Expert Commentary

This transcript has been edited for clarity. 

I usually report five or six studies in the field of neurology that were published in the last months, but July was a vacation month.

I decided to cover another topic, which is the role of glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists beyond diabetes and obesity, and in particular, for the field of neurology and psychiatry. Until a few years ago, the treatment of diabetes with traditional antidiabetic drugs was frustrating for vascular neurologists.

These drugs would lower glucose and had an impact on small-vessel disease, but they had no impact on large-vessel disease, stroke, and vascular mortality. This changed with the sodium-glucose cotransporter 2 antagonists because these drugs were not only effective for diabetes, but they also lowered cardiac mortality, in particular, in patients with cardiac failure.

The next generation of antidiabetic drugs were the GLP-1 receptor agonists and the combined GIP/GLP-1 receptor agonists. These two polypeptides and their receptors play a very important role in diabetes and in obesity. The receptors are found not only in the pancreas but also in the intestinal system, the liver, and the central nervous system.

We have a number of preclinical models, mostly in transgenic mice, which show that these drugs are not effective only in diabetes and obesity, but also in liver disease, kidney failure, and neurodegenerative diseases. GLP-1 receptor agonists also have powerful anti-inflammatory properties. These drugs reduce body weight, and they have positive effects on blood pressure and lipid metabolism. 

In the studies on the use of GLP-1 receptor agonists in diabetes, a meta-analysis with more than 58,000 patients showed a significant risk reduction for stroke compared with placebo, and this risk reduction was in the range of 80%.
 

Stroke, Smoking, and Alcohol

A meta-analysis on the use of GLP-1 receptor agonists in over 30,000 nondiabetic patients with obesity found a significant reduction in blood pressure, mortality, and the risk of myocardial infarction. There was no significant decrease in the risk of stroke, but most probably this is due to the fact that strokes are much less frequent in obesity than in diabetes.

You all know that obesity is also a major risk factor for sleep apnea syndrome. Recently, two large studies with the GIP/GLP-1 receptor agonist tirzepatide found a significant improvement in sleep apnea syndrome compared to placebo, regardless of whether patients needed continuous positive airway pressure therapy or not.

In the therapy studies on diabetes and obesity, there were indications that some smokers in the studies stopped their nicotine consumption. A small pilot study with exenatide in 84 overweight patients who were smokers showed that 46% of patients on exenatide stopped smoking compared with 27% in the placebo group. This could be an indication that GLP-1 receptor agonists have activity on the reward system in the brain. Currently, there are a number of larger placebo-controlled trials ongoing. 

Another aspect is alcohol consumption. An epidemiologic study in Denmark using data from the National Health Registry showed that the incidence of alcohol-related events decreased significantly in almost 40,000 patients with diabetes when they were treated with GLP-1 receptor agonists compared with other antidiabetic drugs.

A retrospective cohort study from the United States with over 80,000 patients with obesity showed that treatment with GLP-1 receptor agonists was associated with a 50%-60% lower risk for occurrence or recurrence of high alcohol consumption. There is only one small study with exenatide, which was not really informative.

There are a number of studies underway for GLP-1 receptor agonists compared with placebo in patients with alcohol dependence or alcohol consumption. Preclinical models also indicate that these drugs might be effective in cocaine abuse, and there is one placebo-controlled study ongoing. 
 

Parkinson’s Disease

Let’s come to neurology. Preclinical models of Parkinson’s disease have shown neuroprotective activities of GLP-1. Until now, we have three randomized placebo-controlled trials with exenatide, NLY01, and lixisenatide. Two of these studies were positive, showing that the symptoms of Parkinson’s disease were stable over time and deteriorated with placebo. One study was neutral. This means we need more large-scale placebo-controlled studies in the early phases of Parkinson’s disease. 

Another potential use of GIP/GLP-1 receptor agonists is in dementia. These substances, as you know, have positive effects on high blood pressure and vascular risk factors. 

A working group in China analyzed 27 studies on the treatment of diabetes. A small number of randomized studies and a large number of cohort studies showed that modern antidiabetic drugs reduce the risk for dementia. The risk reduction for dementia for the GLP-1 receptor agonists was 75%. At the moment, there are only small prospective studies and they are not conclusive. Again, we need large-scale placebo-controlled studies.

The most important limitation at the moment beyond the cost is the other adverse drug reactions with the GLP-1 receptor agonists; these include nausea, vomiting, diarrhea, and constipation. There might be a slightly increased risk for pancreatitis. The US Food and Drug Administration recently reported there is no increased risk for suicide. Another potential adverse drug reaction is nonatherosclerotic anterior optic neuropathy. 

These drugs, GLP-1 receptor agonists and GIP agonists, are also investigated in a variety of other non-neurologic diseases. The focus here is on metabolic liver disease, such as fatty liver and kidney diseases. Smaller, positive studies have been conducted in this area, and large placebo-controlled trials for both indications are currently underway.

If these diverse therapeutic properties would turn out to be really the case with GLP-1 receptor agonists, this would lead to a significant expansion of the range of indications. If we consider cost, this would be the end of our healthcare systems because we cannot afford this. In addition, the new antidiabetic drugs and the treatment of obesity are available only to a limited extent.

Finally, at least for neurology, it’s unclear whether the impact of these diseases is in the brain or whether it’s indirect, due to the effectiveness on vascular risk factors and concomitant diseases. In the next 5 years, we will learn whether GLP-1 or GIP/GLP-1 receptor agonists are the new wonder drugs in medicine.
 

Dr. Diener is Professor in the Department of Neurology, Stroke Center-Headache Center, University Duisburg-Essen, Essen, Germany; he has disclosed conflicts of interest with numerous pharmaceutical companies.
 

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

This transcript has been edited for clarity. 

I usually report five or six studies in the field of neurology that were published in the last months, but July was a vacation month.

I decided to cover another topic, which is the role of glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists beyond diabetes and obesity, and in particular, for the field of neurology and psychiatry. Until a few years ago, the treatment of diabetes with traditional antidiabetic drugs was frustrating for vascular neurologists.

These drugs would lower glucose and had an impact on small-vessel disease, but they had no impact on large-vessel disease, stroke, and vascular mortality. This changed with the sodium-glucose cotransporter 2 antagonists because these drugs were not only effective for diabetes, but they also lowered cardiac mortality, in particular, in patients with cardiac failure.

The next generation of antidiabetic drugs were the GLP-1 receptor agonists and the combined GIP/GLP-1 receptor agonists. These two polypeptides and their receptors play a very important role in diabetes and in obesity. The receptors are found not only in the pancreas but also in the intestinal system, the liver, and the central nervous system.

We have a number of preclinical models, mostly in transgenic mice, which show that these drugs are not effective only in diabetes and obesity, but also in liver disease, kidney failure, and neurodegenerative diseases. GLP-1 receptor agonists also have powerful anti-inflammatory properties. These drugs reduce body weight, and they have positive effects on blood pressure and lipid metabolism. 

In the studies on the use of GLP-1 receptor agonists in diabetes, a meta-analysis with more than 58,000 patients showed a significant risk reduction for stroke compared with placebo, and this risk reduction was in the range of 80%.
 

Stroke, Smoking, and Alcohol

A meta-analysis on the use of GLP-1 receptor agonists in over 30,000 nondiabetic patients with obesity found a significant reduction in blood pressure, mortality, and the risk of myocardial infarction. There was no significant decrease in the risk of stroke, but most probably this is due to the fact that strokes are much less frequent in obesity than in diabetes.

You all know that obesity is also a major risk factor for sleep apnea syndrome. Recently, two large studies with the GIP/GLP-1 receptor agonist tirzepatide found a significant improvement in sleep apnea syndrome compared to placebo, regardless of whether patients needed continuous positive airway pressure therapy or not.

In the therapy studies on diabetes and obesity, there were indications that some smokers in the studies stopped their nicotine consumption. A small pilot study with exenatide in 84 overweight patients who were smokers showed that 46% of patients on exenatide stopped smoking compared with 27% in the placebo group. This could be an indication that GLP-1 receptor agonists have activity on the reward system in the brain. Currently, there are a number of larger placebo-controlled trials ongoing. 

Another aspect is alcohol consumption. An epidemiologic study in Denmark using data from the National Health Registry showed that the incidence of alcohol-related events decreased significantly in almost 40,000 patients with diabetes when they were treated with GLP-1 receptor agonists compared with other antidiabetic drugs.

A retrospective cohort study from the United States with over 80,000 patients with obesity showed that treatment with GLP-1 receptor agonists was associated with a 50%-60% lower risk for occurrence or recurrence of high alcohol consumption. There is only one small study with exenatide, which was not really informative.

There are a number of studies underway for GLP-1 receptor agonists compared with placebo in patients with alcohol dependence or alcohol consumption. Preclinical models also indicate that these drugs might be effective in cocaine abuse, and there is one placebo-controlled study ongoing. 
 

Parkinson’s Disease

Let’s come to neurology. Preclinical models of Parkinson’s disease have shown neuroprotective activities of GLP-1. Until now, we have three randomized placebo-controlled trials with exenatide, NLY01, and lixisenatide. Two of these studies were positive, showing that the symptoms of Parkinson’s disease were stable over time and deteriorated with placebo. One study was neutral. This means we need more large-scale placebo-controlled studies in the early phases of Parkinson’s disease. 

Another potential use of GIP/GLP-1 receptor agonists is in dementia. These substances, as you know, have positive effects on high blood pressure and vascular risk factors. 

A working group in China analyzed 27 studies on the treatment of diabetes. A small number of randomized studies and a large number of cohort studies showed that modern antidiabetic drugs reduce the risk for dementia. The risk reduction for dementia for the GLP-1 receptor agonists was 75%. At the moment, there are only small prospective studies and they are not conclusive. Again, we need large-scale placebo-controlled studies.

The most important limitation at the moment beyond the cost is the other adverse drug reactions with the GLP-1 receptor agonists; these include nausea, vomiting, diarrhea, and constipation. There might be a slightly increased risk for pancreatitis. The US Food and Drug Administration recently reported there is no increased risk for suicide. Another potential adverse drug reaction is nonatherosclerotic anterior optic neuropathy. 

These drugs, GLP-1 receptor agonists and GIP agonists, are also investigated in a variety of other non-neurologic diseases. The focus here is on metabolic liver disease, such as fatty liver and kidney diseases. Smaller, positive studies have been conducted in this area, and large placebo-controlled trials for both indications are currently underway.

If these diverse therapeutic properties would turn out to be really the case with GLP-1 receptor agonists, this would lead to a significant expansion of the range of indications. If we consider cost, this would be the end of our healthcare systems because we cannot afford this. In addition, the new antidiabetic drugs and the treatment of obesity are available only to a limited extent.

Finally, at least for neurology, it’s unclear whether the impact of these diseases is in the brain or whether it’s indirect, due to the effectiveness on vascular risk factors and concomitant diseases. In the next 5 years, we will learn whether GLP-1 or GIP/GLP-1 receptor agonists are the new wonder drugs in medicine.
 

Dr. Diener is Professor in the Department of Neurology, Stroke Center-Headache Center, University Duisburg-Essen, Essen, Germany; he has disclosed conflicts of interest with numerous pharmaceutical companies.
 

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

This transcript has been edited for clarity. 

I usually report five or six studies in the field of neurology that were published in the last months, but July was a vacation month.

I decided to cover another topic, which is the role of glucagon-like peptide 1 (GLP-1) and glucose-dependent insulinotropic polypeptide (GIP) receptor agonists beyond diabetes and obesity, and in particular, for the field of neurology and psychiatry. Until a few years ago, the treatment of diabetes with traditional antidiabetic drugs was frustrating for vascular neurologists.

These drugs would lower glucose and had an impact on small-vessel disease, but they had no impact on large-vessel disease, stroke, and vascular mortality. This changed with the sodium-glucose cotransporter 2 antagonists because these drugs were not only effective for diabetes, but they also lowered cardiac mortality, in particular, in patients with cardiac failure.

The next generation of antidiabetic drugs were the GLP-1 receptor agonists and the combined GIP/GLP-1 receptor agonists. These two polypeptides and their receptors play a very important role in diabetes and in obesity. The receptors are found not only in the pancreas but also in the intestinal system, the liver, and the central nervous system.

We have a number of preclinical models, mostly in transgenic mice, which show that these drugs are not effective only in diabetes and obesity, but also in liver disease, kidney failure, and neurodegenerative diseases. GLP-1 receptor agonists also have powerful anti-inflammatory properties. These drugs reduce body weight, and they have positive effects on blood pressure and lipid metabolism. 

In the studies on the use of GLP-1 receptor agonists in diabetes, a meta-analysis with more than 58,000 patients showed a significant risk reduction for stroke compared with placebo, and this risk reduction was in the range of 80%.
 

Stroke, Smoking, and Alcohol

A meta-analysis on the use of GLP-1 receptor agonists in over 30,000 nondiabetic patients with obesity found a significant reduction in blood pressure, mortality, and the risk of myocardial infarction. There was no significant decrease in the risk of stroke, but most probably this is due to the fact that strokes are much less frequent in obesity than in diabetes.

You all know that obesity is also a major risk factor for sleep apnea syndrome. Recently, two large studies with the GIP/GLP-1 receptor agonist tirzepatide found a significant improvement in sleep apnea syndrome compared to placebo, regardless of whether patients needed continuous positive airway pressure therapy or not.

In the therapy studies on diabetes and obesity, there were indications that some smokers in the studies stopped their nicotine consumption. A small pilot study with exenatide in 84 overweight patients who were smokers showed that 46% of patients on exenatide stopped smoking compared with 27% in the placebo group. This could be an indication that GLP-1 receptor agonists have activity on the reward system in the brain. Currently, there are a number of larger placebo-controlled trials ongoing. 

Another aspect is alcohol consumption. An epidemiologic study in Denmark using data from the National Health Registry showed that the incidence of alcohol-related events decreased significantly in almost 40,000 patients with diabetes when they were treated with GLP-1 receptor agonists compared with other antidiabetic drugs.

A retrospective cohort study from the United States with over 80,000 patients with obesity showed that treatment with GLP-1 receptor agonists was associated with a 50%-60% lower risk for occurrence or recurrence of high alcohol consumption. There is only one small study with exenatide, which was not really informative.

There are a number of studies underway for GLP-1 receptor agonists compared with placebo in patients with alcohol dependence or alcohol consumption. Preclinical models also indicate that these drugs might be effective in cocaine abuse, and there is one placebo-controlled study ongoing. 
 

Parkinson’s Disease

Let’s come to neurology. Preclinical models of Parkinson’s disease have shown neuroprotective activities of GLP-1. Until now, we have three randomized placebo-controlled trials with exenatide, NLY01, and lixisenatide. Two of these studies were positive, showing that the symptoms of Parkinson’s disease were stable over time and deteriorated with placebo. One study was neutral. This means we need more large-scale placebo-controlled studies in the early phases of Parkinson’s disease. 

Another potential use of GIP/GLP-1 receptor agonists is in dementia. These substances, as you know, have positive effects on high blood pressure and vascular risk factors. 

A working group in China analyzed 27 studies on the treatment of diabetes. A small number of randomized studies and a large number of cohort studies showed that modern antidiabetic drugs reduce the risk for dementia. The risk reduction for dementia for the GLP-1 receptor agonists was 75%. At the moment, there are only small prospective studies and they are not conclusive. Again, we need large-scale placebo-controlled studies.

The most important limitation at the moment beyond the cost is the other adverse drug reactions with the GLP-1 receptor agonists; these include nausea, vomiting, diarrhea, and constipation. There might be a slightly increased risk for pancreatitis. The US Food and Drug Administration recently reported there is no increased risk for suicide. Another potential adverse drug reaction is nonatherosclerotic anterior optic neuropathy. 

These drugs, GLP-1 receptor agonists and GIP agonists, are also investigated in a variety of other non-neurologic diseases. The focus here is on metabolic liver disease, such as fatty liver and kidney diseases. Smaller, positive studies have been conducted in this area, and large placebo-controlled trials for both indications are currently underway.

If these diverse therapeutic properties would turn out to be really the case with GLP-1 receptor agonists, this would lead to a significant expansion of the range of indications. If we consider cost, this would be the end of our healthcare systems because we cannot afford this. In addition, the new antidiabetic drugs and the treatment of obesity are available only to a limited extent.

Finally, at least for neurology, it’s unclear whether the impact of these diseases is in the brain or whether it’s indirect, due to the effectiveness on vascular risk factors and concomitant diseases. In the next 5 years, we will learn whether GLP-1 or GIP/GLP-1 receptor agonists are the new wonder drugs in medicine.
 

Dr. Diener is Professor in the Department of Neurology, Stroke Center-Headache Center, University Duisburg-Essen, Essen, Germany; he has disclosed conflicts of interest with numerous pharmaceutical companies.
 

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

This transcript has been edited for clarity. 

Today I am going to talk about the position statement from the American Headache Society (AHS) “Calcitonin gene-related peptide [CGRP]–targeting therapies are a first-line option for the prevention of migraine”. This update is of critical importance because about three fourths of people with migraine get their care from a primary care clinician, not from a neurologist or a headache specialist. CGRP-targeting therapies have transformed migraine care at the specialty level, but many in primary care are not yet familiar with this class of medicines. Until this new statement was released, CGRPs were not viewed as first-line agents for migraine. That has now changed.

Two main types of therapy for people with migraine headache are: (1) acute or abortive therapy (when a headache develops, it is treated), and (2) preventive therapy. Preventive therapy is typically used when the patient has headaches on 4 or more days per month. Preventive therapy is aimed at reducing the frequency and severity of headaches. About 40% of patients with migraine qualify for preventive therapy, but only a minority are receiving it. 

The armamentarium for preventive therapy of migraines had not changed in a long time — until now. First-line preventive therapy has traditionally consisted of three classes of agents: beta-blockers, tricyclic antidepressants, and topiramate. These medicines were developed for different therapeutic purposes, yet they work for migraines. These drugs may have off-target effects that can make them difficult to tolerate. 

Based on new evidence, candesartan — an angiotensin receptor blocker (ARB) — is now also a first-line drug for migraine. This is good news, because ARBs are a drug class that we have a lot of experience with, are easy to use, and could be an excellent choice for people with concomitant hypertension or chronic kidney disease. The serotonin-norepinephrine reuptake inhibitors (venlafaxine and duloxetine) are also considered first-line agents for migraine treatment. 

In the AHS’s new position statement, the two main drug classes are small-molecule CGRP receptor antagonists and monoclonal antibodies. 

The role of the neuropeptide CGRP in migraine was originally discovered after finding that blood levels of CGRP were elevated during migraine attacks. This led to the discovery of agents that blocked CGRP, initially for acute treatment of migraine, and then for preventive therapy. Multiple clinical studies show the CGRP targeting therapies to be as or even more effective than traditional first-line agents at decreasing the number of migraine days per month.

The efficacy and safety of these agents have been demonstrated in both randomized trials and in real-world studies. Other important positive endpoints include fewer days of migraine, reduced acute medication use, and improvements in many quality-of-life outcomes. Studies also have shown that CGRP-targeting therapies are well tolerated and safe, with very few serious adverse events. 

Furthermore, studies have shown the CGRP targeting therapies are effective in individuals who have failed multiple other first-line therapies. They fit now both as first-line agents and as agents that can be used in difficult-to-treat patients as well as in patients who struggle with acute medication overuse, which is often very challenging. 

To quote from the AHS statement, “The evidence supporting the efficacy, tolerability, and safety of CGRP-targeting therapies for migraine prevention is substantial in its volume, scope, and quality.”

Side effects are uncommon and can include hypertension, constipation, and Raynaud phenomenon. 

The position statement is strong and is based on a lot of evidence and clinical experience. CGRP-targeting therapies are now first-line agents for the prevention of migraine headache. We should learn more about and begin to feel comfortable using this class of agents because they stand to benefit our patients greatly. I’d suggest looking at the table below and picking one new agent to become familiar with so that you can add that agent to your toolbox. 

Medscape

Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, Bayer, and Teva.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

Today I am going to talk about the position statement from the American Headache Society (AHS) “Calcitonin gene-related peptide [CGRP]–targeting therapies are a first-line option for the prevention of migraine”. This update is of critical importance because about three fourths of people with migraine get their care from a primary care clinician, not from a neurologist or a headache specialist. CGRP-targeting therapies have transformed migraine care at the specialty level, but many in primary care are not yet familiar with this class of medicines. Until this new statement was released, CGRPs were not viewed as first-line agents for migraine. That has now changed.

Two main types of therapy for people with migraine headache are: (1) acute or abortive therapy (when a headache develops, it is treated), and (2) preventive therapy. Preventive therapy is typically used when the patient has headaches on 4 or more days per month. Preventive therapy is aimed at reducing the frequency and severity of headaches. About 40% of patients with migraine qualify for preventive therapy, but only a minority are receiving it. 

The armamentarium for preventive therapy of migraines had not changed in a long time — until now. First-line preventive therapy has traditionally consisted of three classes of agents: beta-blockers, tricyclic antidepressants, and topiramate. These medicines were developed for different therapeutic purposes, yet they work for migraines. These drugs may have off-target effects that can make them difficult to tolerate. 

Based on new evidence, candesartan — an angiotensin receptor blocker (ARB) — is now also a first-line drug for migraine. This is good news, because ARBs are a drug class that we have a lot of experience with, are easy to use, and could be an excellent choice for people with concomitant hypertension or chronic kidney disease. The serotonin-norepinephrine reuptake inhibitors (venlafaxine and duloxetine) are also considered first-line agents for migraine treatment. 

In the AHS’s new position statement, the two main drug classes are small-molecule CGRP receptor antagonists and monoclonal antibodies. 

The role of the neuropeptide CGRP in migraine was originally discovered after finding that blood levels of CGRP were elevated during migraine attacks. This led to the discovery of agents that blocked CGRP, initially for acute treatment of migraine, and then for preventive therapy. Multiple clinical studies show the CGRP targeting therapies to be as or even more effective than traditional first-line agents at decreasing the number of migraine days per month.

The efficacy and safety of these agents have been demonstrated in both randomized trials and in real-world studies. Other important positive endpoints include fewer days of migraine, reduced acute medication use, and improvements in many quality-of-life outcomes. Studies also have shown that CGRP-targeting therapies are well tolerated and safe, with very few serious adverse events. 

Furthermore, studies have shown the CGRP targeting therapies are effective in individuals who have failed multiple other first-line therapies. They fit now both as first-line agents and as agents that can be used in difficult-to-treat patients as well as in patients who struggle with acute medication overuse, which is often very challenging. 

To quote from the AHS statement, “The evidence supporting the efficacy, tolerability, and safety of CGRP-targeting therapies for migraine prevention is substantial in its volume, scope, and quality.”

Side effects are uncommon and can include hypertension, constipation, and Raynaud phenomenon. 

The position statement is strong and is based on a lot of evidence and clinical experience. CGRP-targeting therapies are now first-line agents for the prevention of migraine headache. We should learn more about and begin to feel comfortable using this class of agents because they stand to benefit our patients greatly. I’d suggest looking at the table below and picking one new agent to become familiar with so that you can add that agent to your toolbox. 

Medscape

Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, Bayer, and Teva.

A version of this article appeared on Medscape.com.

This transcript has been edited for clarity. 

Today I am going to talk about the position statement from the American Headache Society (AHS) “Calcitonin gene-related peptide [CGRP]–targeting therapies are a first-line option for the prevention of migraine”. This update is of critical importance because about three fourths of people with migraine get their care from a primary care clinician, not from a neurologist or a headache specialist. CGRP-targeting therapies have transformed migraine care at the specialty level, but many in primary care are not yet familiar with this class of medicines. Until this new statement was released, CGRPs were not viewed as first-line agents for migraine. That has now changed.

Two main types of therapy for people with migraine headache are: (1) acute or abortive therapy (when a headache develops, it is treated), and (2) preventive therapy. Preventive therapy is typically used when the patient has headaches on 4 or more days per month. Preventive therapy is aimed at reducing the frequency and severity of headaches. About 40% of patients with migraine qualify for preventive therapy, but only a minority are receiving it. 

The armamentarium for preventive therapy of migraines had not changed in a long time — until now. First-line preventive therapy has traditionally consisted of three classes of agents: beta-blockers, tricyclic antidepressants, and topiramate. These medicines were developed for different therapeutic purposes, yet they work for migraines. These drugs may have off-target effects that can make them difficult to tolerate. 

Based on new evidence, candesartan — an angiotensin receptor blocker (ARB) — is now also a first-line drug for migraine. This is good news, because ARBs are a drug class that we have a lot of experience with, are easy to use, and could be an excellent choice for people with concomitant hypertension or chronic kidney disease. The serotonin-norepinephrine reuptake inhibitors (venlafaxine and duloxetine) are also considered first-line agents for migraine treatment. 

In the AHS’s new position statement, the two main drug classes are small-molecule CGRP receptor antagonists and monoclonal antibodies. 

The role of the neuropeptide CGRP in migraine was originally discovered after finding that blood levels of CGRP were elevated during migraine attacks. This led to the discovery of agents that blocked CGRP, initially for acute treatment of migraine, and then for preventive therapy. Multiple clinical studies show the CGRP targeting therapies to be as or even more effective than traditional first-line agents at decreasing the number of migraine days per month.

The efficacy and safety of these agents have been demonstrated in both randomized trials and in real-world studies. Other important positive endpoints include fewer days of migraine, reduced acute medication use, and improvements in many quality-of-life outcomes. Studies also have shown that CGRP-targeting therapies are well tolerated and safe, with very few serious adverse events. 

Furthermore, studies have shown the CGRP targeting therapies are effective in individuals who have failed multiple other first-line therapies. They fit now both as first-line agents and as agents that can be used in difficult-to-treat patients as well as in patients who struggle with acute medication overuse, which is often very challenging. 

To quote from the AHS statement, “The evidence supporting the efficacy, tolerability, and safety of CGRP-targeting therapies for migraine prevention is substantial in its volume, scope, and quality.”

Side effects are uncommon and can include hypertension, constipation, and Raynaud phenomenon. 

The position statement is strong and is based on a lot of evidence and clinical experience. CGRP-targeting therapies are now first-line agents for the prevention of migraine headache. We should learn more about and begin to feel comfortable using this class of agents because they stand to benefit our patients greatly. I’d suggest looking at the table below and picking one new agent to become familiar with so that you can add that agent to your toolbox. 

Medscape

Dr. Skolnik, professor, Department of Family Medicine, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, and associate director, Department of Family Medicine, Abington Jefferson Health, Abington, Pennsylvania, disclosed ties with AstraZeneca, Teva, Eli Lilly, Boehringer Ingelheim, Sanofi, Sanofi Pasteur, GlaxoSmithKline, Merck, Bayer, and Teva.

A version of this article appeared on Medscape.com.

Dunne F, Newman C, Alvarez-Iglesia A, et al. Early metformin in gestational diabetes: a randomized clinical trial. JAMA. 2023;330:1547-1556. doi:10.1001/jama .2023.19869

EXPERT COMMENTARY

Gestational diabetes mellitus occurs in 4% to 7% of pregnancies, and the prevalence is likely to continue to increase given the rising rates of hypertension, obesity, advanced maternal age, and other medical comorbidities in pregnant persons in the United States.^1,2 Uncontrolled hyperglycemia in pregnancy is associated swith many adverse perinatal outcomes, including stillbirth, macrosomia, admission to the neonatal intensive care unit (NICU), development of hypertensive disorders, and cesarean deliveries. Hence, it is important to investigate and identify the optimal management of gestational diabetes.

Metformin, an oral biguanide, although studied for gestational diabetes treatment in phase 3 randomized clinical open-label trials, often is avoided in patients who are pregnant (with the exception of patients who have needle aversions, are financially unable to use insulin, or are unable to administer insulin safely).^1,2 Metformin is a highly effective first-line agent in the management of both prediabetes and type 2 diabetes, which begs us to question if there is a role for it in the management of gestational diabetes.

Details about the study

The study by Dunne and colleagues was a randomized controlled trial (RCT) conducted in a 1:1 parallel fashion at two institutions in Ireland from 2017–2022. The primary outcome assessed if treatment with metformin would reduce fasting blood glucose levels and the initiation of insulin among women diagnosed with gestational diabetes. A total of 510 participants enrolled in the study, with 268 receiving metformin (up to a maximum dose of 2,500 mg) at diagnosis and 267 receiving an identical placebo. Blood sugar levels were monitored 7 times a day, and medication adherence was assessed every 4 weeks.

Results. At 32 or 38 weeks’ gestation, 56.8% of patients in the metformin arm, and 63.7% of patients in the placebo arm required insulin or had fasting blood glucose levels above 5.1 mmol/L (91.8mg/dL), which was a statistically insignificant difference (P = .13). Although there was similarly no difference in the total amount of insulin used in each study group, the percentage of patients who required insulin initiation was decreased in the metformin arm (38.4% vs 51.1%; P = .004).

Study strengths and weaknesses

The authors conducted a well-designed double-blinded RCT—in both rural and tertiary care settings. Additionally, the study had an impressive 90% patient adherence rate for home blood glucose monitoring 7 times per day. The study arms were balanced for body mass index, as obesity is a known contributor to the development of gestational diabetes and response to insulin.

This study findings’ generalizability is limited across subpopulations given the lack of ethnic and racial diversity—the study population was 80% White. Additionally, utilization of the World Health Organization guidelines for diagnosing gestational diabetes, although adopted by most associations across the world, limits its application to areas of the world that use the National Diabetes Data Group or the Carpenter-Coustan diagnosis guidelines.^3,4 Furthermore, the diagnosis of gestational diabetes, which was based on 1 elevated value of a 2-hour glucose tolerance test, has limited scientific support, has not been proven to improve obstetric outcomes, and may increase health care costs when compared with the 2-step method.⁵ The criteria for insulin initiation in the trial was based on having 2 elevated measures of blood glucose during home glucose monitoring, a criteria that is much stricter than what is used in other countries or clinical practice. The trial authors concluded that use of metformin had a statistically significant reduction in neonates weighing > 4,000 g and > 90th% of weight, but they did not assess study group differences in neonatal skin fold thickness or anthropometric measurements, as reported in the Metformin in Gestational Diabetes trials.⁶ ●

Dunne F, Newman C, Alvarez-Iglesia A, et al. Early metformin in gestational diabetes: a randomized clinical trial. JAMA. 2023;330:1547-1556. doi:10.1001/jama .2023.19869

EXPERT COMMENTARY

Gestational diabetes mellitus occurs in 4% to 7% of pregnancies, and the prevalence is likely to continue to increase given the rising rates of hypertension, obesity, advanced maternal age, and other medical comorbidities in pregnant persons in the United States.^1,2 Uncontrolled hyperglycemia in pregnancy is associated swith many adverse perinatal outcomes, including stillbirth, macrosomia, admission to the neonatal intensive care unit (NICU), development of hypertensive disorders, and cesarean deliveries. Hence, it is important to investigate and identify the optimal management of gestational diabetes.

Metformin, an oral biguanide, although studied for gestational diabetes treatment in phase 3 randomized clinical open-label trials, often is avoided in patients who are pregnant (with the exception of patients who have needle aversions, are financially unable to use insulin, or are unable to administer insulin safely).^1,2 Metformin is a highly effective first-line agent in the management of both prediabetes and type 2 diabetes, which begs us to question if there is a role for it in the management of gestational diabetes.

Details about the study

The study by Dunne and colleagues was a randomized controlled trial (RCT) conducted in a 1:1 parallel fashion at two institutions in Ireland from 2017–2022. The primary outcome assessed if treatment with metformin would reduce fasting blood glucose levels and the initiation of insulin among women diagnosed with gestational diabetes. A total of 510 participants enrolled in the study, with 268 receiving metformin (up to a maximum dose of 2,500 mg) at diagnosis and 267 receiving an identical placebo. Blood sugar levels were monitored 7 times a day, and medication adherence was assessed every 4 weeks.

Results. At 32 or 38 weeks’ gestation, 56.8% of patients in the metformin arm, and 63.7% of patients in the placebo arm required insulin or had fasting blood glucose levels above 5.1 mmol/L (91.8mg/dL), which was a statistically insignificant difference (P = .13). Although there was similarly no difference in the total amount of insulin used in each study group, the percentage of patients who required insulin initiation was decreased in the metformin arm (38.4% vs 51.1%; P = .004).

Study strengths and weaknesses

The authors conducted a well-designed double-blinded RCT—in both rural and tertiary care settings. Additionally, the study had an impressive 90% patient adherence rate for home blood glucose monitoring 7 times per day. The study arms were balanced for body mass index, as obesity is a known contributor to the development of gestational diabetes and response to insulin.

This study findings’ generalizability is limited across subpopulations given the lack of ethnic and racial diversity—the study population was 80% White. Additionally, utilization of the World Health Organization guidelines for diagnosing gestational diabetes, although adopted by most associations across the world, limits its application to areas of the world that use the National Diabetes Data Group or the Carpenter-Coustan diagnosis guidelines.^3,4 Furthermore, the diagnosis of gestational diabetes, which was based on 1 elevated value of a 2-hour glucose tolerance test, has limited scientific support, has not been proven to improve obstetric outcomes, and may increase health care costs when compared with the 2-step method.⁵ The criteria for insulin initiation in the trial was based on having 2 elevated measures of blood glucose during home glucose monitoring, a criteria that is much stricter than what is used in other countries or clinical practice. The trial authors concluded that use of metformin had a statistically significant reduction in neonates weighing > 4,000 g and > 90th% of weight, but they did not assess study group differences in neonatal skin fold thickness or anthropometric measurements, as reported in the Metformin in Gestational Diabetes trials.⁶ ●

Dunne F, Newman C, Alvarez-Iglesia A, et al. Early metformin in gestational diabetes: a randomized clinical trial. JAMA. 2023;330:1547-1556. doi:10.1001/jama .2023.19869

EXPERT COMMENTARY

Gestational diabetes mellitus occurs in 4% to 7% of pregnancies, and the prevalence is likely to continue to increase given the rising rates of hypertension, obesity, advanced maternal age, and other medical comorbidities in pregnant persons in the United States.^1,2 Uncontrolled hyperglycemia in pregnancy is associated swith many adverse perinatal outcomes, including stillbirth, macrosomia, admission to the neonatal intensive care unit (NICU), development of hypertensive disorders, and cesarean deliveries. Hence, it is important to investigate and identify the optimal management of gestational diabetes.

Metformin, an oral biguanide, although studied for gestational diabetes treatment in phase 3 randomized clinical open-label trials, often is avoided in patients who are pregnant (with the exception of patients who have needle aversions, are financially unable to use insulin, or are unable to administer insulin safely).^1,2 Metformin is a highly effective first-line agent in the management of both prediabetes and type 2 diabetes, which begs us to question if there is a role for it in the management of gestational diabetes.

Details about the study

The study by Dunne and colleagues was a randomized controlled trial (RCT) conducted in a 1:1 parallel fashion at two institutions in Ireland from 2017–2022. The primary outcome assessed if treatment with metformin would reduce fasting blood glucose levels and the initiation of insulin among women diagnosed with gestational diabetes. A total of 510 participants enrolled in the study, with 268 receiving metformin (up to a maximum dose of 2,500 mg) at diagnosis and 267 receiving an identical placebo. Blood sugar levels were monitored 7 times a day, and medication adherence was assessed every 4 weeks.

Results. At 32 or 38 weeks’ gestation, 56.8% of patients in the metformin arm, and 63.7% of patients in the placebo arm required insulin or had fasting blood glucose levels above 5.1 mmol/L (91.8mg/dL), which was a statistically insignificant difference (P = .13). Although there was similarly no difference in the total amount of insulin used in each study group, the percentage of patients who required insulin initiation was decreased in the metformin arm (38.4% vs 51.1%; P = .004).

Study strengths and weaknesses

The authors conducted a well-designed double-blinded RCT—in both rural and tertiary care settings. Additionally, the study had an impressive 90% patient adherence rate for home blood glucose monitoring 7 times per day. The study arms were balanced for body mass index, as obesity is a known contributor to the development of gestational diabetes and response to insulin.

This study findings’ generalizability is limited across subpopulations given the lack of ethnic and racial diversity—the study population was 80% White. Additionally, utilization of the World Health Organization guidelines for diagnosing gestational diabetes, although adopted by most associations across the world, limits its application to areas of the world that use the National Diabetes Data Group or the Carpenter-Coustan diagnosis guidelines.^3,4 Furthermore, the diagnosis of gestational diabetes, which was based on 1 elevated value of a 2-hour glucose tolerance test, has limited scientific support, has not been proven to improve obstetric outcomes, and may increase health care costs when compared with the 2-step method.⁵ The criteria for insulin initiation in the trial was based on having 2 elevated measures of blood glucose during home glucose monitoring, a criteria that is much stricter than what is used in other countries or clinical practice. The trial authors concluded that use of metformin had a statistically significant reduction in neonates weighing > 4,000 g and > 90th% of weight, but they did not assess study group differences in neonatal skin fold thickness or anthropometric measurements, as reported in the Metformin in Gestational Diabetes trials.⁶ ●

Meaidi A, Mascolo A, Sessa M, et al. Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study. BMJ. 2023;382:e074450. doi:10.1136/bmj-2022-074450

EXPERT COMMENTARY

Combination (estrogen plus progestin) hormonal contraceptives as well as non–aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of VTE events, including lower extremity clots and pulmonary embolism. Taking contraceptives formulated with ethinyl estradiol increases hepatic production of clotting factors on a dose-related basis. Newer progestins, including desogestrel and drospirenone, also may contribute to an elevated VTE risk, although this association is controversial.¹ NSAIDs promote platelet aggregation, thereby activating the clotting system and formation of clots. Although studies that assessed the association between NSAID use and thrombosis have focused on arterial clots, a substantial literature suggests that NSAIDs, including older NSAIDs (such as ibuprofen, diclofenac, and naproxen), also increase VTE risk.²

Although combination contraceptives (oral contraceptives, patches, vaginal rings) and NSAIDs are both commonly used by reproductive-age women, little data have assessed the impact of concomitant use of these medications on VTE risk. Accordingly, investigators in Denmark, using national databases, conducted a retrospective cohort study to assess the impact that independent as well as concomitant use of these medications have on VTE risk.

Details of the study

Meaidi and colleagues included in the cohort reproductive-age women living in Denmark between 1996 and 2017 with no history of thrombosis, thrombophilia, cancer, tubal sterilization, hysterectomy, bilateral oophorectomy, or infertility treatment. National prescription data were used to assess exposure to hormonal contraception.

The investigators classified hormonal contraception into 3 VTE risk categories:

1. high risk—estrogen-progestin patches and vaginal rings; oral contraceptives containing 50 µg of ethinyl estradiol; or the progestins desogestrel, drospirenone, gestodene, or cyproterone (with the latter 2 progestins not available in the United States)
2. medium risk—all other combination oral contraceptives, including those formulated with the progestins norethindrone, norethindrone acetate, norgestrel, and levonorgestrel, as well as depot medroxyprogesterone acetate
3. low/no risk—progestin-only pills, implants, and progestin-containing intrauterine devices (IUDs).

Because in Denmark NSAIDs are prescribed as a single package containing no more than 30 tablets, time exposed to non–aspirin NSAIDs was assumed to last 1 week from the prescription date.

The authors considered first-time diagnoses of lower limb venous thrombosis or pulmonary embolism that were made in hospitals to represent VTE. They also constructed a subgroup of VTE patients in whom the diagnosis was either confirmed with imaging or followed by prescription of an anticoagulant.

To address potential confounding, the authors adjusted their analysis based on age, calendar year, educational attainment, occurrence of pregnancy, surgery, hypertension, diabetes, polycystic ovary syndrome, endometriosis, migraine, systemic connective tissue diseases, inflammatory polyarthropathies, and use of tranexamic acid (a medication that may increase VTE risk). They also censored (temporarily excluded women from analysis) episodes associated with a transiently elevated risk of VTE: pregnancy and 6 months following delivery, 12 weeks after other pregnancy terminations, 8 weeks following any surgery involving hospital admission, and 8 weeks following prescription of tranexamic acid.

Continue to: VTEs associated with risk category of hormonal contraception used...

Results. The overall cohort included more than 2 million women who were followed for a median of 10 years. During 21.0 million person-years, 8,710 VTE events were diagnosed; almost one-third of these were pulmonary embolisms, with the remainder diagnosed as lower extremity VTE. Of these 8,710 women diagnosed with VTE, 7,043 (81%) were confirmed with either diagnostic imaging or prescription of an anticoagulant. Unfortunately, 228 women (2.6%) died within 30 days of the diagnosis of VTE.

The investigators identified concomitant use of hormonal contraception and NSAIDs in more than 500,000 women. Among women with such concomitant use, 58% were using contraceptives that were high risk while 23% used medium-risk and 19% used low/no-risk contraceptives. Ibuprofen (60%) was the most commonly used NSAID, followed by diclofenac (20%) and naproxen (6%). Between 97% and 98% of high-risk and medium-risk contraceptives were combination pills; 89% of low/no-risk contraceptives were progestin IUDs.

Compared with nonuse of both hormonal contraceptives and NSAIDs, incidence rate ratios of VTE adjusted for age, calendar year, and education were 8.1 (95% confidence interval [CI], 6.9–9.6) for use of NSAIDs only, 4.2 (95% CI, 4.0–4.4) for use of high-risk contraceptives only, 3.0 (95% CI, 2.8–3.2) for medium-risk contraceptive use, and 1.1 (95% CI, 1.0–1.3) for use of low/no-risk hormonal contraception. Risk of VTE was approximately twice as high with the use of diclofenac only compared with the risks associated with ibuprofen or naproxen use only.

With respect to concomitant use of NSAIDs and hormonal contraception, incidence rate ratios of VTE were 50.6 (95% CI, 44.2–57.8), 26.1 (95% CI, 19.6–34.7), and 5.7 (95% CI, 3.3–10.1), respectively, with use of high-risk, medium-risk, and low/no-risk hormonal contraceptives. Adjusting for time updated information on occurrences of migraine, connective tissue disorder, inflammatory polyarthropathies, endometriosis, polycystic ovary syndrome, hypertension, and diabetes did not materially affect these associations.

When analysis was limited to women without these occurring conditions, rate ratios were somewhat higher (5.7 and 4.1) for use of high-risk and medium-risk contraceptives only. Incidence rate ratios in this subcohort of healthier women were substantially higher for NSAID use only (15.0), and 111.7, 43.2, and 13.0, respectively, for concomitant use of NSAIDs with high-risk, medium-risk, and low/no-risk contraceptives. In this analysis of healthier women, diclofenac continued to be associated with substantially higher risks of VTE than ibuprofen or naproxen. When the stricter definition of VTE (confirmed cases) was used, adjusted rate ratios remained similar.

Absolute risks of VTE

Although some of the elevated rate ratios noted in this study might appear alarming, it is important to keep in mind that the baseline incidence of VTE in healthy reproductive-age women is low. Accordingly, as the authors pointed out, even among women who used NSAIDs concomitantly with high-risk combination hormonal contraceptives, the absolute risk of VTE was 2/10,000.

Study strengths and limitations

Strengths of this analysis by Meaidi and colleagues include the use of large, essentially all-inclusive national registries. In addition, nationwide Danish registry data that indicate a diagnosis of VTE have been found to have a high positive predictive value.³ Another strength is the large number of potentially confounding factors that the authors controlled for.

One potential limitation of their analysis is that the use of only prescribed NSAIDs was considered. Fortunately, however, the prevalence of over-the-counter ibuprofen use in Denmark is not high enough to materially affect the authors’ findings.⁴ Another potential limitation was that information on smoking and body mass index was not available for most of the women included in the study cohort. The authors countered this limitation by pointing out that, in Denmark, smoking and obesity are highly correlated with educational status, and that all analyses were adjusted for educational status. ●

Meaidi A, Mascolo A, Sessa M, et al. Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study. BMJ. 2023;382:e074450. doi:10.1136/bmj-2022-074450

EXPERT COMMENTARY

Combination (estrogen plus progestin) hormonal contraceptives as well as non–aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of VTE events, including lower extremity clots and pulmonary embolism. Taking contraceptives formulated with ethinyl estradiol increases hepatic production of clotting factors on a dose-related basis. Newer progestins, including desogestrel and drospirenone, also may contribute to an elevated VTE risk, although this association is controversial.¹ NSAIDs promote platelet aggregation, thereby activating the clotting system and formation of clots. Although studies that assessed the association between NSAID use and thrombosis have focused on arterial clots, a substantial literature suggests that NSAIDs, including older NSAIDs (such as ibuprofen, diclofenac, and naproxen), also increase VTE risk.²

Although combination contraceptives (oral contraceptives, patches, vaginal rings) and NSAIDs are both commonly used by reproductive-age women, little data have assessed the impact of concomitant use of these medications on VTE risk. Accordingly, investigators in Denmark, using national databases, conducted a retrospective cohort study to assess the impact that independent as well as concomitant use of these medications have on VTE risk.

Details of the study

Meaidi and colleagues included in the cohort reproductive-age women living in Denmark between 1996 and 2017 with no history of thrombosis, thrombophilia, cancer, tubal sterilization, hysterectomy, bilateral oophorectomy, or infertility treatment. National prescription data were used to assess exposure to hormonal contraception.

The investigators classified hormonal contraception into 3 VTE risk categories:

1. high risk—estrogen-progestin patches and vaginal rings; oral contraceptives containing 50 µg of ethinyl estradiol; or the progestins desogestrel, drospirenone, gestodene, or cyproterone (with the latter 2 progestins not available in the United States)
2. medium risk—all other combination oral contraceptives, including those formulated with the progestins norethindrone, norethindrone acetate, norgestrel, and levonorgestrel, as well as depot medroxyprogesterone acetate
3. low/no risk—progestin-only pills, implants, and progestin-containing intrauterine devices (IUDs).

Because in Denmark NSAIDs are prescribed as a single package containing no more than 30 tablets, time exposed to non–aspirin NSAIDs was assumed to last 1 week from the prescription date.

The authors considered first-time diagnoses of lower limb venous thrombosis or pulmonary embolism that were made in hospitals to represent VTE. They also constructed a subgroup of VTE patients in whom the diagnosis was either confirmed with imaging or followed by prescription of an anticoagulant.

To address potential confounding, the authors adjusted their analysis based on age, calendar year, educational attainment, occurrence of pregnancy, surgery, hypertension, diabetes, polycystic ovary syndrome, endometriosis, migraine, systemic connective tissue diseases, inflammatory polyarthropathies, and use of tranexamic acid (a medication that may increase VTE risk). They also censored (temporarily excluded women from analysis) episodes associated with a transiently elevated risk of VTE: pregnancy and 6 months following delivery, 12 weeks after other pregnancy terminations, 8 weeks following any surgery involving hospital admission, and 8 weeks following prescription of tranexamic acid.

Continue to: VTEs associated with risk category of hormonal contraception used...

Results. The overall cohort included more than 2 million women who were followed for a median of 10 years. During 21.0 million person-years, 8,710 VTE events were diagnosed; almost one-third of these were pulmonary embolisms, with the remainder diagnosed as lower extremity VTE. Of these 8,710 women diagnosed with VTE, 7,043 (81%) were confirmed with either diagnostic imaging or prescription of an anticoagulant. Unfortunately, 228 women (2.6%) died within 30 days of the diagnosis of VTE.

The investigators identified concomitant use of hormonal contraception and NSAIDs in more than 500,000 women. Among women with such concomitant use, 58% were using contraceptives that were high risk while 23% used medium-risk and 19% used low/no-risk contraceptives. Ibuprofen (60%) was the most commonly used NSAID, followed by diclofenac (20%) and naproxen (6%). Between 97% and 98% of high-risk and medium-risk contraceptives were combination pills; 89% of low/no-risk contraceptives were progestin IUDs.

Compared with nonuse of both hormonal contraceptives and NSAIDs, incidence rate ratios of VTE adjusted for age, calendar year, and education were 8.1 (95% confidence interval [CI], 6.9–9.6) for use of NSAIDs only, 4.2 (95% CI, 4.0–4.4) for use of high-risk contraceptives only, 3.0 (95% CI, 2.8–3.2) for medium-risk contraceptive use, and 1.1 (95% CI, 1.0–1.3) for use of low/no-risk hormonal contraception. Risk of VTE was approximately twice as high with the use of diclofenac only compared with the risks associated with ibuprofen or naproxen use only.

With respect to concomitant use of NSAIDs and hormonal contraception, incidence rate ratios of VTE were 50.6 (95% CI, 44.2–57.8), 26.1 (95% CI, 19.6–34.7), and 5.7 (95% CI, 3.3–10.1), respectively, with use of high-risk, medium-risk, and low/no-risk hormonal contraceptives. Adjusting for time updated information on occurrences of migraine, connective tissue disorder, inflammatory polyarthropathies, endometriosis, polycystic ovary syndrome, hypertension, and diabetes did not materially affect these associations.

When analysis was limited to women without these occurring conditions, rate ratios were somewhat higher (5.7 and 4.1) for use of high-risk and medium-risk contraceptives only. Incidence rate ratios in this subcohort of healthier women were substantially higher for NSAID use only (15.0), and 111.7, 43.2, and 13.0, respectively, for concomitant use of NSAIDs with high-risk, medium-risk, and low/no-risk contraceptives. In this analysis of healthier women, diclofenac continued to be associated with substantially higher risks of VTE than ibuprofen or naproxen. When the stricter definition of VTE (confirmed cases) was used, adjusted rate ratios remained similar.

Absolute risks of VTE

Although some of the elevated rate ratios noted in this study might appear alarming, it is important to keep in mind that the baseline incidence of VTE in healthy reproductive-age women is low. Accordingly, as the authors pointed out, even among women who used NSAIDs concomitantly with high-risk combination hormonal contraceptives, the absolute risk of VTE was 2/10,000.

Study strengths and limitations

Strengths of this analysis by Meaidi and colleagues include the use of large, essentially all-inclusive national registries. In addition, nationwide Danish registry data that indicate a diagnosis of VTE have been found to have a high positive predictive value.³ Another strength is the large number of potentially confounding factors that the authors controlled for.

One potential limitation of their analysis is that the use of only prescribed NSAIDs was considered. Fortunately, however, the prevalence of over-the-counter ibuprofen use in Denmark is not high enough to materially affect the authors’ findings.⁴ Another potential limitation was that information on smoking and body mass index was not available for most of the women included in the study cohort. The authors countered this limitation by pointing out that, in Denmark, smoking and obesity are highly correlated with educational status, and that all analyses were adjusted for educational status. ●

Meaidi A, Mascolo A, Sessa M, et al. Venous thromboembolism with use of hormonal contraception and non-steroidal anti-inflammatory drugs: nationwide cohort study. BMJ. 2023;382:e074450. doi:10.1136/bmj-2022-074450

EXPERT COMMENTARY

Combination (estrogen plus progestin) hormonal contraceptives as well as non–aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) increase the risk of VTE events, including lower extremity clots and pulmonary embolism. Taking contraceptives formulated with ethinyl estradiol increases hepatic production of clotting factors on a dose-related basis. Newer progestins, including desogestrel and drospirenone, also may contribute to an elevated VTE risk, although this association is controversial.¹ NSAIDs promote platelet aggregation, thereby activating the clotting system and formation of clots. Although studies that assessed the association between NSAID use and thrombosis have focused on arterial clots, a substantial literature suggests that NSAIDs, including older NSAIDs (such as ibuprofen, diclofenac, and naproxen), also increase VTE risk.²

Although combination contraceptives (oral contraceptives, patches, vaginal rings) and NSAIDs are both commonly used by reproductive-age women, little data have assessed the impact of concomitant use of these medications on VTE risk. Accordingly, investigators in Denmark, using national databases, conducted a retrospective cohort study to assess the impact that independent as well as concomitant use of these medications have on VTE risk.

Details of the study

Meaidi and colleagues included in the cohort reproductive-age women living in Denmark between 1996 and 2017 with no history of thrombosis, thrombophilia, cancer, tubal sterilization, hysterectomy, bilateral oophorectomy, or infertility treatment. National prescription data were used to assess exposure to hormonal contraception.

The investigators classified hormonal contraception into 3 VTE risk categories:

1. high risk—estrogen-progestin patches and vaginal rings; oral contraceptives containing 50 µg of ethinyl estradiol; or the progestins desogestrel, drospirenone, gestodene, or cyproterone (with the latter 2 progestins not available in the United States)
2. medium risk—all other combination oral contraceptives, including those formulated with the progestins norethindrone, norethindrone acetate, norgestrel, and levonorgestrel, as well as depot medroxyprogesterone acetate
3. low/no risk—progestin-only pills, implants, and progestin-containing intrauterine devices (IUDs).

Because in Denmark NSAIDs are prescribed as a single package containing no more than 30 tablets, time exposed to non–aspirin NSAIDs was assumed to last 1 week from the prescription date.

The authors considered first-time diagnoses of lower limb venous thrombosis or pulmonary embolism that were made in hospitals to represent VTE. They also constructed a subgroup of VTE patients in whom the diagnosis was either confirmed with imaging or followed by prescription of an anticoagulant.

To address potential confounding, the authors adjusted their analysis based on age, calendar year, educational attainment, occurrence of pregnancy, surgery, hypertension, diabetes, polycystic ovary syndrome, endometriosis, migraine, systemic connective tissue diseases, inflammatory polyarthropathies, and use of tranexamic acid (a medication that may increase VTE risk). They also censored (temporarily excluded women from analysis) episodes associated with a transiently elevated risk of VTE: pregnancy and 6 months following delivery, 12 weeks after other pregnancy terminations, 8 weeks following any surgery involving hospital admission, and 8 weeks following prescription of tranexamic acid.

Continue to: VTEs associated with risk category of hormonal contraception used...

Results. The overall cohort included more than 2 million women who were followed for a median of 10 years. During 21.0 million person-years, 8,710 VTE events were diagnosed; almost one-third of these were pulmonary embolisms, with the remainder diagnosed as lower extremity VTE. Of these 8,710 women diagnosed with VTE, 7,043 (81%) were confirmed with either diagnostic imaging or prescription of an anticoagulant. Unfortunately, 228 women (2.6%) died within 30 days of the diagnosis of VTE.

The investigators identified concomitant use of hormonal contraception and NSAIDs in more than 500,000 women. Among women with such concomitant use, 58% were using contraceptives that were high risk while 23% used medium-risk and 19% used low/no-risk contraceptives. Ibuprofen (60%) was the most commonly used NSAID, followed by diclofenac (20%) and naproxen (6%). Between 97% and 98% of high-risk and medium-risk contraceptives were combination pills; 89% of low/no-risk contraceptives were progestin IUDs.

Compared with nonuse of both hormonal contraceptives and NSAIDs, incidence rate ratios of VTE adjusted for age, calendar year, and education were 8.1 (95% confidence interval [CI], 6.9–9.6) for use of NSAIDs only, 4.2 (95% CI, 4.0–4.4) for use of high-risk contraceptives only, 3.0 (95% CI, 2.8–3.2) for medium-risk contraceptive use, and 1.1 (95% CI, 1.0–1.3) for use of low/no-risk hormonal contraception. Risk of VTE was approximately twice as high with the use of diclofenac only compared with the risks associated with ibuprofen or naproxen use only.

With respect to concomitant use of NSAIDs and hormonal contraception, incidence rate ratios of VTE were 50.6 (95% CI, 44.2–57.8), 26.1 (95% CI, 19.6–34.7), and 5.7 (95% CI, 3.3–10.1), respectively, with use of high-risk, medium-risk, and low/no-risk hormonal contraceptives. Adjusting for time updated information on occurrences of migraine, connective tissue disorder, inflammatory polyarthropathies, endometriosis, polycystic ovary syndrome, hypertension, and diabetes did not materially affect these associations.

When analysis was limited to women without these occurring conditions, rate ratios were somewhat higher (5.7 and 4.1) for use of high-risk and medium-risk contraceptives only. Incidence rate ratios in this subcohort of healthier women were substantially higher for NSAID use only (15.0), and 111.7, 43.2, and 13.0, respectively, for concomitant use of NSAIDs with high-risk, medium-risk, and low/no-risk contraceptives. In this analysis of healthier women, diclofenac continued to be associated with substantially higher risks of VTE than ibuprofen or naproxen. When the stricter definition of VTE (confirmed cases) was used, adjusted rate ratios remained similar.

Absolute risks of VTE

Although some of the elevated rate ratios noted in this study might appear alarming, it is important to keep in mind that the baseline incidence of VTE in healthy reproductive-age women is low. Accordingly, as the authors pointed out, even among women who used NSAIDs concomitantly with high-risk combination hormonal contraceptives, the absolute risk of VTE was 2/10,000.

Study strengths and limitations

Strengths of this analysis by Meaidi and colleagues include the use of large, essentially all-inclusive national registries. In addition, nationwide Danish registry data that indicate a diagnosis of VTE have been found to have a high positive predictive value.³ Another strength is the large number of potentially confounding factors that the authors controlled for.

One potential limitation of their analysis is that the use of only prescribed NSAIDs was considered. Fortunately, however, the prevalence of over-the-counter ibuprofen use in Denmark is not high enough to materially affect the authors’ findings.⁴ Another potential limitation was that information on smoking and body mass index was not available for most of the women included in the study cohort. The authors countered this limitation by pointing out that, in Denmark, smoking and obesity are highly correlated with educational status, and that all analyses were adjusted for educational status. ●

Restrepo J, Herrera T, Samakoses R, et al. Ten-year follow-up of 9-valent human papillomavirus vaccine: immunogenicity, effectiveness, and safety. Pediatrics. 2023;152:e2022060993. doi:10.1542/peds.2022-060993

EXPERT COMMENTARY

Infection with human papillomavirus (HPV) is associated with nearly all cases of cervical cancer. Long-term safety and efficacy of the bivalent (Cervarix) and quadrivalent (Gardasil) vaccines have been demonstrated for up to 10 to 14 years.^1-6 It is estimated that the 9-valent vaccine (Gardasil 9), which was licensed in 2014 and protects against HPV 16/18/31/33/45/52/58 and HPV 6/11, could prevent up to 90% of cervical cancer cases. The bivalent and quadrivalent vaccines could ideally prevent 70% of cases of cervical cancer. In a recent study, authors compared the efficacy and safety of the newer 9-valent vaccine at 10 years with long-term outcomes of previous vaccine studies.⁷

Details of the study

Study V503-002 conducted by Luxembourg and colleagues originally enrolled 1,935 boys and girls from 66 sites in Africa, Asia, Europe, Latin America, and North America to receive 3 doses of the 9-valent HPV vaccine, with follow-up for 12 to 36 months to monitor safety and immunogenicity.⁸ In an extension of this investigation, Restrepo and colleagues revisited 40 of these sites in 13 countries to gather 10 years of long-term follow-up data.⁷

The final long-term follow-up cohort included 971 girls and 301 boys aged 9 to 15 at vaccination.

Results. At month 126, participants continued to have very high seropositive rates (81%–100%, depending on assay sensitivity and HPV type). There were no cases of high-grade cervical, vaginal, or vulvar dysplasia related to HPV strains covered in the vaccine. Rates of infection in women with the vaccine-targeted HPV types were very low—54.6 per 10,000 person-years—compared with 927.4 per 10,000 person-years for HPV types not included in the vaccine. No adverse events attributable to the vaccine were reported.

Study strengths and limitations

Strengths of this study included the use of rigorous end points similar to those used in the initial efficacy studies for easy comparison. Limitations included the relatively small size, which precluded a robust assessment of adverse events, as well as the lack of controls. Furthermore, this study looked at children receiving 3 doses of HPV vaccine prior to the age of 15 and may not be generalizable to people who receive the vaccine at an older age or in fewer doses. ●

Restrepo J, Herrera T, Samakoses R, et al. Ten-year follow-up of 9-valent human papillomavirus vaccine: immunogenicity, effectiveness, and safety. Pediatrics. 2023;152:e2022060993. doi:10.1542/peds.2022-060993

EXPERT COMMENTARY

Infection with human papillomavirus (HPV) is associated with nearly all cases of cervical cancer. Long-term safety and efficacy of the bivalent (Cervarix) and quadrivalent (Gardasil) vaccines have been demonstrated for up to 10 to 14 years.^1-6 It is estimated that the 9-valent vaccine (Gardasil 9), which was licensed in 2014 and protects against HPV 16/18/31/33/45/52/58 and HPV 6/11, could prevent up to 90% of cervical cancer cases. The bivalent and quadrivalent vaccines could ideally prevent 70% of cases of cervical cancer. In a recent study, authors compared the efficacy and safety of the newer 9-valent vaccine at 10 years with long-term outcomes of previous vaccine studies.⁷

Details of the study

Study V503-002 conducted by Luxembourg and colleagues originally enrolled 1,935 boys and girls from 66 sites in Africa, Asia, Europe, Latin America, and North America to receive 3 doses of the 9-valent HPV vaccine, with follow-up for 12 to 36 months to monitor safety and immunogenicity.⁸ In an extension of this investigation, Restrepo and colleagues revisited 40 of these sites in 13 countries to gather 10 years of long-term follow-up data.⁷

The final long-term follow-up cohort included 971 girls and 301 boys aged 9 to 15 at vaccination.

Results. At month 126, participants continued to have very high seropositive rates (81%–100%, depending on assay sensitivity and HPV type). There were no cases of high-grade cervical, vaginal, or vulvar dysplasia related to HPV strains covered in the vaccine. Rates of infection in women with the vaccine-targeted HPV types were very low—54.6 per 10,000 person-years—compared with 927.4 per 10,000 person-years for HPV types not included in the vaccine. No adverse events attributable to the vaccine were reported.

Study strengths and limitations

Strengths of this study included the use of rigorous end points similar to those used in the initial efficacy studies for easy comparison. Limitations included the relatively small size, which precluded a robust assessment of adverse events, as well as the lack of controls. Furthermore, this study looked at children receiving 3 doses of HPV vaccine prior to the age of 15 and may not be generalizable to people who receive the vaccine at an older age or in fewer doses. ●

Restrepo J, Herrera T, Samakoses R, et al. Ten-year follow-up of 9-valent human papillomavirus vaccine: immunogenicity, effectiveness, and safety. Pediatrics. 2023;152:e2022060993. doi:10.1542/peds.2022-060993

EXPERT COMMENTARY

Infection with human papillomavirus (HPV) is associated with nearly all cases of cervical cancer. Long-term safety and efficacy of the bivalent (Cervarix) and quadrivalent (Gardasil) vaccines have been demonstrated for up to 10 to 14 years.^1-6 It is estimated that the 9-valent vaccine (Gardasil 9), which was licensed in 2014 and protects against HPV 16/18/31/33/45/52/58 and HPV 6/11, could prevent up to 90% of cervical cancer cases. The bivalent and quadrivalent vaccines could ideally prevent 70% of cases of cervical cancer. In a recent study, authors compared the efficacy and safety of the newer 9-valent vaccine at 10 years with long-term outcomes of previous vaccine studies.⁷

Details of the study

Study V503-002 conducted by Luxembourg and colleagues originally enrolled 1,935 boys and girls from 66 sites in Africa, Asia, Europe, Latin America, and North America to receive 3 doses of the 9-valent HPV vaccine, with follow-up for 12 to 36 months to monitor safety and immunogenicity.⁸ In an extension of this investigation, Restrepo and colleagues revisited 40 of these sites in 13 countries to gather 10 years of long-term follow-up data.⁷

The final long-term follow-up cohort included 971 girls and 301 boys aged 9 to 15 at vaccination.

Results. At month 126, participants continued to have very high seropositive rates (81%–100%, depending on assay sensitivity and HPV type). There were no cases of high-grade cervical, vaginal, or vulvar dysplasia related to HPV strains covered in the vaccine. Rates of infection in women with the vaccine-targeted HPV types were very low—54.6 per 10,000 person-years—compared with 927.4 per 10,000 person-years for HPV types not included in the vaccine. No adverse events attributable to the vaccine were reported.

Study strengths and limitations

Strengths of this study included the use of rigorous end points similar to those used in the initial efficacy studies for easy comparison. Limitations included the relatively small size, which precluded a robust assessment of adverse events, as well as the lack of controls. Furthermore, this study looked at children receiving 3 doses of HPV vaccine prior to the age of 15 and may not be generalizable to people who receive the vaccine at an older age or in fewer doses. ●

PHOTO:PEAKSTOCK/SHUTTERSTOCK

Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med. 2023;176:1172-1180. doi:10.7326/M23-0133

EXPERT COMMENTARY

A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease. The goal of screening is to detect the condition early enough to treat it most effectively, and ultimately to decrease morbidity and mortality related to the disease. Overdiagnosis refers to the finding of a cancer that would not have caused clinical problems during a person’s lifetime.

Current guidelines for the early detection of breast cancer vary considerably, including recommendations for what age to initiate screening, the cadence of screening (annual or biannual), the use of ancillary screening for people with dense breasts, and importantly the upper age limit for which screening is advised. The US Preventive Services Task Force recommends continuing screening to age 74. The American Cancer Society suggests ongoing screening if life expectancy is estimated at more than 10 years, and the American College of Physicians recommends stopping screening at age 75, or younger if life expectancy is less than 10 years. The American College of Obstetricians and Gynecologists states that women at average risk of breast cancer should continue screening mammography until at least age 75.

Overdiagnosis is a difficult concept for clinicians to understand let alone explain to our patients. Recently, Richman and colleagues published the results of their study aimed at estimating overdiagnosis associated with breast cancer screening among older women.¹ As Dr. Otis Brawley, former Chief Medical and Scientific Officer of the American Cancer Society and current Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, states in the editorial that accompanies the study by Richman and colleagues, “Some tumors are not destined to grow, spread, and kill due to their genomics or their microenvironment. A second type of overdiagnosis involves small tumors that do have the potential to grow but will not grow fast enough to bother the patient within their natural lifetime.”²

Although screening mammography in older women results in frequent false positives that require additional imaging as well as biopsies, we have become more aware of the potential of overdiagnosis as an important downside of screening mammography in an elderly population.

Continue to: Details of the study...

Details of the study

Using the SEER registry to identify breast cancers linked to a 5% sample of Medicare beneficiaries, Richman and colleagues (funded by the National Cancer Institute and based at Yale University) conducted a retrospectivecohort study to estimate the likelihood of overdiagnosis associated with screening mammography among older women over 15 years of follow-up. Specifically, they assessed the difference in cumulative incidence of in situ and invasive breast cancer among women aged 70 years and older without a history of breast cancer when screened in 2002. During the subsequent 3 years, participants either continued screening (screened group) or did not (unscreened group). Women were followed through 2017.

Among almost 55,000 women followed, 88% were White, 6% were Black, and 3% were Hispanic. Mean follow-up was 13.7 years among women aged 70 to 74 years at baseline. For those aged 75 to 84 at baseline, mean follow-up was 10 years, and for those aged 85 years and older, mean follow-up was 5.7 years.

Estimated rates of overdiagnosis. Overall, among women aged 70 to 74 at baseline who were eventually diagnosed with breast cancer, the investigators estimated that 31% of these cancers were overdiagnosed. The corresponding percentage of breast cancers estimated to represent overdiagnosis climbed to 47% for those aged 75 to 84 years at baseline and to 54% for those aged 85 years and older at baseline.

The investigators assessed the impact of greater screening among women with a first-degree relative with a diagnosis of breast cancer and determined that this did not explain their results. With respect to cancer stage, the investigators noted that overdiagnosis was more prevalent among in situ and localized invasive cancers compared with those with regional or distant spread. Of note, the incidence of cancer with regional or distant spread was neither higher nor lower among those who were screened. Finally, the investigators did not observe significant differences in breast cancer–specific mortality by screening status.

The proportion of cancers that were overdiagnosed was particularly high among women with in situ as well as those with localized invasive disease. The investigators pointed out that as many as 90% of women aged 80 and older diagnosed with localized cancer undergo surgery, and almost two-thirds of those older than 70 years have radiation therapy for early-stage disease. In addition to the burdens associated with these treatments for overdiagnosed cancers in older women, simply being diagnosed with breast cancer profoundly affects the health and well-being of women, resulting in anxiety and substantial reductions in quality of life.

The authors also noted that some studies suggest that, among breast cancers diagnosed with screening, chemotherapy is less likely to be employed among older women, a screening benefit that must be weighed against the high likelihood of overdiagnosis. However, this benefit is unlikely to be meaningful for the majority of patients in this study who presented with in situ or early invasive lesions since chemotherapy often is not recommended for such women.

Study strengths and limitations

If screening mammography is effective, the incidence of advanced-stage tumors and breast cancer–specific mortality should be reduced in screened populations. Accordingly, in this large, long-term study using reliable sources of data, the findings that the incidence of advanced-stage disease as well as breast cancer–specific mortality were similar in the screened and unscreened cohorts provides powerful evidence that screening mammography is not effective in older women.³

As the authors pointed out, their findings regarding a high prevalence of overdiagnosis associated with screening mammography in older women are consistent with findings of other studies, some of which used different methodology.

The authors acknowledged that some women in their Medicare cohort who initially continued screening likely stopped screening subsequently, while some who initially did not continue screening might have been screened subsequently. They went on to indicate that if patients were completely adherent with subsequent screening (or not getting screened) the likelihood that cancers among screened women were overdiagnosed would be even higher.

Lead-time bias occurs when screening finds a cancer earlier than that cancer would have been diagnosed because of symptoms. This study followed the cohorts over a long timeframe to reduce the possibility that lead time was inappropriately identified as overdiagnosis. They also observed that, among women aged 85 and older, most cohort members had died by the end of study follow-up; accordingly, lead time is not likely to have explained their findings.

Limitations. The authors acknowledged that miscoding the mammogram type (screening vs diagnostic) could result in higher estimates of overdiagnosis. In their most conservative sensitivity analysis, the overdiagnosis rates could be as low as 15% for women aged 70 to 74, 36% for those aged 75 to 84, and 44% for people aged 85 and older.

Because this was an observational cohort study, unmeasured differences in breast cancer risk and underlying health factors may have been confounders. Specifically, people with severe life-threatening conditions that limited their expected life span may have chosen not to undergo regular screening. Although the authors did attempt to adjust for these factors, there may have been unrecognized confounders. This study was designed to estimate overdiagnosis, and therefore the specific benefits and harms of screening could not be addressed based on the data collected. ●

PHOTO:PEAKSTOCK/SHUTTERSTOCK

Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med. 2023;176:1172-1180. doi:10.7326/M23-0133

EXPERT COMMENTARY

A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease. The goal of screening is to detect the condition early enough to treat it most effectively, and ultimately to decrease morbidity and mortality related to the disease. Overdiagnosis refers to the finding of a cancer that would not have caused clinical problems during a person’s lifetime.

Current guidelines for the early detection of breast cancer vary considerably, including recommendations for what age to initiate screening, the cadence of screening (annual or biannual), the use of ancillary screening for people with dense breasts, and importantly the upper age limit for which screening is advised. The US Preventive Services Task Force recommends continuing screening to age 74. The American Cancer Society suggests ongoing screening if life expectancy is estimated at more than 10 years, and the American College of Physicians recommends stopping screening at age 75, or younger if life expectancy is less than 10 years. The American College of Obstetricians and Gynecologists states that women at average risk of breast cancer should continue screening mammography until at least age 75.

Overdiagnosis is a difficult concept for clinicians to understand let alone explain to our patients. Recently, Richman and colleagues published the results of their study aimed at estimating overdiagnosis associated with breast cancer screening among older women.¹ As Dr. Otis Brawley, former Chief Medical and Scientific Officer of the American Cancer Society and current Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, states in the editorial that accompanies the study by Richman and colleagues, “Some tumors are not destined to grow, spread, and kill due to their genomics or their microenvironment. A second type of overdiagnosis involves small tumors that do have the potential to grow but will not grow fast enough to bother the patient within their natural lifetime.”²

Although screening mammography in older women results in frequent false positives that require additional imaging as well as biopsies, we have become more aware of the potential of overdiagnosis as an important downside of screening mammography in an elderly population.

Continue to: Details of the study...

Details of the study

Using the SEER registry to identify breast cancers linked to a 5% sample of Medicare beneficiaries, Richman and colleagues (funded by the National Cancer Institute and based at Yale University) conducted a retrospectivecohort study to estimate the likelihood of overdiagnosis associated with screening mammography among older women over 15 years of follow-up. Specifically, they assessed the difference in cumulative incidence of in situ and invasive breast cancer among women aged 70 years and older without a history of breast cancer when screened in 2002. During the subsequent 3 years, participants either continued screening (screened group) or did not (unscreened group). Women were followed through 2017.

Among almost 55,000 women followed, 88% were White, 6% were Black, and 3% were Hispanic. Mean follow-up was 13.7 years among women aged 70 to 74 years at baseline. For those aged 75 to 84 at baseline, mean follow-up was 10 years, and for those aged 85 years and older, mean follow-up was 5.7 years.

Estimated rates of overdiagnosis. Overall, among women aged 70 to 74 at baseline who were eventually diagnosed with breast cancer, the investigators estimated that 31% of these cancers were overdiagnosed. The corresponding percentage of breast cancers estimated to represent overdiagnosis climbed to 47% for those aged 75 to 84 years at baseline and to 54% for those aged 85 years and older at baseline.

The investigators assessed the impact of greater screening among women with a first-degree relative with a diagnosis of breast cancer and determined that this did not explain their results. With respect to cancer stage, the investigators noted that overdiagnosis was more prevalent among in situ and localized invasive cancers compared with those with regional or distant spread. Of note, the incidence of cancer with regional or distant spread was neither higher nor lower among those who were screened. Finally, the investigators did not observe significant differences in breast cancer–specific mortality by screening status.

The proportion of cancers that were overdiagnosed was particularly high among women with in situ as well as those with localized invasive disease. The investigators pointed out that as many as 90% of women aged 80 and older diagnosed with localized cancer undergo surgery, and almost two-thirds of those older than 70 years have radiation therapy for early-stage disease. In addition to the burdens associated with these treatments for overdiagnosed cancers in older women, simply being diagnosed with breast cancer profoundly affects the health and well-being of women, resulting in anxiety and substantial reductions in quality of life.

The authors also noted that some studies suggest that, among breast cancers diagnosed with screening, chemotherapy is less likely to be employed among older women, a screening benefit that must be weighed against the high likelihood of overdiagnosis. However, this benefit is unlikely to be meaningful for the majority of patients in this study who presented with in situ or early invasive lesions since chemotherapy often is not recommended for such women.

Study strengths and limitations

If screening mammography is effective, the incidence of advanced-stage tumors and breast cancer–specific mortality should be reduced in screened populations. Accordingly, in this large, long-term study using reliable sources of data, the findings that the incidence of advanced-stage disease as well as breast cancer–specific mortality were similar in the screened and unscreened cohorts provides powerful evidence that screening mammography is not effective in older women.³

As the authors pointed out, their findings regarding a high prevalence of overdiagnosis associated with screening mammography in older women are consistent with findings of other studies, some of which used different methodology.

The authors acknowledged that some women in their Medicare cohort who initially continued screening likely stopped screening subsequently, while some who initially did not continue screening might have been screened subsequently. They went on to indicate that if patients were completely adherent with subsequent screening (or not getting screened) the likelihood that cancers among screened women were overdiagnosed would be even higher.

Lead-time bias occurs when screening finds a cancer earlier than that cancer would have been diagnosed because of symptoms. This study followed the cohorts over a long timeframe to reduce the possibility that lead time was inappropriately identified as overdiagnosis. They also observed that, among women aged 85 and older, most cohort members had died by the end of study follow-up; accordingly, lead time is not likely to have explained their findings.

Limitations. The authors acknowledged that miscoding the mammogram type (screening vs diagnostic) could result in higher estimates of overdiagnosis. In their most conservative sensitivity analysis, the overdiagnosis rates could be as low as 15% for women aged 70 to 74, 36% for those aged 75 to 84, and 44% for people aged 85 and older.

Because this was an observational cohort study, unmeasured differences in breast cancer risk and underlying health factors may have been confounders. Specifically, people with severe life-threatening conditions that limited their expected life span may have chosen not to undergo regular screening. Although the authors did attempt to adjust for these factors, there may have been unrecognized confounders. This study was designed to estimate overdiagnosis, and therefore the specific benefits and harms of screening could not be addressed based on the data collected. ●

PHOTO:PEAKSTOCK/SHUTTERSTOCK

Richman IB, Long JB, Soulos PR, et al. Estimating breast cancer overdiagnosis after screening mammography among older women in the United States. Ann Intern Med. 2023;176:1172-1180. doi:10.7326/M23-0133

EXPERT COMMENTARY

A screening test is performed to detect potential health disorders or diseases in people who do not have any symptoms of disease. The goal of screening is to detect the condition early enough to treat it most effectively, and ultimately to decrease morbidity and mortality related to the disease. Overdiagnosis refers to the finding of a cancer that would not have caused clinical problems during a person’s lifetime.

Current guidelines for the early detection of breast cancer vary considerably, including recommendations for what age to initiate screening, the cadence of screening (annual or biannual), the use of ancillary screening for people with dense breasts, and importantly the upper age limit for which screening is advised. The US Preventive Services Task Force recommends continuing screening to age 74. The American Cancer Society suggests ongoing screening if life expectancy is estimated at more than 10 years, and the American College of Physicians recommends stopping screening at age 75, or younger if life expectancy is less than 10 years. The American College of Obstetricians and Gynecologists states that women at average risk of breast cancer should continue screening mammography until at least age 75.

Overdiagnosis is a difficult concept for clinicians to understand let alone explain to our patients. Recently, Richman and colleagues published the results of their study aimed at estimating overdiagnosis associated with breast cancer screening among older women.¹ As Dr. Otis Brawley, former Chief Medical and Scientific Officer of the American Cancer Society and current Distinguished Professor of Oncology and Epidemiology at Johns Hopkins University, states in the editorial that accompanies the study by Richman and colleagues, “Some tumors are not destined to grow, spread, and kill due to their genomics or their microenvironment. A second type of overdiagnosis involves small tumors that do have the potential to grow but will not grow fast enough to bother the patient within their natural lifetime.”²

Although screening mammography in older women results in frequent false positives that require additional imaging as well as biopsies, we have become more aware of the potential of overdiagnosis as an important downside of screening mammography in an elderly population.

Continue to: Details of the study...

Details of the study

Using the SEER registry to identify breast cancers linked to a 5% sample of Medicare beneficiaries, Richman and colleagues (funded by the National Cancer Institute and based at Yale University) conducted a retrospectivecohort study to estimate the likelihood of overdiagnosis associated with screening mammography among older women over 15 years of follow-up. Specifically, they assessed the difference in cumulative incidence of in situ and invasive breast cancer among women aged 70 years and older without a history of breast cancer when screened in 2002. During the subsequent 3 years, participants either continued screening (screened group) or did not (unscreened group). Women were followed through 2017.

Among almost 55,000 women followed, 88% were White, 6% were Black, and 3% were Hispanic. Mean follow-up was 13.7 years among women aged 70 to 74 years at baseline. For those aged 75 to 84 at baseline, mean follow-up was 10 years, and for those aged 85 years and older, mean follow-up was 5.7 years.

Estimated rates of overdiagnosis. Overall, among women aged 70 to 74 at baseline who were eventually diagnosed with breast cancer, the investigators estimated that 31% of these cancers were overdiagnosed. The corresponding percentage of breast cancers estimated to represent overdiagnosis climbed to 47% for those aged 75 to 84 years at baseline and to 54% for those aged 85 years and older at baseline.

The investigators assessed the impact of greater screening among women with a first-degree relative with a diagnosis of breast cancer and determined that this did not explain their results. With respect to cancer stage, the investigators noted that overdiagnosis was more prevalent among in situ and localized invasive cancers compared with those with regional or distant spread. Of note, the incidence of cancer with regional or distant spread was neither higher nor lower among those who were screened. Finally, the investigators did not observe significant differences in breast cancer–specific mortality by screening status.

The proportion of cancers that were overdiagnosed was particularly high among women with in situ as well as those with localized invasive disease. The investigators pointed out that as many as 90% of women aged 80 and older diagnosed with localized cancer undergo surgery, and almost two-thirds of those older than 70 years have radiation therapy for early-stage disease. In addition to the burdens associated with these treatments for overdiagnosed cancers in older women, simply being diagnosed with breast cancer profoundly affects the health and well-being of women, resulting in anxiety and substantial reductions in quality of life.

The authors also noted that some studies suggest that, among breast cancers diagnosed with screening, chemotherapy is less likely to be employed among older women, a screening benefit that must be weighed against the high likelihood of overdiagnosis. However, this benefit is unlikely to be meaningful for the majority of patients in this study who presented with in situ or early invasive lesions since chemotherapy often is not recommended for such women.

Study strengths and limitations

If screening mammography is effective, the incidence of advanced-stage tumors and breast cancer–specific mortality should be reduced in screened populations. Accordingly, in this large, long-term study using reliable sources of data, the findings that the incidence of advanced-stage disease as well as breast cancer–specific mortality were similar in the screened and unscreened cohorts provides powerful evidence that screening mammography is not effective in older women.³

As the authors pointed out, their findings regarding a high prevalence of overdiagnosis associated with screening mammography in older women are consistent with findings of other studies, some of which used different methodology.

The authors acknowledged that some women in their Medicare cohort who initially continued screening likely stopped screening subsequently, while some who initially did not continue screening might have been screened subsequently. They went on to indicate that if patients were completely adherent with subsequent screening (or not getting screened) the likelihood that cancers among screened women were overdiagnosed would be even higher.

Lead-time bias occurs when screening finds a cancer earlier than that cancer would have been diagnosed because of symptoms. This study followed the cohorts over a long timeframe to reduce the possibility that lead time was inappropriately identified as overdiagnosis. They also observed that, among women aged 85 and older, most cohort members had died by the end of study follow-up; accordingly, lead time is not likely to have explained their findings.

Limitations. The authors acknowledged that miscoding the mammogram type (screening vs diagnostic) could result in higher estimates of overdiagnosis. In their most conservative sensitivity analysis, the overdiagnosis rates could be as low as 15% for women aged 70 to 74, 36% for those aged 75 to 84, and 44% for people aged 85 and older.

Because this was an observational cohort study, unmeasured differences in breast cancer risk and underlying health factors may have been confounders. Specifically, people with severe life-threatening conditions that limited their expected life span may have chosen not to undergo regular screening. Although the authors did attempt to adjust for these factors, there may have been unrecognized confounders. This study was designed to estimate overdiagnosis, and therefore the specific benefits and harms of screening could not be addressed based on the data collected. ●

Deligiannidis KM, Meltzer-Brody S, Maximos B, et al. Zuranolone for the treatment of postpartum depression. Am J Psychiatry. 2023;180:668-675. doi:10.1176/appi.ajp.20220785.

EXPERT COMMENTARY

Postpartum depression affects approximately 17.2% of patients in the peripartum period.¹ Typical pharmacologic treatment of PPD includes selective serotonin reuptake inhibitors (SSRIs), which may take up to 12 weeks to take effect. Postpartum depression is thought to be secondary to maladaptation to hormonal fluctuations in the peripartum period, including allopregnanolone, a positive allosteric modulator of GABA_A (γ-aminobutyric acid type A)receptors and a metabolite of progesterone, levels of which increase in pregnancy and abruptly decrease following delivery.¹ In 2019, the GABA_A receptor modulator brexanalone was approved by the US Food and Drug Administration (FDA) to treat PPD through continuous intravenous infusion over 60 hours in the hospital setting.

Zuranolone, an allosteric modulator of GABA_A receptors, also has been studied as an investigational medication for rapid treatment of PPD. Prior studies demonstrated the efficacy of oral zuranolone 30 mg daily for the treatment of PPD² and 50 mg for the treatment of major depression in nonpregnant patients.³ Deligiannidis and colleagues conducted a trial to investigate the 50-mg dose of zuranolone for the treatment of PPD. (Notably, in August 2023, the FDA approved oral zuranolone once daily for 14 days for the treatment of PPD.) Following the FDA approval, the American College of Obstetricians and Gynecologists (ACOG) released a Practice Advisory recommending consideration of zuranolone for PPD that takes into account balancing the benefits and risks, including known sedative effects, potential need for decreasing the dose due to adverse effects, lack of safety data in lactation, and unknown long-term efficacy.⁴

Details of the study

This randomized, double-blind, placebo-controlled study included 196 patients with an episode of major depression, characterized as a baseline score of 26 or greater on the Hamilton Depression Rating Scale (HAM-D) beginning in the third trimester or within the first 4 weeks postpartum. Patients were randomly assigned in a 1:1 ratio to receive zuranolone 50 mg daily or placebo, with stratification by stable concurrent antidepressant use. Treatment duration was for 14 days, with follow-up through day 45.

The study’s primary outcome was a change in the baseline HAM-D score at day 15. Changes in HAM-D score also were recorded at days 3, 28, and 45.

The 2 study groups were well balanced by demographic and baseline characteristics. In both groups, the majority of patients experienced the onset of their major depressive episodes within the first 4 weeks postpartum. Completion rates of the 14-day treatment course and 45-day follow-up were high and similar in both groups; 170 patients completed the study. The rate of concurrent psychiatric medications taken, most of which were SSRIs, was similar between the 2 groups at approximately 15% of patients.

Results. A statistically significant improvement in the primary outcome (the change in HAM-D score) at day 15 occurred in patients who received zuranolone versus placebo (P = .001). Additionally, there were statistically significant improvements in the secondary outcomes HAM-D scores at days 3, 28, and 45. Initial response, as measured by changes in HAM-D scores, occurred at a median duration of 9 days in the zuranolone group and 43 days in the placebo group. More patients in the zuranolone group achieved a reduction in HAM-D score at 15 days (57.0% vs 38.9%; P = .02). Zuranolone was associated with a higher rate of HAM-D remission at day 45 (44.0% vs 29.4%; P = .02).

With regard to safety, 16.3% of patients (17) in the zuranolone group (vs 1% in the placebo group) experienced an adverse event, most commonly somnolence, dizziness, and sedation, which led to a dose reduction. However, 15 of these 17 patients still completed the study, and there were no serious adverse events.

Study strengths and limitations

This study’s strengths include the double-blinded design that was continued throughout the duration of the follow-up. Additionally, the study population was heterogeneous andreflective of patients from diverse racial and ethnic backgrounds. Lastly, only minor and moderate adverse events were reported and, despite this, nearly all patients who experienced adverse events completed the study.

Limitations of the study include the lack of generalizability, as patients with bipolar disorder and mild or moderate PPD were excluded. Additionally, the majority of patients had depressive episodes within the first 4 weeks postpartum, thereby excluding patients with depressive episodes at other time points in the peripartum period. Further, as breastfeeding was prohibited, safety in lactating patients using zuranolone is unknown. Lastly, the study follow-up period was 45 days; therefore, the long-term efficacy of zuranolone treatment is unclear. ●

Deligiannidis KM, Meltzer-Brody S, Maximos B, et al. Zuranolone for the treatment of postpartum depression. Am J Psychiatry. 2023;180:668-675. doi:10.1176/appi.ajp.20220785.

EXPERT COMMENTARY

Postpartum depression affects approximately 17.2% of patients in the peripartum period.¹ Typical pharmacologic treatment of PPD includes selective serotonin reuptake inhibitors (SSRIs), which may take up to 12 weeks to take effect. Postpartum depression is thought to be secondary to maladaptation to hormonal fluctuations in the peripartum period, including allopregnanolone, a positive allosteric modulator of GABA_A (γ-aminobutyric acid type A)receptors and a metabolite of progesterone, levels of which increase in pregnancy and abruptly decrease following delivery.¹ In 2019, the GABA_A receptor modulator brexanalone was approved by the US Food and Drug Administration (FDA) to treat PPD through continuous intravenous infusion over 60 hours in the hospital setting.

Zuranolone, an allosteric modulator of GABA_A receptors, also has been studied as an investigational medication for rapid treatment of PPD. Prior studies demonstrated the efficacy of oral zuranolone 30 mg daily for the treatment of PPD² and 50 mg for the treatment of major depression in nonpregnant patients.³ Deligiannidis and colleagues conducted a trial to investigate the 50-mg dose of zuranolone for the treatment of PPD. (Notably, in August 2023, the FDA approved oral zuranolone once daily for 14 days for the treatment of PPD.) Following the FDA approval, the American College of Obstetricians and Gynecologists (ACOG) released a Practice Advisory recommending consideration of zuranolone for PPD that takes into account balancing the benefits and risks, including known sedative effects, potential need for decreasing the dose due to adverse effects, lack of safety data in lactation, and unknown long-term efficacy.⁴

Details of the study

This randomized, double-blind, placebo-controlled study included 196 patients with an episode of major depression, characterized as a baseline score of 26 or greater on the Hamilton Depression Rating Scale (HAM-D) beginning in the third trimester or within the first 4 weeks postpartum. Patients were randomly assigned in a 1:1 ratio to receive zuranolone 50 mg daily or placebo, with stratification by stable concurrent antidepressant use. Treatment duration was for 14 days, with follow-up through day 45.

The study’s primary outcome was a change in the baseline HAM-D score at day 15. Changes in HAM-D score also were recorded at days 3, 28, and 45.

The 2 study groups were well balanced by demographic and baseline characteristics. In both groups, the majority of patients experienced the onset of their major depressive episodes within the first 4 weeks postpartum. Completion rates of the 14-day treatment course and 45-day follow-up were high and similar in both groups; 170 patients completed the study. The rate of concurrent psychiatric medications taken, most of which were SSRIs, was similar between the 2 groups at approximately 15% of patients.

Results. A statistically significant improvement in the primary outcome (the change in HAM-D score) at day 15 occurred in patients who received zuranolone versus placebo (P = .001). Additionally, there were statistically significant improvements in the secondary outcomes HAM-D scores at days 3, 28, and 45. Initial response, as measured by changes in HAM-D scores, occurred at a median duration of 9 days in the zuranolone group and 43 days in the placebo group. More patients in the zuranolone group achieved a reduction in HAM-D score at 15 days (57.0% vs 38.9%; P = .02). Zuranolone was associated with a higher rate of HAM-D remission at day 45 (44.0% vs 29.4%; P = .02).

With regard to safety, 16.3% of patients (17) in the zuranolone group (vs 1% in the placebo group) experienced an adverse event, most commonly somnolence, dizziness, and sedation, which led to a dose reduction. However, 15 of these 17 patients still completed the study, and there were no serious adverse events.

Study strengths and limitations

This study’s strengths include the double-blinded design that was continued throughout the duration of the follow-up. Additionally, the study population was heterogeneous andreflective of patients from diverse racial and ethnic backgrounds. Lastly, only minor and moderate adverse events were reported and, despite this, nearly all patients who experienced adverse events completed the study.

Limitations of the study include the lack of generalizability, as patients with bipolar disorder and mild or moderate PPD were excluded. Additionally, the majority of patients had depressive episodes within the first 4 weeks postpartum, thereby excluding patients with depressive episodes at other time points in the peripartum period. Further, as breastfeeding was prohibited, safety in lactating patients using zuranolone is unknown. Lastly, the study follow-up period was 45 days; therefore, the long-term efficacy of zuranolone treatment is unclear. ●

Deligiannidis KM, Meltzer-Brody S, Maximos B, et al. Zuranolone for the treatment of postpartum depression. Am J Psychiatry. 2023;180:668-675. doi:10.1176/appi.ajp.20220785.

EXPERT COMMENTARY

Postpartum depression affects approximately 17.2% of patients in the peripartum period.¹ Typical pharmacologic treatment of PPD includes selective serotonin reuptake inhibitors (SSRIs), which may take up to 12 weeks to take effect. Postpartum depression is thought to be secondary to maladaptation to hormonal fluctuations in the peripartum period, including allopregnanolone, a positive allosteric modulator of GABA_A (γ-aminobutyric acid type A)receptors and a metabolite of progesterone, levels of which increase in pregnancy and abruptly decrease following delivery.¹ In 2019, the GABA_A receptor modulator brexanalone was approved by the US Food and Drug Administration (FDA) to treat PPD through continuous intravenous infusion over 60 hours in the hospital setting.

Zuranolone, an allosteric modulator of GABA_A receptors, also has been studied as an investigational medication for rapid treatment of PPD. Prior studies demonstrated the efficacy of oral zuranolone 30 mg daily for the treatment of PPD² and 50 mg for the treatment of major depression in nonpregnant patients.³ Deligiannidis and colleagues conducted a trial to investigate the 50-mg dose of zuranolone for the treatment of PPD. (Notably, in August 2023, the FDA approved oral zuranolone once daily for 14 days for the treatment of PPD.) Following the FDA approval, the American College of Obstetricians and Gynecologists (ACOG) released a Practice Advisory recommending consideration of zuranolone for PPD that takes into account balancing the benefits and risks, including known sedative effects, potential need for decreasing the dose due to adverse effects, lack of safety data in lactation, and unknown long-term efficacy.⁴

Details of the study

This randomized, double-blind, placebo-controlled study included 196 patients with an episode of major depression, characterized as a baseline score of 26 or greater on the Hamilton Depression Rating Scale (HAM-D) beginning in the third trimester or within the first 4 weeks postpartum. Patients were randomly assigned in a 1:1 ratio to receive zuranolone 50 mg daily or placebo, with stratification by stable concurrent antidepressant use. Treatment duration was for 14 days, with follow-up through day 45.

The study’s primary outcome was a change in the baseline HAM-D score at day 15. Changes in HAM-D score also were recorded at days 3, 28, and 45.

The 2 study groups were well balanced by demographic and baseline characteristics. In both groups, the majority of patients experienced the onset of their major depressive episodes within the first 4 weeks postpartum. Completion rates of the 14-day treatment course and 45-day follow-up were high and similar in both groups; 170 patients completed the study. The rate of concurrent psychiatric medications taken, most of which were SSRIs, was similar between the 2 groups at approximately 15% of patients.

Results. A statistically significant improvement in the primary outcome (the change in HAM-D score) at day 15 occurred in patients who received zuranolone versus placebo (P = .001). Additionally, there were statistically significant improvements in the secondary outcomes HAM-D scores at days 3, 28, and 45. Initial response, as measured by changes in HAM-D scores, occurred at a median duration of 9 days in the zuranolone group and 43 days in the placebo group. More patients in the zuranolone group achieved a reduction in HAM-D score at 15 days (57.0% vs 38.9%; P = .02). Zuranolone was associated with a higher rate of HAM-D remission at day 45 (44.0% vs 29.4%; P = .02).

With regard to safety, 16.3% of patients (17) in the zuranolone group (vs 1% in the placebo group) experienced an adverse event, most commonly somnolence, dizziness, and sedation, which led to a dose reduction. However, 15 of these 17 patients still completed the study, and there were no serious adverse events.

Study strengths and limitations

This study’s strengths include the double-blinded design that was continued throughout the duration of the follow-up. Additionally, the study population was heterogeneous andreflective of patients from diverse racial and ethnic backgrounds. Lastly, only minor and moderate adverse events were reported and, despite this, nearly all patients who experienced adverse events completed the study.

Limitations of the study include the lack of generalizability, as patients with bipolar disorder and mild or moderate PPD were excluded. Additionally, the majority of patients had depressive episodes within the first 4 weeks postpartum, thereby excluding patients with depressive episodes at other time points in the peripartum period. Further, as breastfeeding was prohibited, safety in lactating patients using zuranolone is unknown. Lastly, the study follow-up period was 45 days; therefore, the long-term efficacy of zuranolone treatment is unclear. ●

Hirshberg A, Zhu Y, Smith-McLallen A, et al. Association of a remote blood pressure monitoring program with postpartum adverse outcomes. Obstet Gynecol. 2023;141:1163-1170. doi:10.1097/AOG.0000000000005197. 

EXPERT COMMENTARY

Courtney Bisson, MD, is a Maternal-Fetal Medicine Fellow, University of Chicago/NorthShore University HealthSystem, Chicago, Illinois.

Sarosh Rana, MD, MPH, is Professor of Obstetrics and Gynecology and Section Chief, Maternal-Fetal Medicine, University of Chicago.

Hypertensive disorders of pregnancy account for a significant amount of morbidity during pregnancy and postpartum. In the pregnant population, data have shown that the implementation of a standardized blood pressure education program, provision of a blood pressure cuff, and assistance with postpartum follow-up result in improved blood pressures and postpartum follow-up for up to 6 weeks. In the nonpregnant population, literature suggests that RBPM in patients with hypertension results in improved outcomes, although the long-term impact of RBPM in the postpartum population remains unclear.

Recently, Hirshberg and colleagues published the results of a retrospective cohort study that assessed the impact of RBPM with text message reminders for 10 days postpartum on a composite of adverse maternal outcomes, readmissions, and follow-up within 1 year postpartum.¹

PHOTO: MICROGEN/SHUTTERSTOCK

Details of the study

The retrospective cohort study was conducted during 2017–2021 based on insurance claims of patients with hypertensive disorders of pregnancy who were enrolled in a twice-daily text message–based RBPM program for 10 days postpartum.

Data from 1,700 patients enrolled in RBPM were compared with that of propensity score matched controls that included 2,297 women not enrolled in RBPM. Of these controls, 1,276 patients (cohort C) simultaneously received care at other institutions without RBPM, and 1,021 patients (cohort A) received care at the same institution prior to implementation of RBPM.

Results. Patients in the RBPM group were found to have a significantly lower rate of composite adverse maternal outcomes compared with their matched cohorts in the year after delivery. (Individual adverse outcomes included stroke, disseminated intravascular coagulation, eclampsia, pulmonary edema, renal injury or liver failure, HELLP [hemolysis, elevated liver enzymes, low platelet count] syndrome, myocardial infarction, and cardiomyopathy.) Rates were 2.9% versus 4.7% (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.40–0.98) in the RBPM group compared with cohort A; rates in the RBPM group compared with cohort C were 3.2% versus 4.5% (OR, 0.71; 95% CI, 0.47–1.07).

Although not statistically significant, rates of emergency department visits and readmissions also were lower in the RBPM patients. Those enrolled in the RBPM program were more likely to have follow-up with cardiologists or specialist visits within 6 months postpartum. Fewer emergency department visits and readmissions resulted in lower health care utilization costs.

Study strengths and limitations

This study’s strength lies in its design and implementation of standardized protocols that allowed assessment of clinically meaningful outcomes postpartum. Although the program for RBPM was for only 10 days postpartum, it showed effects beyond the timeframe of the direct care. No such prior data exist evaluating a program’s effectiveness in improving postpartum clinical outcomes and costs through 1 year postdelivery.

Study limitations include residual bias from unobserved confounders, analysis of only 1 payer type, lack of patient level data, and evaluation of disparity. ●

Hirshberg A, Zhu Y, Smith-McLallen A, et al. Association of a remote blood pressure monitoring program with postpartum adverse outcomes. Obstet Gynecol. 2023;141:1163-1170. doi:10.1097/AOG.0000000000005197. 

EXPERT COMMENTARY

Courtney Bisson, MD, is a Maternal-Fetal Medicine Fellow, University of Chicago/NorthShore University HealthSystem, Chicago, Illinois.

Sarosh Rana, MD, MPH, is Professor of Obstetrics and Gynecology and Section Chief, Maternal-Fetal Medicine, University of Chicago.

Hypertensive disorders of pregnancy account for a significant amount of morbidity during pregnancy and postpartum. In the pregnant population, data have shown that the implementation of a standardized blood pressure education program, provision of a blood pressure cuff, and assistance with postpartum follow-up result in improved blood pressures and postpartum follow-up for up to 6 weeks. In the nonpregnant population, literature suggests that RBPM in patients with hypertension results in improved outcomes, although the long-term impact of RBPM in the postpartum population remains unclear.

Recently, Hirshberg and colleagues published the results of a retrospective cohort study that assessed the impact of RBPM with text message reminders for 10 days postpartum on a composite of adverse maternal outcomes, readmissions, and follow-up within 1 year postpartum.¹

PHOTO: MICROGEN/SHUTTERSTOCK

Details of the study

The retrospective cohort study was conducted during 2017–2021 based on insurance claims of patients with hypertensive disorders of pregnancy who were enrolled in a twice-daily text message–based RBPM program for 10 days postpartum.

Data from 1,700 patients enrolled in RBPM were compared with that of propensity score matched controls that included 2,297 women not enrolled in RBPM. Of these controls, 1,276 patients (cohort C) simultaneously received care at other institutions without RBPM, and 1,021 patients (cohort A) received care at the same institution prior to implementation of RBPM.

Results. Patients in the RBPM group were found to have a significantly lower rate of composite adverse maternal outcomes compared with their matched cohorts in the year after delivery. (Individual adverse outcomes included stroke, disseminated intravascular coagulation, eclampsia, pulmonary edema, renal injury or liver failure, HELLP [hemolysis, elevated liver enzymes, low platelet count] syndrome, myocardial infarction, and cardiomyopathy.) Rates were 2.9% versus 4.7% (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.40–0.98) in the RBPM group compared with cohort A; rates in the RBPM group compared with cohort C were 3.2% versus 4.5% (OR, 0.71; 95% CI, 0.47–1.07).

Although not statistically significant, rates of emergency department visits and readmissions also were lower in the RBPM patients. Those enrolled in the RBPM program were more likely to have follow-up with cardiologists or specialist visits within 6 months postpartum. Fewer emergency department visits and readmissions resulted in lower health care utilization costs.

Study strengths and limitations

This study’s strength lies in its design and implementation of standardized protocols that allowed assessment of clinically meaningful outcomes postpartum. Although the program for RBPM was for only 10 days postpartum, it showed effects beyond the timeframe of the direct care. No such prior data exist evaluating a program’s effectiveness in improving postpartum clinical outcomes and costs through 1 year postdelivery.

Study limitations include residual bias from unobserved confounders, analysis of only 1 payer type, lack of patient level data, and evaluation of disparity. ●

Hirshberg A, Zhu Y, Smith-McLallen A, et al. Association of a remote blood pressure monitoring program with postpartum adverse outcomes. Obstet Gynecol. 2023;141:1163-1170. doi:10.1097/AOG.0000000000005197. 

EXPERT COMMENTARY

Courtney Bisson, MD, is a Maternal-Fetal Medicine Fellow, University of Chicago/NorthShore University HealthSystem, Chicago, Illinois.

Sarosh Rana, MD, MPH, is Professor of Obstetrics and Gynecology and Section Chief, Maternal-Fetal Medicine, University of Chicago.

Hypertensive disorders of pregnancy account for a significant amount of morbidity during pregnancy and postpartum. In the pregnant population, data have shown that the implementation of a standardized blood pressure education program, provision of a blood pressure cuff, and assistance with postpartum follow-up result in improved blood pressures and postpartum follow-up for up to 6 weeks. In the nonpregnant population, literature suggests that RBPM in patients with hypertension results in improved outcomes, although the long-term impact of RBPM in the postpartum population remains unclear.

Recently, Hirshberg and colleagues published the results of a retrospective cohort study that assessed the impact of RBPM with text message reminders for 10 days postpartum on a composite of adverse maternal outcomes, readmissions, and follow-up within 1 year postpartum.¹

PHOTO: MICROGEN/SHUTTERSTOCK

Details of the study

The retrospective cohort study was conducted during 2017–2021 based on insurance claims of patients with hypertensive disorders of pregnancy who were enrolled in a twice-daily text message–based RBPM program for 10 days postpartum.

Data from 1,700 patients enrolled in RBPM were compared with that of propensity score matched controls that included 2,297 women not enrolled in RBPM. Of these controls, 1,276 patients (cohort C) simultaneously received care at other institutions without RBPM, and 1,021 patients (cohort A) received care at the same institution prior to implementation of RBPM.

Results. Patients in the RBPM group were found to have a significantly lower rate of composite adverse maternal outcomes compared with their matched cohorts in the year after delivery. (Individual adverse outcomes included stroke, disseminated intravascular coagulation, eclampsia, pulmonary edema, renal injury or liver failure, HELLP [hemolysis, elevated liver enzymes, low platelet count] syndrome, myocardial infarction, and cardiomyopathy.) Rates were 2.9% versus 4.7% (odds ratio [OR], 0.61; 95% confidence interval [CI], 0.40–0.98) in the RBPM group compared with cohort A; rates in the RBPM group compared with cohort C were 3.2% versus 4.5% (OR, 0.71; 95% CI, 0.47–1.07).

Although not statistically significant, rates of emergency department visits and readmissions also were lower in the RBPM patients. Those enrolled in the RBPM program were more likely to have follow-up with cardiologists or specialist visits within 6 months postpartum. Fewer emergency department visits and readmissions resulted in lower health care utilization costs.

Study strengths and limitations

This study’s strength lies in its design and implementation of standardized protocols that allowed assessment of clinically meaningful outcomes postpartum. Although the program for RBPM was for only 10 days postpartum, it showed effects beyond the timeframe of the direct care. No such prior data exist evaluating a program’s effectiveness in improving postpartum clinical outcomes and costs through 1 year postdelivery.

Study limitations include residual bias from unobserved confounders, analysis of only 1 payer type, lack of patient level data, and evaluation of disparity. ●

Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.

EXPERT COMMENTARY

Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.¹

Details of the study

The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.¹ This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.

Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.²

The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.³

The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.

The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.

Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.

Results. At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.

The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.

The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.

Study strengths and limitations

A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.

A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.

Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●

Acknowledgement

The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.

Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.

EXPERT COMMENTARY

Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.¹

Details of the study

The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.¹ This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.

Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.²

The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.³

The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.

The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.

Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.

Results. At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.

The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.

The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.

Study strengths and limitations

A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.

A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.

Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●

Acknowledgement

The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.

Yeung LK, Alschuler DM, Wall M, et al. Multivitamin supplementation improves memory in older adults: a randomized clinical trial. Am J Clin Nutrition. 2023;118:273-282. doi:10.1016/j.ajcnut.2023.05.011.

EXPERT COMMENTARY

Preservation of function, both physical and cognitive, is key to long-term health and well-being. Age-related loss of function drives millions of people to spend an enormous amount of money each year on unregulated therapies—vitamins, supplements, infusions, hormones, and “natural” products—all toward the promise of improvement or preservation of physical strength, sexual function, and maintenance of lean body mass and cognitive abilities. Yeung and colleagues set out to determine whether the daily use of a multivitamin/mineral supplement (Centrum Silver) would impact memory in older adults.¹

Details of the study

The COSMOS-Web study was designed to test the authors’ primary hypothesis that daily dietary flavanols would improve memory over 1 year.¹ This study was embedded within the larger COSMOS (COcoa Supplement and Multivitamin Outcomes Study) trial, in which 21,442 people were recruited to assess the impact of flavanols and multivitamin supplements on cardiovascular and cancer outcomes.

Results of another ancillary study, the COSMOS-Mind trial (n = 2,262, average age 73, 60% female), reported no improvement with flavanols compared with placebo on a battery of tests of cognitive function administered by phone. In COSMOS-Mind, however, it was concluded that a daily multivitamin/mineral supplement improved the composite score of cognitive tests compared with placebo, particularly in participants with a history of cardiovascular disease.²

The COSMOS-Web trial recruited an additional cohort within the larger COSMOS trial from 2016–2017 (n = 3,562, average age 71, 67% female) to participate in this study specifically geared to assess memory, using the web-based ModRey test (a test of memory validated for use in a nonimpaired population). To qualify for enrollment, participants had to have access to an internet-connected computer. They were randomly assigned in a 2 x 2 study design to receive a daily multivitamin supplement or placebo; each of these cohorts was further divided into a flavanol supplementation or a placebo group. Analysis of the data showed no association between flavanol use and performance on any of the measures of memory or cognitive function.³

The COSMOS-Web trial assessed episodic recall, a function of hippocampus-mediated cognition that is particularly vulnerable to the effects of aging as demonstrated previously by neuroimaging and neuropsychological studies. The authors deployed a battery of 3 tests via a web platform for patients to complete online and independently.

The prespecified primary outcome was performance on episodic recall as measured by the ModRey test after 1 year of supplementation with multivitamins versus placebo. The ModRey test presents a series of 20 words at 3-second intervals to participants. At the conclusion of the last word, participants were asked to recall as many words as they could; after completing the 2 additional tasks, participants were asked again to recall the words. A secondary outcome of this test is the ratio of delayed to immediate recall.

Two additional tests were administered to assess cognitive performance related to different brain regions, the ModBent test (assessing novel object recognition) and the Flanker task (a measure of executive function). There was a placebo run-in phase during which participants’ adherence to daily supplement intake was ascertained. Participants were excluded if they demonstrated less than 75% adherence to study pills during the run-in placebo phase. The cognitive tasks were presented at study initiation and at yearly intervals for 3 years. The authors chose to use the results at 1 year as their primary outcome to assess the impact of supplementation during the period when adherence would be highest.

Results. At baseline, the placebo cohort recalled 7.2 words of 20 compared with 7.1 in the supplement group. In both groups there was a practice effect, with improvement in scores in the placebo group to 7.65 words and in the multivitamin group to 7.81 words. The improvement from baseline was statistically significantly better (0.71 words) in the multivitamin cohort than in the placebo group (0.45 words). There was no improvement in either group in the ModRey memory retention test (ability to recall the words after 15 minutes) or in the ModBent or Flanker tests. At 3 years of treatment, the placebo group improved by 0.92 words (SD, 3.22) whereas the multivitamin group improved by 1.13 words (SD, 3.39). These changes remained statistically significant.

The group with cardiovascular disease had lower baseline performance on the ModRey test. With supplementation, however, the improvement in this cohort was significantly greater than in those without cardiovascular disease at 1 year. The authors acknowledged that the changes were small and may not have been noticeable to the individuals, but they argued that even small changes as demonstrated in this study can have large health benefits at a population level.

The results of the COSMOS-Web trial corroborate the findings of the COSMOS-Mind study with respect to the benefits of multivitamin/mineral supplementation on cognitive test performance, particularly in a population with preexisting cardiovascular disease. The tests used across the 2 studies were different, which lends greater reliability to the findings.

Study strengths and limitations

A major strength of this study is its careful, rigorous design as a double-blind, placebo-controlled trial in a large patient population. Great care was devoted to ensuring study medication adherence. Another strength is that the cognitive tests chosen for the COSMOS-Web trial have been validated in cognitively normal populations, not those already impaired.

A limitation, however, is in the demographics of the study. The patient population was overwhelmingly White (93%), 67% were female, and they were well educated (94.8% having completed some college or beyond). Their baseline health was good; only 4.7% had a history of cardiovascular disease. Although generalizability of the study results from this population may be concerning,relative benefits of supplementation in this healthy, generally well-nourished and educated group may be lower than might be expected in a more nutritionally and educationally challenged population.

Finally, the difference between the placebo and active supplementation groups was small. Whether this less-than-1-word difference in immediate memory recall is noticeable by a patient is questionable. Both groups improved in their test performance over time—a consequence of serial cognitive tests of any kind. Although the authors calculated that the difference in recall translates to a 3-year reduction in age-related memory decline, it is hard to reconcile that with the fact that both groups actually improved over the 3 years of the study. ●

Acknowledgement

The author would like to thank JoAnn Manson, MD, DrPH, NCMP, for her assistance in evaluating the study.

Ryu KJ, Kim MS, Lee JY, et al. Risk of endometrial polyps, hyperplasia, carcinoma, and uterine cancer after tamoxifen treatment in premenopausal women with breast cancer. JAMA Netw Open. 2022;5:e2243951.

EXPERT COMMENTARY

Tamoxifen is a selective estrogen receptor modulator (SERM) approved by the US Food and Drug Administration (FDA) for both adjuvant treatment of invasive or metastatic breast cancer with hormone receptor (HR)–positive tumors (duration, 5 to 10 years) and for reduction of future breast cancers in certain high-risk individuals (duration, 5 years). It is also occasionally used for non-FDA approved indications, such as cyclic mastodynia.

Because breast cancer is among the most frequently diagnosed cancers in the United States (297,790 new cases expected in 2023) and approximately 80% are HR-positive tumors that will require hormonal adjuvant therapy,¹ physicians and other gynecologic clinicians should have a working understanding of tamoxifen, including the risks and benefits associated with its use. Among the recognized serious adverse effects of tamoxifen is the increased risk of endometrial cancer in menopausal patients. This adverse effect creates a potential conundrum for clinicians who may be managing patients with tamoxifen to treat or prevent breast cancer, while also increasing the risk of another cancer. Prior prospective studies of tamoxifen have demonstrated a statistically and clinically significant increased risk of endometrial cancer in menopausal patients but not in premenopausal patients.

A recent study challenged those previous findings, suggesting that the risk of endometrial cancer is similar in both premenopausal and postmenopausal patients taking tamoxifen for treatment of breast cancer.²

Details of the study

The study by Ryu and colleagues used data from the Korean National Health Insurance Service, which covers 97% of the Korean population.² The authors selected patients being treated for invasive breast cancer from January 1, 2003, through December 31, 2018, who were between the ages of 20 and 50 years when the breast cancer diagnosis was first made. Patients with a diagnostic code entered into their electronic health record that was consistent with menopausal status were excluded, along with any patients with a current or prior history of aromatase inhibitor use (for which one must be naturally, medically, or surgically menopausal to use). Based on these exclusions, the study cohort was then assumed to be premenopausal.

The study group included patients diagnosed with invasive breast cancer who were treated with adjuvant hormonal therapy with tamoxifen (n = 34,637), and the control group included patients with invasive breast cancer who were not treated with adjuvant hormonal therapy (n = 43,683). The primary study end point was the finding of endometrial or uterine pathology, including endometrial polyps, endometrial hyperplasia, endometrial cancer, and other uterine malignant neoplasms not originating in the endometrium (for example, uterine sarcomas).

Because this was a retrospective cohort study that included all eligible patients, the 2 groups were not matched. The treatment group was statistically older, had a higher body mass index (BMI) and a larger waist circumference, were more likely to be hypertensive, and included more patients with diabetes than the control group—all known risk factors for endometrial cancer. However, after adjusting for these 4 factors, an increased risk of endometrial cancer remained in the tamoxifen group compared with the control group (hazard ratio [HR], 3.77; 95% confidence interval [CI], 3.04–4.66). In addition, tamoxifen use was independently associated with an increased risk of endometrial polyps (HR, 3.90; 95% CI, 3.65–4.16), endometrial hyperplasia (HR, 5.56; 95% CI, 5.06–6.12), and other uterine cancers (HR, 2.27; 95% CI, 1.54–3.33). In a subgroup analysis, the risk for endometrial cancer was not higher in patients treated for more than 5 years of tamoxifen compared with those treated for 5 years or less.

Study strengths and limitations

A major strength of this study was the large number of study participants (n = 34,637 tamoxifen; n = 43,683 control), the long duration of follow-up (up to 15 years), and use of a single source of data with coverage of nearly the entire population of Korea. While the 2 study populations (tamoxifen vs no tamoxifen) were initially unbalanced in terms of endometrial cancer risk (age, BMI, concurrent diagnoses of hypertension and diabetes), the authors corrected for this with a multivariate analysis.

Furthermore, while the likely homogeneity of the study population may not make the results generalizable, the authors noted that Korean patients have a higher tendency toward early-onset breast cancer. This observation could make this cohort better suited for a study on premenopausal effects of tamoxifen.

Limitations. These data are provocative as they conflict with level 1 evidence based on multiple well-designed, double-blind, placebo-controlled randomized trials in which tamoxifen use for 5 years did not demonstrate a statistically increased risk of endometrial cancer in patients younger than age 50.^3-5 Because of the importance of the question and the implications for many premenopausal women being treated with tamoxifen, we carefully evaluated the study methodology to better understand this discrepancy.

Continue to: Methodological concerns...

In the study by Ryu and colleagues, we found the definition of premenopausal to be problematic. Ultimately, if patients did not have a diagnosis of menopause in the problem summary list, they were assumed to be premenopausal if they were between the ages of 20 and 50 and not taking an aromatase inhibitor. However, important considerations in this population include the cancer stage and treatment regimens that can and do directly impact menopausal status.

Data demonstrate that early-onset breast cancer tends to be associated with more biologically aggressive characteristics that frequently require adjuvant or neoadjuvant chemotherapy.^6,7 This chemotherapy regimen is comprised most commonly of Adriamycin (doxorubicin), paclitaxel, and cyclophosphamide. Cyclophosphamide is an alkylating agent that is a known gonadotoxin, and it often renders patients either temporarily or permanently menopausal due to chemotherapy-induced ovarian failure. Prior studies have demonstrated that for patients in their 40s, approximately 90% of those treated with cyclophosphamide-containing chemo-therapy for breast cancer will experience chemotherapy-induced amenorrhea (CIA).⁸ Although some patients in their 40s with CIA will resume ovarian function, the majority will not.^8,9

Due to the lack of reliability in diagnosing CIA, blood levels of estradiol and follicle stimulating hormone are often necessary for confirmation and, even so, may be only temporary. One prospective analysis of 4 randomized neoadjuvant/adjuvant breast cancer trials used this approach and demonstrated that 85.1% of the study cohort experienced chemotherapy-induced ovarian failure at the end of their treatment, with some fluctuating back to premenopausal hormonal levels at 6 and 12 months.¹⁰

Furthermore, in the study by Ryu and colleagues, there is no description or confirmation of menstrual patterns in the study group to support the diagnosis of ongoing premenopausal status. Data on CIA and loss of ovarian function, therefore, are critical to the accurate categorization of patients as premenopausal or menopausal in this study. The study also relied on consistent and accurate recording of appropriate medical codes to capture a patient’s menopausal status, which is unclear for this particular population and health system.

In evaluating prior research, multiple studies demonstrated no increased risk of endometrial cancer in premenopausal women taking tamoxifen for breast cancer prevention (TABLE).^3,5 These breast cancer prevention trials have several major advantages in assessing tamoxifen-associated endometrial cancer risk for premenopausal patients compared with the current study:

• Both studies were prospective double-blind, placebo-controlled randomized clinical breast cancer prevention trials with carefully designed and measured outcomes.
• Since these were breast cancer prevention trials, administration of gonadotoxic chemotherapy was not a concern. As a result, miscategorizing patients with chemotherapy-induced menopause as premenopausal would not be expected, and premature menopause would not be expected at a higher rate than the general population.
• Careful histories were required prior to study entry and throughout the study, including data on menopausal status and menstrual and uterine bleeding histories.¹¹

In these prevention trials, the effect of tamoxifen on uterine pathology demonstratedrepeatable evidence that there was a statistically significant increased risk of endometrial cancer in postmenopausal women, but there was no similar increased risk of endometrial cancer in premenopausal women (TABLE).^3,5 Interestingly, the magnitude of the endometrial cancer risk found in the premenopausal patients in the study by Ryu and colleagues (RR, 3.77) is comparable to that of the menopausal group in the prevention trials, raising concern that many or most of the patients in the treatment group assumed to be premenopausal may have indeed been “menopausal” for some or all the time they were taking tamoxifen due to the possible aforementioned reasons. ●

Ryu KJ, Kim MS, Lee JY, et al. Risk of endometrial polyps, hyperplasia, carcinoma, and uterine cancer after tamoxifen treatment in premenopausal women with breast cancer. JAMA Netw Open. 2022;5:e2243951.

EXPERT COMMENTARY

Tamoxifen is a selective estrogen receptor modulator (SERM) approved by the US Food and Drug Administration (FDA) for both adjuvant treatment of invasive or metastatic breast cancer with hormone receptor (HR)–positive tumors (duration, 5 to 10 years) and for reduction of future breast cancers in certain high-risk individuals (duration, 5 years). It is also occasionally used for non-FDA approved indications, such as cyclic mastodynia.

Because breast cancer is among the most frequently diagnosed cancers in the United States (297,790 new cases expected in 2023) and approximately 80% are HR-positive tumors that will require hormonal adjuvant therapy,¹ physicians and other gynecologic clinicians should have a working understanding of tamoxifen, including the risks and benefits associated with its use. Among the recognized serious adverse effects of tamoxifen is the increased risk of endometrial cancer in menopausal patients. This adverse effect creates a potential conundrum for clinicians who may be managing patients with tamoxifen to treat or prevent breast cancer, while also increasing the risk of another cancer. Prior prospective studies of tamoxifen have demonstrated a statistically and clinically significant increased risk of endometrial cancer in menopausal patients but not in premenopausal patients.

A recent study challenged those previous findings, suggesting that the risk of endometrial cancer is similar in both premenopausal and postmenopausal patients taking tamoxifen for treatment of breast cancer.²

Details of the study

The study by Ryu and colleagues used data from the Korean National Health Insurance Service, which covers 97% of the Korean population.² The authors selected patients being treated for invasive breast cancer from January 1, 2003, through December 31, 2018, who were between the ages of 20 and 50 years when the breast cancer diagnosis was first made. Patients with a diagnostic code entered into their electronic health record that was consistent with menopausal status were excluded, along with any patients with a current or prior history of aromatase inhibitor use (for which one must be naturally, medically, or surgically menopausal to use). Based on these exclusions, the study cohort was then assumed to be premenopausal.

The study group included patients diagnosed with invasive breast cancer who were treated with adjuvant hormonal therapy with tamoxifen (n = 34,637), and the control group included patients with invasive breast cancer who were not treated with adjuvant hormonal therapy (n = 43,683). The primary study end point was the finding of endometrial or uterine pathology, including endometrial polyps, endometrial hyperplasia, endometrial cancer, and other uterine malignant neoplasms not originating in the endometrium (for example, uterine sarcomas).

Because this was a retrospective cohort study that included all eligible patients, the 2 groups were not matched. The treatment group was statistically older, had a higher body mass index (BMI) and a larger waist circumference, were more likely to be hypertensive, and included more patients with diabetes than the control group—all known risk factors for endometrial cancer. However, after adjusting for these 4 factors, an increased risk of endometrial cancer remained in the tamoxifen group compared with the control group (hazard ratio [HR], 3.77; 95% confidence interval [CI], 3.04–4.66). In addition, tamoxifen use was independently associated with an increased risk of endometrial polyps (HR, 3.90; 95% CI, 3.65–4.16), endometrial hyperplasia (HR, 5.56; 95% CI, 5.06–6.12), and other uterine cancers (HR, 2.27; 95% CI, 1.54–3.33). In a subgroup analysis, the risk for endometrial cancer was not higher in patients treated for more than 5 years of tamoxifen compared with those treated for 5 years or less.

Study strengths and limitations

A major strength of this study was the large number of study participants (n = 34,637 tamoxifen; n = 43,683 control), the long duration of follow-up (up to 15 years), and use of a single source of data with coverage of nearly the entire population of Korea. While the 2 study populations (tamoxifen vs no tamoxifen) were initially unbalanced in terms of endometrial cancer risk (age, BMI, concurrent diagnoses of hypertension and diabetes), the authors corrected for this with a multivariate analysis.

Furthermore, while the likely homogeneity of the study population may not make the results generalizable, the authors noted that Korean patients have a higher tendency toward early-onset breast cancer. This observation could make this cohort better suited for a study on premenopausal effects of tamoxifen.

Limitations. These data are provocative as they conflict with level 1 evidence based on multiple well-designed, double-blind, placebo-controlled randomized trials in which tamoxifen use for 5 years did not demonstrate a statistically increased risk of endometrial cancer in patients younger than age 50.^3-5 Because of the importance of the question and the implications for many premenopausal women being treated with tamoxifen, we carefully evaluated the study methodology to better understand this discrepancy.

Continue to: Methodological concerns...

In the study by Ryu and colleagues, we found the definition of premenopausal to be problematic. Ultimately, if patients did not have a diagnosis of menopause in the problem summary list, they were assumed to be premenopausal if they were between the ages of 20 and 50 and not taking an aromatase inhibitor. However, important considerations in this population include the cancer stage and treatment regimens that can and do directly impact menopausal status.

Data demonstrate that early-onset breast cancer tends to be associated with more biologically aggressive characteristics that frequently require adjuvant or neoadjuvant chemotherapy.^6,7 This chemotherapy regimen is comprised most commonly of Adriamycin (doxorubicin), paclitaxel, and cyclophosphamide. Cyclophosphamide is an alkylating agent that is a known gonadotoxin, and it often renders patients either temporarily or permanently menopausal due to chemotherapy-induced ovarian failure. Prior studies have demonstrated that for patients in their 40s, approximately 90% of those treated with cyclophosphamide-containing chemo-therapy for breast cancer will experience chemotherapy-induced amenorrhea (CIA).⁸ Although some patients in their 40s with CIA will resume ovarian function, the majority will not.^8,9

Due to the lack of reliability in diagnosing CIA, blood levels of estradiol and follicle stimulating hormone are often necessary for confirmation and, even so, may be only temporary. One prospective analysis of 4 randomized neoadjuvant/adjuvant breast cancer trials used this approach and demonstrated that 85.1% of the study cohort experienced chemotherapy-induced ovarian failure at the end of their treatment, with some fluctuating back to premenopausal hormonal levels at 6 and 12 months.¹⁰

Furthermore, in the study by Ryu and colleagues, there is no description or confirmation of menstrual patterns in the study group to support the diagnosis of ongoing premenopausal status. Data on CIA and loss of ovarian function, therefore, are critical to the accurate categorization of patients as premenopausal or menopausal in this study. The study also relied on consistent and accurate recording of appropriate medical codes to capture a patient’s menopausal status, which is unclear for this particular population and health system.

In evaluating prior research, multiple studies demonstrated no increased risk of endometrial cancer in premenopausal women taking tamoxifen for breast cancer prevention (TABLE).^3,5 These breast cancer prevention trials have several major advantages in assessing tamoxifen-associated endometrial cancer risk for premenopausal patients compared with the current study:

• Both studies were prospective double-blind, placebo-controlled randomized clinical breast cancer prevention trials with carefully designed and measured outcomes.
• Since these were breast cancer prevention trials, administration of gonadotoxic chemotherapy was not a concern. As a result, miscategorizing patients with chemotherapy-induced menopause as premenopausal would not be expected, and premature menopause would not be expected at a higher rate than the general population.
• Careful histories were required prior to study entry and throughout the study, including data on menopausal status and menstrual and uterine bleeding histories.¹¹

In these prevention trials, the effect of tamoxifen on uterine pathology demonstratedrepeatable evidence that there was a statistically significant increased risk of endometrial cancer in postmenopausal women, but there was no similar increased risk of endometrial cancer in premenopausal women (TABLE).^3,5 Interestingly, the magnitude of the endometrial cancer risk found in the premenopausal patients in the study by Ryu and colleagues (RR, 3.77) is comparable to that of the menopausal group in the prevention trials, raising concern that many or most of the patients in the treatment group assumed to be premenopausal may have indeed been “menopausal” for some or all the time they were taking tamoxifen due to the possible aforementioned reasons. ●

Ryu KJ, Kim MS, Lee JY, et al. Risk of endometrial polyps, hyperplasia, carcinoma, and uterine cancer after tamoxifen treatment in premenopausal women with breast cancer. JAMA Netw Open. 2022;5:e2243951.

EXPERT COMMENTARY

Tamoxifen is a selective estrogen receptor modulator (SERM) approved by the US Food and Drug Administration (FDA) for both adjuvant treatment of invasive or metastatic breast cancer with hormone receptor (HR)–positive tumors (duration, 5 to 10 years) and for reduction of future breast cancers in certain high-risk individuals (duration, 5 years). It is also occasionally used for non-FDA approved indications, such as cyclic mastodynia.

Because breast cancer is among the most frequently diagnosed cancers in the United States (297,790 new cases expected in 2023) and approximately 80% are HR-positive tumors that will require hormonal adjuvant therapy,¹ physicians and other gynecologic clinicians should have a working understanding of tamoxifen, including the risks and benefits associated with its use. Among the recognized serious adverse effects of tamoxifen is the increased risk of endometrial cancer in menopausal patients. This adverse effect creates a potential conundrum for clinicians who may be managing patients with tamoxifen to treat or prevent breast cancer, while also increasing the risk of another cancer. Prior prospective studies of tamoxifen have demonstrated a statistically and clinically significant increased risk of endometrial cancer in menopausal patients but not in premenopausal patients.

A recent study challenged those previous findings, suggesting that the risk of endometrial cancer is similar in both premenopausal and postmenopausal patients taking tamoxifen for treatment of breast cancer.²

Details of the study

The study by Ryu and colleagues used data from the Korean National Health Insurance Service, which covers 97% of the Korean population.² The authors selected patients being treated for invasive breast cancer from January 1, 2003, through December 31, 2018, who were between the ages of 20 and 50 years when the breast cancer diagnosis was first made. Patients with a diagnostic code entered into their electronic health record that was consistent with menopausal status were excluded, along with any patients with a current or prior history of aromatase inhibitor use (for which one must be naturally, medically, or surgically menopausal to use). Based on these exclusions, the study cohort was then assumed to be premenopausal.

The study group included patients diagnosed with invasive breast cancer who were treated with adjuvant hormonal therapy with tamoxifen (n = 34,637), and the control group included patients with invasive breast cancer who were not treated with adjuvant hormonal therapy (n = 43,683). The primary study end point was the finding of endometrial or uterine pathology, including endometrial polyps, endometrial hyperplasia, endometrial cancer, and other uterine malignant neoplasms not originating in the endometrium (for example, uterine sarcomas).

Because this was a retrospective cohort study that included all eligible patients, the 2 groups were not matched. The treatment group was statistically older, had a higher body mass index (BMI) and a larger waist circumference, were more likely to be hypertensive, and included more patients with diabetes than the control group—all known risk factors for endometrial cancer. However, after adjusting for these 4 factors, an increased risk of endometrial cancer remained in the tamoxifen group compared with the control group (hazard ratio [HR], 3.77; 95% confidence interval [CI], 3.04–4.66). In addition, tamoxifen use was independently associated with an increased risk of endometrial polyps (HR, 3.90; 95% CI, 3.65–4.16), endometrial hyperplasia (HR, 5.56; 95% CI, 5.06–6.12), and other uterine cancers (HR, 2.27; 95% CI, 1.54–3.33). In a subgroup analysis, the risk for endometrial cancer was not higher in patients treated for more than 5 years of tamoxifen compared with those treated for 5 years or less.

Study strengths and limitations

A major strength of this study was the large number of study participants (n = 34,637 tamoxifen; n = 43,683 control), the long duration of follow-up (up to 15 years), and use of a single source of data with coverage of nearly the entire population of Korea. While the 2 study populations (tamoxifen vs no tamoxifen) were initially unbalanced in terms of endometrial cancer risk (age, BMI, concurrent diagnoses of hypertension and diabetes), the authors corrected for this with a multivariate analysis.

Furthermore, while the likely homogeneity of the study population may not make the results generalizable, the authors noted that Korean patients have a higher tendency toward early-onset breast cancer. This observation could make this cohort better suited for a study on premenopausal effects of tamoxifen.

Limitations. These data are provocative as they conflict with level 1 evidence based on multiple well-designed, double-blind, placebo-controlled randomized trials in which tamoxifen use for 5 years did not demonstrate a statistically increased risk of endometrial cancer in patients younger than age 50.^3-5 Because of the importance of the question and the implications for many premenopausal women being treated with tamoxifen, we carefully evaluated the study methodology to better understand this discrepancy.

Continue to: Methodological concerns...

In the study by Ryu and colleagues, we found the definition of premenopausal to be problematic. Ultimately, if patients did not have a diagnosis of menopause in the problem summary list, they were assumed to be premenopausal if they were between the ages of 20 and 50 and not taking an aromatase inhibitor. However, important considerations in this population include the cancer stage and treatment regimens that can and do directly impact menopausal status.

Data demonstrate that early-onset breast cancer tends to be associated with more biologically aggressive characteristics that frequently require adjuvant or neoadjuvant chemotherapy.^6,7 This chemotherapy regimen is comprised most commonly of Adriamycin (doxorubicin), paclitaxel, and cyclophosphamide. Cyclophosphamide is an alkylating agent that is a known gonadotoxin, and it often renders patients either temporarily or permanently menopausal due to chemotherapy-induced ovarian failure. Prior studies have demonstrated that for patients in their 40s, approximately 90% of those treated with cyclophosphamide-containing chemo-therapy for breast cancer will experience chemotherapy-induced amenorrhea (CIA).⁸ Although some patients in their 40s with CIA will resume ovarian function, the majority will not.^8,9

Due to the lack of reliability in diagnosing CIA, blood levels of estradiol and follicle stimulating hormone are often necessary for confirmation and, even so, may be only temporary. One prospective analysis of 4 randomized neoadjuvant/adjuvant breast cancer trials used this approach and demonstrated that 85.1% of the study cohort experienced chemotherapy-induced ovarian failure at the end of their treatment, with some fluctuating back to premenopausal hormonal levels at 6 and 12 months.¹⁰

Furthermore, in the study by Ryu and colleagues, there is no description or confirmation of menstrual patterns in the study group to support the diagnosis of ongoing premenopausal status. Data on CIA and loss of ovarian function, therefore, are critical to the accurate categorization of patients as premenopausal or menopausal in this study. The study also relied on consistent and accurate recording of appropriate medical codes to capture a patient’s menopausal status, which is unclear for this particular population and health system.

In evaluating prior research, multiple studies demonstrated no increased risk of endometrial cancer in premenopausal women taking tamoxifen for breast cancer prevention (TABLE).^3,5 These breast cancer prevention trials have several major advantages in assessing tamoxifen-associated endometrial cancer risk for premenopausal patients compared with the current study:

• Both studies were prospective double-blind, placebo-controlled randomized clinical breast cancer prevention trials with carefully designed and measured outcomes.
• Since these were breast cancer prevention trials, administration of gonadotoxic chemotherapy was not a concern. As a result, miscategorizing patients with chemotherapy-induced menopause as premenopausal would not be expected, and premature menopause would not be expected at a higher rate than the general population.
• Careful histories were required prior to study entry and throughout the study, including data on menopausal status and menstrual and uterine bleeding histories.¹¹

In these prevention trials, the effect of tamoxifen on uterine pathology demonstratedrepeatable evidence that there was a statistically significant increased risk of endometrial cancer in postmenopausal women, but there was no similar increased risk of endometrial cancer in premenopausal women (TABLE).^3,5 Interestingly, the magnitude of the endometrial cancer risk found in the premenopausal patients in the study by Ryu and colleagues (RR, 3.77) is comparable to that of the menopausal group in the prevention trials, raising concern that many or most of the patients in the treatment group assumed to be premenopausal may have indeed been “menopausal” for some or all the time they were taking tamoxifen due to the possible aforementioned reasons. ●