.”

A 2022 UK multicenter trial found no difference between the evening and morning administration groups in a composite outcome of vascular death, nonfatal myocardial infarction, or nonfatal stroke.

The baseline characteristics of patients in the evening and morning administration groups were similar, but statistically significant differences existed in BMI (29.6 vs 29.7; P = .030) and sleep-time systolic BP percent decline (9.3 vs 9.0; P < .001). Mean baseline 48-hour BP was 132/77 mm Hg. Hypertension was defined as an awake systolic BP ≥ 135 mm Hg or diastolic BP ≥ 85 mm Hg, or asleep systolic BP ≥ 120 mm Hg or diastolic BP ≥ 70 mm Hg. BP readings were confirmed with 48-hour ABPM. Exclusion criteria included pregnancy, a history of substance use disorder, night-shift work, and cardiovascular disease (defined as unstable angina, heart failure, life-threatening arrhythmia, atrial fibrillation, kidney failure, and grade III-IV retinopathy).

Prescribers were free to prescribe medicines from 5 classes (diuretic, angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, calcium channel blocker, or beta-blocker) as they thought appropriate, were encouraged to use fixed-dose combination pills, and were told not to use split (eg, twice per day) dosing. Annual ­48-hour ABPM was completed, and patients’ electronic health records were analyzed by blinded investigators. Median follow-up was 6.3 years, and only 84 participants failed to complete the minimum 1-year participation requirement.

Continue to: The primary outcome...

The primary outcome—a composite of cardiovascular death, myocardial infarction, coronary revascularization, heart failure, or stroke—occurred in 1752 patients, favoring the bedtime group (HR = 0.55; 95% CI, 0.50-0.61; P < .001). The calculated number of events was 1130 in the morning administration group and 622 in the evening administration group; the authors did not explicitly report the event numbers in each group. Each component of the composite outcome also favored evening administration (P < .001 for all): cardiovascular death (HR = 0.44; 95% CI, 0.34-0.56), myocardial infarction (HR = 0.66; 95% CI, 0.52-0.84), coronary revascularization (HR = 0.60; 95% CI, 0.47-0.75), heart failure (HR = 0.58; 95% CI, 0.49-0.70), and stroke (HR = 0.51; 95% CI, 0.41-0.63).

The complicated, layered study design and randomization methods limit the ability to critically appraise the study.

Smaller Spanish study also supported evening administration

A prior, smaller, prospective randomized trial conducted by the same researchers as the Hygia Project found even greater benefits to evening BP medication administration.⁴ The 2156 Spanish patients (52% men; average age, 55 years) from multiple primary care offices were randomized 1:1 to BP medication administration either upon awakening or at bedtime. Dozens of baseline characteristics were evenly distributed except for age (55.0 vs 56.3; P = .021) and creatinine (0.96 vs 0.98; P = .028), both of which were lower in the evening group.

After a median follow-up of 5.6 years, the bedtime group had significantly lower total events (187 events in the morning group vs 68 in the evening group; relative risk [RR] = 0.39; 95% CI, 0.29-0.51; P < .001). Individual cardiovascular outcomes also dramatically favored the evening group: total deaths (12 vs 28; P = .008), cardiovascular deaths (3 vs 14; P = .006), cardiovascular disease events (30 vs 74; P < .001), stroke (7 vs 24; P = .001), and heart failure (8 vs 33; P < .001).

Limits of both the UK trial and the Hygia Project trial included single countries of study with a lack of racial and ethnic diversity, and greater nonadherence to the evening administration of the medications.

Recommendations from others

A 2022 consensus statement from the International Society of Hypertension, published before the UK trial, recommended against bedtime dosing until more high-quality data became available. They pointed to evidence showing higher medication adherence with morning dosing, risk for asleep BP dropping, and worsening daytime BP control as reasons to continue morning administration.⁵ Other reviewers have questioned the Hygia Project results due to their reported implausibly large effects on cardiovascular outcomes, noting that independent attempts to verify the methods and the data have proven challenging and are not completed.⁶

Editor’s takeaway

I confess that I was swayed by the results of the Hygia Project; for a year or so, I advised my patients to take at least 1 BP pill at night. But after the UK study came out, I needed to reconsider. I began to worry that the great outcomes of nocturnal therapy may have been a mirage. I have returned to counseling patients to take their BP medications in whichever way fosters consistency while minimizing adverse effects for them.

A large Canadian clinical trial has found that using small-volume tubes to collect blood samples for laboratory testing of intensive care unit patients can reduce blood transfusions without affecting lab results.

“We showed in a large pragmatic cluster trial that automatically collect less blood for laboratory testing reduced red blood cell transfusions by about 10 units of red blood cells per 100 patients in the ICU,” lead study author Deborah M. Siegal, MD, associate professor at the University of Ottawa and scientist at the Ottawa Hospital Research Institute, said.

The study was coordinated by the Population Health Research Institute, an affiliate of McMaster University in Hamilton (Ont.) Health Sciences, where Dr. Siegal worked before moving to Ottawa.

The STRATUS randomized clinical trial, published in JAMA, involved 25 adult medical-surgical ICUs across Canada, where 21,201 patients were randomized to either standard-volume or small-volume tubes for collecting blood samples. During the course of the study, each site switched to the small-volume collection tubes.

“We also showed there were no negative effects on lab testing, and by that we measured the sufficiency of  the specimens,” Dr. Siegal added. “We were able to show that there wasn’t a problem with the amount of blood that was available for the tests to be done.”

The samples were collected from February 2019 through January 2021, through the period of COVID-19 restrictions. Dr. Siegal explained that 6,210 patients admitted early in the COVID-19 pandemic were excluded from the primary analysis, but were included in secondary analyses.

 

Study results

While the study found no significant difference in RBC units per patient per ICU stage – a relative risk of .91 (95% confidence interval, 0.79-1.05; P = .19), it did find an absolute reduction of 7.24 RBC units/100 patients per ICU stay. 

Findings from the secondary analyses, which included 27,411 patients, were:

• A 12% reduction in RBC units per patient per ICU stay after switching from standard-volume to small-volume tubes (RR, 0.88; 95%  CI, 0.77-1; P = .04).
• An absolute reduction of 9.84 RBC units/100 patients per ICU stay (95% CI, 0.24-20.76).

In the primary analysis population, the median transfusion-adjusted hemoglobin was not statistically different between the standard- and small-volume collection tube groups, with an average difference of 0.1 g/dL (95% CI, –0.04 to .23), but it was lower in the secondary population, with a mean difference of .17 g/dL (95% CI, 0.05-0.29).

“Those patients that we analyzed in the secondary analysis population received about 36,000 units of blood, just in 25 ICU units in Canada in less than 2 years,” Dr. Siegal said. “If we saved 10 units per 100 patients, that’s 1,500 units of blood. That really speaks to a small effect at the individual patient level but really potential for widespread effect. We are now in a period of blood product shortage not only in Canada but worldwide.”

 

First clinical trial for small tubes

Dr. Siegal noted this was the first clinical trial to compare standard- and small-volume blood collection tools, “and also to show there is both a benefit and a lack of harm,” Dr. Siegal said. “We thought that a randomized trial was the best way to move the needle. If we could design a trial of a large population of patients to show benefit and no harm, it would be a win, and that’s in fact what happened.”

She added, “The tubes essentially have the same cost, work the same, and go on the same equipment the same way the standard-volume tubes do, so it wasn’t a practice change for people in the hospital.”

The study also found an identical low rate of unusable specimens did not differ regardless of the type of collection tube: less than .03%.

Dr. Siegal said the study group is collaborating with hematology stakeholders in Canada, including Canadian Blood Services, which provides blood plasma to the country’s provincial and territorial health systems, and is reaching out to the American Society of Hematology.

“We’re going to target both hematologists and critical  care providers and, even more broadly than the critical care community, hospitals, because anemia is big problem in hospitals,” Dr. Siegal said. “I think we can think about this more broadly.”

The study received funding from the Hamilton Academic Health Sciences Organization. Dr. Siegal disclosed relationships with Bristol-Myers Squibb-Pfizer, AstraZeneca and Roche.

A large Canadian clinical trial has found that using small-volume tubes to collect blood samples for laboratory testing of intensive care unit patients can reduce blood transfusions without affecting lab results.

“We showed in a large pragmatic cluster trial that automatically collect less blood for laboratory testing reduced red blood cell transfusions by about 10 units of red blood cells per 100 patients in the ICU,” lead study author Deborah M. Siegal, MD, associate professor at the University of Ottawa and scientist at the Ottawa Hospital Research Institute, said.

The study was coordinated by the Population Health Research Institute, an affiliate of McMaster University in Hamilton (Ont.) Health Sciences, where Dr. Siegal worked before moving to Ottawa.

The STRATUS randomized clinical trial, published in JAMA, involved 25 adult medical-surgical ICUs across Canada, where 21,201 patients were randomized to either standard-volume or small-volume tubes for collecting blood samples. During the course of the study, each site switched to the small-volume collection tubes.

“We also showed there were no negative effects on lab testing, and by that we measured the sufficiency of  the specimens,” Dr. Siegal added. “We were able to show that there wasn’t a problem with the amount of blood that was available for the tests to be done.”

The samples were collected from February 2019 through January 2021, through the period of COVID-19 restrictions. Dr. Siegal explained that 6,210 patients admitted early in the COVID-19 pandemic were excluded from the primary analysis, but were included in secondary analyses.

 

Study results

While the study found no significant difference in RBC units per patient per ICU stage – a relative risk of .91 (95% confidence interval, 0.79-1.05; P = .19), it did find an absolute reduction of 7.24 RBC units/100 patients per ICU stay. 

Findings from the secondary analyses, which included 27,411 patients, were:

• A 12% reduction in RBC units per patient per ICU stay after switching from standard-volume to small-volume tubes (RR, 0.88; 95%  CI, 0.77-1; P = .04).
• An absolute reduction of 9.84 RBC units/100 patients per ICU stay (95% CI, 0.24-20.76).

In the primary analysis population, the median transfusion-adjusted hemoglobin was not statistically different between the standard- and small-volume collection tube groups, with an average difference of 0.1 g/dL (95% CI, –0.04 to .23), but it was lower in the secondary population, with a mean difference of .17 g/dL (95% CI, 0.05-0.29).

“Those patients that we analyzed in the secondary analysis population received about 36,000 units of blood, just in 25 ICU units in Canada in less than 2 years,” Dr. Siegal said. “If we saved 10 units per 100 patients, that’s 1,500 units of blood. That really speaks to a small effect at the individual patient level but really potential for widespread effect. We are now in a period of blood product shortage not only in Canada but worldwide.”

 

First clinical trial for small tubes

Dr. Siegal noted this was the first clinical trial to compare standard- and small-volume blood collection tools, “and also to show there is both a benefit and a lack of harm,” Dr. Siegal said. “We thought that a randomized trial was the best way to move the needle. If we could design a trial of a large population of patients to show benefit and no harm, it would be a win, and that’s in fact what happened.”

She added, “The tubes essentially have the same cost, work the same, and go on the same equipment the same way the standard-volume tubes do, so it wasn’t a practice change for people in the hospital.”

The study also found an identical low rate of unusable specimens did not differ regardless of the type of collection tube: less than .03%.

Dr. Siegal said the study group is collaborating with hematology stakeholders in Canada, including Canadian Blood Services, which provides blood plasma to the country’s provincial and territorial health systems, and is reaching out to the American Society of Hematology.

“We’re going to target both hematologists and critical  care providers and, even more broadly than the critical care community, hospitals, because anemia is big problem in hospitals,” Dr. Siegal said. “I think we can think about this more broadly.”

The study received funding from the Hamilton Academic Health Sciences Organization. Dr. Siegal disclosed relationships with Bristol-Myers Squibb-Pfizer, AstraZeneca and Roche.

A large Canadian clinical trial has found that using small-volume tubes to collect blood samples for laboratory testing of intensive care unit patients can reduce blood transfusions without affecting lab results.

“We showed in a large pragmatic cluster trial that automatically collect less blood for laboratory testing reduced red blood cell transfusions by about 10 units of red blood cells per 100 patients in the ICU,” lead study author Deborah M. Siegal, MD, associate professor at the University of Ottawa and scientist at the Ottawa Hospital Research Institute, said.

The study was coordinated by the Population Health Research Institute, an affiliate of McMaster University in Hamilton (Ont.) Health Sciences, where Dr. Siegal worked before moving to Ottawa.

The STRATUS randomized clinical trial, published in JAMA, involved 25 adult medical-surgical ICUs across Canada, where 21,201 patients were randomized to either standard-volume or small-volume tubes for collecting blood samples. During the course of the study, each site switched to the small-volume collection tubes.

“We also showed there were no negative effects on lab testing, and by that we measured the sufficiency of  the specimens,” Dr. Siegal added. “We were able to show that there wasn’t a problem with the amount of blood that was available for the tests to be done.”

The samples were collected from February 2019 through January 2021, through the period of COVID-19 restrictions. Dr. Siegal explained that 6,210 patients admitted early in the COVID-19 pandemic were excluded from the primary analysis, but were included in secondary analyses.

 

Study results

While the study found no significant difference in RBC units per patient per ICU stage – a relative risk of .91 (95% confidence interval, 0.79-1.05; P = .19), it did find an absolute reduction of 7.24 RBC units/100 patients per ICU stay. 

Findings from the secondary analyses, which included 27,411 patients, were:

• A 12% reduction in RBC units per patient per ICU stay after switching from standard-volume to small-volume tubes (RR, 0.88; 95%  CI, 0.77-1; P = .04).
• An absolute reduction of 9.84 RBC units/100 patients per ICU stay (95% CI, 0.24-20.76).

In the primary analysis population, the median transfusion-adjusted hemoglobin was not statistically different between the standard- and small-volume collection tube groups, with an average difference of 0.1 g/dL (95% CI, –0.04 to .23), but it was lower in the secondary population, with a mean difference of .17 g/dL (95% CI, 0.05-0.29).

“Those patients that we analyzed in the secondary analysis population received about 36,000 units of blood, just in 25 ICU units in Canada in less than 2 years,” Dr. Siegal said. “If we saved 10 units per 100 patients, that’s 1,500 units of blood. That really speaks to a small effect at the individual patient level but really potential for widespread effect. We are now in a period of blood product shortage not only in Canada but worldwide.”

 

First clinical trial for small tubes

Dr. Siegal noted this was the first clinical trial to compare standard- and small-volume blood collection tools, “and also to show there is both a benefit and a lack of harm,” Dr. Siegal said. “We thought that a randomized trial was the best way to move the needle. If we could design a trial of a large population of patients to show benefit and no harm, it would be a win, and that’s in fact what happened.”

She added, “The tubes essentially have the same cost, work the same, and go on the same equipment the same way the standard-volume tubes do, so it wasn’t a practice change for people in the hospital.”

The study also found an identical low rate of unusable specimens did not differ regardless of the type of collection tube: less than .03%.

Dr. Siegal said the study group is collaborating with hematology stakeholders in Canada, including Canadian Blood Services, which provides blood plasma to the country’s provincial and territorial health systems, and is reaching out to the American Society of Hematology.

“We’re going to target both hematologists and critical  care providers and, even more broadly than the critical care community, hospitals, because anemia is big problem in hospitals,” Dr. Siegal said. “I think we can think about this more broadly.”

The study received funding from the Hamilton Academic Health Sciences Organization. Dr. Siegal disclosed relationships with Bristol-Myers Squibb-Pfizer, AstraZeneca and Roche.

As the aging population grows and telehealth expands in the wake of the COVID-19 pandemic, an emerging trend of in-home care is reshaping how patients access and receive physical therapy services.

Partnerships between hospitals and home health companies are increasing access to rehabilitation services not only for older adults but also for people in rural areas, those without reliable transportation, and patients with injuries that hinder their driving abilities.

“We find more and more that physical therapy at their home, instead of coming to an outpatient facility, is something more and more folks are requesting,” said Bill Benoit, MBA, chief operating officer of University Hospitals, Cleveland. “In this post-COVID environment, people are getting all different types of services in their home when they’re available, and this is one of them. The pandemic sped up the process of us moving away from the traditional brick and mortar hospital.”

UH recently announced a partnership with Luna Physical Therapy, a company founded in 2018 that provides home services. Luna has teamed up with more than two dozen other hospitals in the United States to offer home-based rehabilitation, according to the company.

The process for arranging in-home therapies through hospital-clinic partnerships is like any other inpatient or outpatient rehabilitation, Mr. Benoit said: A patient meets with a specialist or primary care practitioner, they discuss options, and eventually the clinician recommends physical therapy. The only difference here, he said, is rather than going to a separate facility or a hospital, the patient logs onto a mobile app that matches them with a physical therapist on the basis of their location, needs, and the times they are available.

The prescribing physician oversees the patient’s progress through notes provided by the therapist.

“For the primary care physician or surgeon, they’re not going to see much of a difference,” Mr. Benoit said. “This just adds to that list of options for patients.”
 

Safer, more productive PT

A study, published in the journal Family Practice, found that 76% of patients who are prescribed physical therapy do not initiate the services after it has been recommended.

Aside from the convenience and expanded accessibility for patients, the home therapy option can be more productive, said Denise Wagner, PT, DPT, a physical therapist with Johns Hopkins, Baltimore.

“Home is safer for many patients, but home is also more engaging and motivating,” she said. “Home health clinicians are experts in using whatever they find in the home environment as equipment; many people have stairs in their home, so we can use the rail as something to hold. If patient likes to walk their dog, we can use putting a leash on dog as balance activity.”

Therapy in the home setting helps physical therapists customize programs to fit each patient’s lifestyle, said Gira Shah, PT, a physical therapist with Providence Home Services in Seattle.

For example, patients generally want to know how to function within their own space – navigate their kitchens to make food or get in and out of their bathtubs. Staying in that space allows therapists to focus on those specific goals, Ms. Shah said. “It’s more of a functional therapy. The beauty of this [is that] as therapists we’re trying to assess, ‘what does the patient need to be independent?’ ”

The consulting firm McKinsey predicts that as much as $265 billion in health care services for Medicare recipients will be provided within the home by 2025.

The obvious question is: Why would hospitals partner with clinics rather than offer in-home services on their own?

The answer, like most things in health care, boils down to money.

The billing and documentation system that they use is more efficient than anything hospitals have, said John Brickley, PT, MA, vice president and physical therapist at MedStar Health, a health care system in Maryland and the Washington, D.C., area. MedStar and Luna announced a partnership last June.

“We would financially fall on our face if we tried to use our own billing systems; it would take too much time,” Mr. Brickley said. “Do we need them from a quality-of-care standpoint? No. They have the type of technology that’s not at our disposal.”

Patients should be aware of the difference between home-based PT and other health services for homebound patients, Mr. Brickley said. Medicare considers a patient homebound if they need the help of another person or medical equipment to leave their home or if their doctor believes their condition would worsen with greater mobility.

From the perspective of an insurance company, a home therapy session arranged by a hospital-clinic partnership is an ambulatory appointment and uses the same charging mechanism as most other visits. For a home health care visit, patients must qualify as homebound.

Home-based PT can be used for conditions including neurologic issues, bone and joint problems, balance, and fall deconditioning and prevention. But if a patient needs heavy equipment that cannot be transported, outpatient services are more practical.

That should be determined by the primary care practitioner or specialist evaluating each patient, said Palak Shah, PT, cofounder and head of clinical services at Luna.

“Primary care physicians play a huge role – that’s where patients express their initial concerns,” she said. “It’s up to them to make patients aware about all the options.”

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

As the aging population grows and telehealth expands in the wake of the COVID-19 pandemic, an emerging trend of in-home care is reshaping how patients access and receive physical therapy services.

Partnerships between hospitals and home health companies are increasing access to rehabilitation services not only for older adults but also for people in rural areas, those without reliable transportation, and patients with injuries that hinder their driving abilities.

“We find more and more that physical therapy at their home, instead of coming to an outpatient facility, is something more and more folks are requesting,” said Bill Benoit, MBA, chief operating officer of University Hospitals, Cleveland. “In this post-COVID environment, people are getting all different types of services in their home when they’re available, and this is one of them. The pandemic sped up the process of us moving away from the traditional brick and mortar hospital.”

UH recently announced a partnership with Luna Physical Therapy, a company founded in 2018 that provides home services. Luna has teamed up with more than two dozen other hospitals in the United States to offer home-based rehabilitation, according to the company.

The process for arranging in-home therapies through hospital-clinic partnerships is like any other inpatient or outpatient rehabilitation, Mr. Benoit said: A patient meets with a specialist or primary care practitioner, they discuss options, and eventually the clinician recommends physical therapy. The only difference here, he said, is rather than going to a separate facility or a hospital, the patient logs onto a mobile app that matches them with a physical therapist on the basis of their location, needs, and the times they are available.

The prescribing physician oversees the patient’s progress through notes provided by the therapist.

“For the primary care physician or surgeon, they’re not going to see much of a difference,” Mr. Benoit said. “This just adds to that list of options for patients.”
 

Safer, more productive PT

A study, published in the journal Family Practice, found that 76% of patients who are prescribed physical therapy do not initiate the services after it has been recommended.

Aside from the convenience and expanded accessibility for patients, the home therapy option can be more productive, said Denise Wagner, PT, DPT, a physical therapist with Johns Hopkins, Baltimore.

“Home is safer for many patients, but home is also more engaging and motivating,” she said. “Home health clinicians are experts in using whatever they find in the home environment as equipment; many people have stairs in their home, so we can use the rail as something to hold. If patient likes to walk their dog, we can use putting a leash on dog as balance activity.”

Therapy in the home setting helps physical therapists customize programs to fit each patient’s lifestyle, said Gira Shah, PT, a physical therapist with Providence Home Services in Seattle.

For example, patients generally want to know how to function within their own space – navigate their kitchens to make food or get in and out of their bathtubs. Staying in that space allows therapists to focus on those specific goals, Ms. Shah said. “It’s more of a functional therapy. The beauty of this [is that] as therapists we’re trying to assess, ‘what does the patient need to be independent?’ ”

The consulting firm McKinsey predicts that as much as $265 billion in health care services for Medicare recipients will be provided within the home by 2025.

The obvious question is: Why would hospitals partner with clinics rather than offer in-home services on their own?

The answer, like most things in health care, boils down to money.

The billing and documentation system that they use is more efficient than anything hospitals have, said John Brickley, PT, MA, vice president and physical therapist at MedStar Health, a health care system in Maryland and the Washington, D.C., area. MedStar and Luna announced a partnership last June.

“We would financially fall on our face if we tried to use our own billing systems; it would take too much time,” Mr. Brickley said. “Do we need them from a quality-of-care standpoint? No. They have the type of technology that’s not at our disposal.”

Patients should be aware of the difference between home-based PT and other health services for homebound patients, Mr. Brickley said. Medicare considers a patient homebound if they need the help of another person or medical equipment to leave their home or if their doctor believes their condition would worsen with greater mobility.

From the perspective of an insurance company, a home therapy session arranged by a hospital-clinic partnership is an ambulatory appointment and uses the same charging mechanism as most other visits. For a home health care visit, patients must qualify as homebound.

Home-based PT can be used for conditions including neurologic issues, bone and joint problems, balance, and fall deconditioning and prevention. But if a patient needs heavy equipment that cannot be transported, outpatient services are more practical.

That should be determined by the primary care practitioner or specialist evaluating each patient, said Palak Shah, PT, cofounder and head of clinical services at Luna.

“Primary care physicians play a huge role – that’s where patients express their initial concerns,” she said. “It’s up to them to make patients aware about all the options.”

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

As the aging population grows and telehealth expands in the wake of the COVID-19 pandemic, an emerging trend of in-home care is reshaping how patients access and receive physical therapy services.

Partnerships between hospitals and home health companies are increasing access to rehabilitation services not only for older adults but also for people in rural areas, those without reliable transportation, and patients with injuries that hinder their driving abilities.

“We find more and more that physical therapy at their home, instead of coming to an outpatient facility, is something more and more folks are requesting,” said Bill Benoit, MBA, chief operating officer of University Hospitals, Cleveland. “In this post-COVID environment, people are getting all different types of services in their home when they’re available, and this is one of them. The pandemic sped up the process of us moving away from the traditional brick and mortar hospital.”

UH recently announced a partnership with Luna Physical Therapy, a company founded in 2018 that provides home services. Luna has teamed up with more than two dozen other hospitals in the United States to offer home-based rehabilitation, according to the company.

The process for arranging in-home therapies through hospital-clinic partnerships is like any other inpatient or outpatient rehabilitation, Mr. Benoit said: A patient meets with a specialist or primary care practitioner, they discuss options, and eventually the clinician recommends physical therapy. The only difference here, he said, is rather than going to a separate facility or a hospital, the patient logs onto a mobile app that matches them with a physical therapist on the basis of their location, needs, and the times they are available.

The prescribing physician oversees the patient’s progress through notes provided by the therapist.

“For the primary care physician or surgeon, they’re not going to see much of a difference,” Mr. Benoit said. “This just adds to that list of options for patients.”
 

Safer, more productive PT

A study, published in the journal Family Practice, found that 76% of patients who are prescribed physical therapy do not initiate the services after it has been recommended.

Aside from the convenience and expanded accessibility for patients, the home therapy option can be more productive, said Denise Wagner, PT, DPT, a physical therapist with Johns Hopkins, Baltimore.

“Home is safer for many patients, but home is also more engaging and motivating,” she said. “Home health clinicians are experts in using whatever they find in the home environment as equipment; many people have stairs in their home, so we can use the rail as something to hold. If patient likes to walk their dog, we can use putting a leash on dog as balance activity.”

Therapy in the home setting helps physical therapists customize programs to fit each patient’s lifestyle, said Gira Shah, PT, a physical therapist with Providence Home Services in Seattle.

For example, patients generally want to know how to function within their own space – navigate their kitchens to make food or get in and out of their bathtubs. Staying in that space allows therapists to focus on those specific goals, Ms. Shah said. “It’s more of a functional therapy. The beauty of this [is that] as therapists we’re trying to assess, ‘what does the patient need to be independent?’ ”

The consulting firm McKinsey predicts that as much as $265 billion in health care services for Medicare recipients will be provided within the home by 2025.

The obvious question is: Why would hospitals partner with clinics rather than offer in-home services on their own?

The answer, like most things in health care, boils down to money.

The billing and documentation system that they use is more efficient than anything hospitals have, said John Brickley, PT, MA, vice president and physical therapist at MedStar Health, a health care system in Maryland and the Washington, D.C., area. MedStar and Luna announced a partnership last June.

“We would financially fall on our face if we tried to use our own billing systems; it would take too much time,” Mr. Brickley said. “Do we need them from a quality-of-care standpoint? No. They have the type of technology that’s not at our disposal.”

Patients should be aware of the difference between home-based PT and other health services for homebound patients, Mr. Brickley said. Medicare considers a patient homebound if they need the help of another person or medical equipment to leave their home or if their doctor believes their condition would worsen with greater mobility.

From the perspective of an insurance company, a home therapy session arranged by a hospital-clinic partnership is an ambulatory appointment and uses the same charging mechanism as most other visits. For a home health care visit, patients must qualify as homebound.

Home-based PT can be used for conditions including neurologic issues, bone and joint problems, balance, and fall deconditioning and prevention. But if a patient needs heavy equipment that cannot be transported, outpatient services are more practical.

That should be determined by the primary care practitioner or specialist evaluating each patient, said Palak Shah, PT, cofounder and head of clinical services at Luna.

“Primary care physicians play a huge role – that’s where patients express their initial concerns,” she said. “It’s up to them to make patients aware about all the options.”

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

Regularly using marijuana can significantly increase a person’s risk of heart attack, heart failure, and stroke, according to a pair of new studies that will be presented at a major upcoming medical conference.

People who use marijuana daily have a 34% increased risk of heart failure, compared with people who don’t use the drug, according to one of the new studies.

The new findings leverage health data from 157,000 people in the National Institutes of Health “All of Us” research program. Researchers analyzed whether marijuana users were more likely to experience heart failure than nonusers over the course of nearly 4 years. The results indicated that coronary artery disease was behind marijuana users’ increased risk. (Coronary artery disease is the buildup of plaque on the walls of the arteries that supply blood to the heart.)

The research was conducted by a team at Medstar Health, a large Maryland health care system that operates 10 hospitals plus hundreds of clinics. The findings will be presented at the American Heart Association’s Scientific Sessions 2023 in Philadelphia.

“Our results should encourage more researchers to study the use of marijuana to better understand its health implications, especially on cardiovascular risk,” said researcher Yakubu Bene-Alhasan, MD, MPH, a doctor at Medstar Health in Baltimore. “We want to provide the population with high-quality information on marijuana use and to help inform policy decisions at the state level, to educate patients, and to guide health care professionals.”

About one in five people in the United States use marijuana, according to the Centers for Disease Control and Prevention. The majority of U.S. states allow marijuana to be used legally for medical purposes, and more than 20 states have legalized recreational marijuana, a tracker from the National Conference of State Legislatures shows. 

A second study that will be presented at the conference shows that older people with any combination of type 2 diabetes, high blood pressure, and high cholesterol who use marijuana have an increased risk for a major heart or brain event, compared with people who never used the drug. 

The researchers analyzed data for more than 28,000 people age 65 and older who had health conditions that put them at risk for heart problems and whose medical records showed they were marijuana users but not tobacco users. The results showed at least a 20% increased risk of heart attack, stroke, cardiac arrest, or arrhythmia (irregular heartbeat). 

The findings are significant because medical professionals have long said that research on the long-term health effects of using marijuana are limited. 

“The latest research about cannabis use indicates that smoking and inhaling cannabis increases concentrations of blood carboxyhemoglobin (carbon monoxide, a poisonous gas), tar (partly burned combustible matter) similar to the effects of inhaling a tobacco cigarette, both of which have been linked to heart muscle disease, chest pain, heart rhythm disturbances, heart attacks and other serious conditions,” said Robert L. Page II, PharmD, MSPH, chair of the volunteer writing group for the 2020 American Heart Association Scientific Statement: Medical Marijuana, Recreational Cannabis, and Cardiovascular Health, in a statement. “Together with the results of these two research studies, the cardiovascular risks of cannabis use are becoming clearer and should be carefully considered and monitored by health care professionals and the public.”

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

Regularly using marijuana can significantly increase a person’s risk of heart attack, heart failure, and stroke, according to a pair of new studies that will be presented at a major upcoming medical conference.

People who use marijuana daily have a 34% increased risk of heart failure, compared with people who don’t use the drug, according to one of the new studies.

The new findings leverage health data from 157,000 people in the National Institutes of Health “All of Us” research program. Researchers analyzed whether marijuana users were more likely to experience heart failure than nonusers over the course of nearly 4 years. The results indicated that coronary artery disease was behind marijuana users’ increased risk. (Coronary artery disease is the buildup of plaque on the walls of the arteries that supply blood to the heart.)

The research was conducted by a team at Medstar Health, a large Maryland health care system that operates 10 hospitals plus hundreds of clinics. The findings will be presented at the American Heart Association’s Scientific Sessions 2023 in Philadelphia.

“Our results should encourage more researchers to study the use of marijuana to better understand its health implications, especially on cardiovascular risk,” said researcher Yakubu Bene-Alhasan, MD, MPH, a doctor at Medstar Health in Baltimore. “We want to provide the population with high-quality information on marijuana use and to help inform policy decisions at the state level, to educate patients, and to guide health care professionals.”

About one in five people in the United States use marijuana, according to the Centers for Disease Control and Prevention. The majority of U.S. states allow marijuana to be used legally for medical purposes, and more than 20 states have legalized recreational marijuana, a tracker from the National Conference of State Legislatures shows. 

A second study that will be presented at the conference shows that older people with any combination of type 2 diabetes, high blood pressure, and high cholesterol who use marijuana have an increased risk for a major heart or brain event, compared with people who never used the drug. 

The researchers analyzed data for more than 28,000 people age 65 and older who had health conditions that put them at risk for heart problems and whose medical records showed they were marijuana users but not tobacco users. The results showed at least a 20% increased risk of heart attack, stroke, cardiac arrest, or arrhythmia (irregular heartbeat). 

The findings are significant because medical professionals have long said that research on the long-term health effects of using marijuana are limited. 

“The latest research about cannabis use indicates that smoking and inhaling cannabis increases concentrations of blood carboxyhemoglobin (carbon monoxide, a poisonous gas), tar (partly burned combustible matter) similar to the effects of inhaling a tobacco cigarette, both of which have been linked to heart muscle disease, chest pain, heart rhythm disturbances, heart attacks and other serious conditions,” said Robert L. Page II, PharmD, MSPH, chair of the volunteer writing group for the 2020 American Heart Association Scientific Statement: Medical Marijuana, Recreational Cannabis, and Cardiovascular Health, in a statement. “Together with the results of these two research studies, the cardiovascular risks of cannabis use are becoming clearer and should be carefully considered and monitored by health care professionals and the public.”

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

Regularly using marijuana can significantly increase a person’s risk of heart attack, heart failure, and stroke, according to a pair of new studies that will be presented at a major upcoming medical conference.

People who use marijuana daily have a 34% increased risk of heart failure, compared with people who don’t use the drug, according to one of the new studies.

The new findings leverage health data from 157,000 people in the National Institutes of Health “All of Us” research program. Researchers analyzed whether marijuana users were more likely to experience heart failure than nonusers over the course of nearly 4 years. The results indicated that coronary artery disease was behind marijuana users’ increased risk. (Coronary artery disease is the buildup of plaque on the walls of the arteries that supply blood to the heart.)

The research was conducted by a team at Medstar Health, a large Maryland health care system that operates 10 hospitals plus hundreds of clinics. The findings will be presented at the American Heart Association’s Scientific Sessions 2023 in Philadelphia.

“Our results should encourage more researchers to study the use of marijuana to better understand its health implications, especially on cardiovascular risk,” said researcher Yakubu Bene-Alhasan, MD, MPH, a doctor at Medstar Health in Baltimore. “We want to provide the population with high-quality information on marijuana use and to help inform policy decisions at the state level, to educate patients, and to guide health care professionals.”

About one in five people in the United States use marijuana, according to the Centers for Disease Control and Prevention. The majority of U.S. states allow marijuana to be used legally for medical purposes, and more than 20 states have legalized recreational marijuana, a tracker from the National Conference of State Legislatures shows. 

A second study that will be presented at the conference shows that older people with any combination of type 2 diabetes, high blood pressure, and high cholesterol who use marijuana have an increased risk for a major heart or brain event, compared with people who never used the drug. 

The researchers analyzed data for more than 28,000 people age 65 and older who had health conditions that put them at risk for heart problems and whose medical records showed they were marijuana users but not tobacco users. The results showed at least a 20% increased risk of heart attack, stroke, cardiac arrest, or arrhythmia (irregular heartbeat). 

The findings are significant because medical professionals have long said that research on the long-term health effects of using marijuana are limited. 

“The latest research about cannabis use indicates that smoking and inhaling cannabis increases concentrations of blood carboxyhemoglobin (carbon monoxide, a poisonous gas), tar (partly burned combustible matter) similar to the effects of inhaling a tobacco cigarette, both of which have been linked to heart muscle disease, chest pain, heart rhythm disturbances, heart attacks and other serious conditions,” said Robert L. Page II, PharmD, MSPH, chair of the volunteer writing group for the 2020 American Heart Association Scientific Statement: Medical Marijuana, Recreational Cannabis, and Cardiovascular Health, in a statement. “Together with the results of these two research studies, the cardiovascular risks of cannabis use are becoming clearer and should be carefully considered and monitored by health care professionals and the public.”

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

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

First launched in 2022 in partnership with Three Lakes Foundation, Bridging Specialties™: Timely Diagnosis for ILD is a collaborative initiative hinged on bringing together pulmonary and primary care experts. To shorten the time to diagnosis for interstitial lung diseases (ILDs) like pulmonary fibrosis, the initiative illustrates that there is a need for clinicians to work collaboratively, utilizing the unique strengths of all involved. The steering committee of experts from both fields created a clinician-facing toolkit that, with support of two quality improvement grants, will be introduced into health care institutions in 2024.

Kavitha Selvan, MD, Pulmonary and Critical Care Fellow at the University of Chicago School of Medicine, and Amirahwaty Abdullah, MBBS, Assistant Professor & Critical Care Medicine Associate Program Director at the West Virginia University School of Medicine, are the recipients of the grants. Each recipient will receive funding to implement strategic quality improvement projects designed to work closely with primary care partners and address the needs of their communities to shorten the time to diagnosis for patients with ILD.

Dr. Selvan’s project leverages the diverse population of Chicago and will engage primary care physicians by working closely with the Medical Director of the Primary Care Group within the University of Chicago. “There is a growing body of research that illustrates vast racial and ethnic disparities in ILD outcomes, including time to diagnosis and survival. The diverse community we serve in Chicago provided the inspiration for our project, which we hope will enable us to take a meaningful step toward achieving equity in health care,” Dr. Selvan said. “Through close collaboration with the dedicated physicians in our Primary Care Group, we aim to increase recognition of signs and symptoms suggestive of ILD earlier in the course of disease and streamline the thoughtful, multidisciplinary care our patients need.”

Affecting 400,000 people in the United States, ILDs are often overlooked as a potential diagnosis given their rarity. A proper diagnosis for this disease is further complicated by ubiquitous presenting symptoms that are common in many other diseases, including asthma, COPD, and cardiac conditions, and often leads to a misdiagnosis. This delay in diagnosis, or an outright misdiagnosis, leads to additional delays in receiving proper treatment and, subsequently, a degradation in the patient’s quality of life. For Dr. Abdullah, the rarity of the disease is not the issue; rather, there is an access issue. Because of this, their project will focus on telemedicine implementation to meet the needs of their area. “While ILD is a rare disease, the state of West Virginia has a disproportionately increased prevalence due to a variety of societal factors,” Dr. Abdullah said. “Despite this prevalence, there is one ILD clinic in the state of West Virginia in comparison to 1,253 primary care providers throughout the state. To address this gap, the project will focus on expanding telemedicine capabilities in order to reach these patients virtually through their primary care physicians who would help us to facilitate the video-assisted visits.”

To learn more about the toolkit they will be implementing, visit the CHEST website.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.

Pulmonologist Evan Stepp, MD, FCCP, has a teenage daughter who doesn’t smoke or vape – as far as he knows, Stepp will admit – but the statistics on youth smoking are alarming enough to have him worried.

On one hand, fewer Americans are smoking today than ever before. Since 1992, the percentage of people who told Gallup that they’d had a cigarette in the past week has dropped from 28% to 11%. Meanwhile, the rate of new lung cancer cases declined from 65 per every 100,000 people in 1992 to 34 per 100,000 in 2020, according to the National Cancer Institute.

While those statistics are worth celebrating, they hide an alarming reality: A disproportionate number of teens and young adults today are addicted to nicotine.

According to a November 2022 report from the Centers for Disease Control and Prevention (CDC), 1 in 6 high school students and 1 in 20 middle schoolers are using a nicotine product at least once every day.

“It’s a completely different picture for nicotine cessation in youth,” Dr. Stepp, who is an associate professor at National Jewish Health in Denver, said. “Because of the fact that the nicotine addiction is occurring in a developing brain, which raises many other nicotine-related harms.”
 

Why teens vape

Today’s teens are smoking less actual tobacco, and, instead, overwhelmingly prefer e-cigarettes or vaping. In fact, 85% of high school–aged smokers and 72% of middle school smokers reach for a vape over regular cigarettes or smokeless tobacco, according to the CDC.

It’s not hard to understand why: e-cigarettes use a heating element to turn a nicotine-infused liquid into an aerosol, with no open flame, ash, or lingering smoke. The vapes themselves are easy to conceal, and if someone needed to hide an e-cigarette from particularly perceptive parents or teachers, they can find vapes built into hoodies, fake smartwatches, and USB drives.

Plus, the liquids often come in flavors like fruit, bubble gum, mint, and vanilla, because unflavored nicotine isn’t exactly appealing. “Huge concentrations of nicotine salts are just miserable to breathe in,” Dr. Stepp said. “Flavors are necessary to make these products palatable, and those flavors end up being a huge draw for youth users to get exposed to nicotine addiction.”
 

Challenges surrounding smoking cessation in youth

The powerful effect of nicotine in youth means the need for effective cessation strategies is both more urgent and more difficult. But while physicians can prescribe to adults the antidepressants varenicline and bupropion, along with nicotine replacement therapy, to help ease withdrawal symptoms, the US Food and Drug Administration (FDA) has not approved those medications for anyone under the age of 18.

Research on cessation medications in young people is limited: A recent meta-analysis found only four studies on people between the ages of 12 and 21. In teens, antidepressants seem to help quitting for the first few weeks but are unproven as a long-term solution.

“That really has been a challenge for the 1 in 6 high school students who are current users of tobacco products,” said pediatrician, Susan Walley, MD, a co-author of the American Academy of Pediatrics’ recent position papers on children and smoking.

“One of the things that is important to keep at the forefront of the conversation is that nicotine addiction is a chronic medical disease, and it’s a form of substance abuse,” Dr. Walley said. “We know that we need more research in adolescent tobacco cessation, and it really is about the funding, about research dollars.”

Without medications, smoking cessation in teens relies largely on counseling strategies. A 2017 review published by Cochrane Library found that group counseling was the most effective quitting method, with teens participating in group sessions 35% more likely to stop using nicotine products up to a year later, compared with teens who did not receive any counseling.

Counseling can help educate teens (and parents) on some of the realities of e-cigarettes, bridging the gap between well-established anti-smoking campaigns and the anti-vape campaigns that have yet to catch up.

“We have done a great job promoting cigarette use as dangerous,” Dr. Walley said. “[But] many teens who would never pick up a cigarette –because they know the health risks – are vaping.”
 

How to get a teen to quit

Cessation and prevention strategies are closely linked, and interventions can start in middle school-aged children up through high school and young adults. Simply asking a 12-year-old, “Do you know anyone who smokes?” can help start a conversation that leads to an attempt to quit.

Teens may be compelled to smoke through digital advertising and influencer endorsements on social media platforms, but Gen Z is turned off by the idea that it’s being manipulated by the tobacco industry. Juul, for example, is partially owned by Altria, which makes Marlboros, and Vuse is wholly owned by R.J. Reynolds, which makes Camel cigarettes.

“If you can get somebody to understand that Big Tobacco is trying to manipulate you as a young person to want to illegally obtain and use their products, which are incredibly addictive, thus ensuring you will remain a loyal customer, that could be the thing that pushes them over the hump,” Dr. Stepp said. “You push it away like you would push away a parent trying to tell you how to park a car in the driveway.”

And just because a smoker relapses, it doesn’t mean the cessation was a complete failure. The younger someone is when they stop smoking, the less likely they are to suffer from the long-term health consequences of smoking, according to a 2021 study in the Journal of the American Medical Association. “With the right counseling,” Dr. Walley said, “each relapse is an opportunity for losing the habit permanently.”

This article was adapted from the Summer 2023 online issue of CHEST Advocates. For the full article – and to engage with the other content from this issue – visit https://chestnet.org/chest-­advocates.