Diabetes Drug and Weight Loss; Aspirin and COVID: It's TTHealthWatch! thumbnail

Diabetes Drug and Weight Loss; Aspirin and COVID: It’s TTHealthWatch!

TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week. A transcript of the podcast is below the summary.

This week’s topics include screening for hearing loss in older adults, aspirin and COVID, a diabetes drug for weight loss, and saliva testing for concussion

Program notes:

0:35 Saliva testing for concussion

1:34 1000 Rugby players

2:37 May be available soon

3:35 No results in women

4:01 Aspirin and COVID-19

5:01 No differences in major bleeding

6:01 On aspirin already don’t need to discontinue

7:03 Diabetes medicine and weight loss

8:01 First run in period 11% weight loss

9:02 Injectable medicine

9:15 USPSTF on hearing loss assessment

10:16 Dramatic reduction in price of hearing aids

11:22 If people don’t do anything about it

12:49 End

Transcript:

Elizabeth Tracey: Does aspirin have a role in the treatment of people with COVID-19?

Rick Lange, MD: Use of a diabetic medication for weight loss.

Elizabeth: Should we screen older adults for hearing loss?

Rick: And the spitting image of rugby players with concussion.

Elizabeth: That’s what we’re talking about this week on TT HealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.

Rick: And I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.

Elizabeth: And incredibly clever, so of course we’re going to have to turn to one of the BMJ‘s journals. This is taking a look at can we actually assess concussion on the playing field with a saliva based-test?

Rick: Elizabeth, I served it up as a spitting image of rugby players because this is an attempt to use routinely available body fluid — that is, saliva — to make the diagnosis of concussion. Obviously, that’s a traumatic brain injury. But when you do conventional imaging like CT or MRI imaging of the head, it looks normal, but there’s clearly have been some sort of temporary neurologic damage. We assess that by doing a head injury assessment.

It’s a clinical exam. It would be nice if we could actually have some biomarker that would confirm whether someone did or did not have a concussion. What these investigators said is, “Listen. If someone had some sort of neurologic injury that had a biomarker, you could not only test in the blood or urine, but perhaps even the saliva as well.” Here’s what they did.

They took rugby players — and heaven knows they oftentimes have head injuries — over 1,000 of these rugby players and they tested them at baseline before a game and after a game. Of course, only some of these had head injuries. About 156 of those had concussion. They took the first 15 of those and they tested the saliva and they identified 32 different unique biomarkers — specifically non-coding micro RNAs, for our scientific nerds out there.

On the basis of that, they assessed that 14 of those together in congregate could identify those with versus those without concussion. They applied it to the rest of the group and they found out it was extremely successful — about 96% successful in being predictive of whether a person had a concussion or not.

Now, they compared it to, obviously, controls, but they also compared it to people that had musculoskeletal injuries to prove that it wasn’t just from playing rugby. You had to have a knock on the noggin to get these things in your saliva.

Elizabeth: Of course, the really profoundly good news about this study is this is so easily available. It doesn’t require a finger stick or anything else, just a saliva-based test. I, as I told you before, attended the press conference relative to this study earlier this week and the researchers were predicting that this ought to be pretty practical pretty early.

As we’ve talked about many times, even if we just limit this to professional athletes, it would sure be nice to be able to assess whether they’re at risk for chronic traumatic encephalopathy, or CTE, as they continue play.

Rick: What you want to do is identify those with concussion and give them a chance to heal. By the way, these biomarkers oftentimes had things to do with neurologic injury, their neuron degeneration, or Alzheimer’s kinds of things, or depression, so there is some biologic plausibility. Saliva was collected an hour after a head injury and then up to 36 to 48 hours to show that it was still positive. This needs to be proven in a larger group. It’s a proof of concept and I hope we’re able to report on this in the future with larger patient studies.

Elizabeth: Me too. One thing that they did identify in talking about these results was that they do not have any results in women. We have reported previously that women soccer players actually experience worse head injuries than male counterparts, so this data from women is going to be really important, and also from children.

Rick: Yeah. Again, this study was done in world-class rugby players — I mean top-tier. You’re right. We need to expand the patient population as well and see whether this actually holds up in other sports.

Elizabeth: Let’s turn from here to a study that’s taking a look at the role of aspirin in folks with COVID-19. This is from the journal Anesthesia. It’s a retrospective observational cohort study of adult patients admitted with COVID-19 disease to multiple hospitals in the U.S. between March of 2020 and July of 2020.

They included only 412 patients in this analysis, and what they were looking at was the role of aspirin; 314, or 76%-plus of these did not receive aspirin, while only 98 patients, the n getting smaller, almost 24%, received aspirin within 24 hours of admission or 7 days before admission.

Basically, what they showed was that aspirin was able to ameliorate some of the thrombosis that we’ve seen associated with people who have really bad COVID-19 disease and independently associated with a decreased risk of mechanical ventilation. No differences in major bleeding or overt thrombosis between those aspirin users and the non-aspirin users.

This is, to me at least, intriguing because a lot like dexamethasone, a drug with which we have a ton of experience, and suggests that maybe it would be useful in helping people when they present with COVID-19 and have to be hospitalized.

Rick: As you suggest, there was a significant reduction, a 40% to 45% reduction of someone that came in the hospital that, “Did they need to be put on a ventilator or did they die?” Now, there is biologic plausibility because the infection, as you talked about, increases the risk of thrombosis — that is, the formation of a clot — and we know that aspirin prevents platelets from aggregating, prevents that clot from forming. We also know it’s anti-inflammatory. We know that some of the response in COVID is an inflammation as well.

We do need to make mention, this is not a randomized controlled trial. They just observed, “Hey, it looked like the people that came in on aspirin did better.” Therefore they tried to adjust for that, so we need to actually properly test this in a randomized controlled trial. It suggests that people who are on aspirin when they come into the hospital with COVID, they probably don’t need to be taken off of it. Should we put people on aspirin when they come into the hospital? That still remains to be determined.

Elizabeth: I think it was also interesting that the patients who received the aspirin had significantly higher rates of hypertension, diabetes, coronary artery disease, and renal disease. We’re already well aware that these are risk factors for more severe COVID-19 disease, so I sort of hearken back to, “Chicken and the egg, which comes first?”

Rick: Yep. In the statistics they tried to adjust for those features, but oftentimes that adjustment is not as precise as we’d like. These are the kind of studies that prompt randomized controlled trials rather than definitively answer a question.

Elizabeth: I guess I’m wondering if they’re going to prompt people to put people on aspirin prophylactically, just based on these results.

Rick: Yeah, and because the data doesn’t show an increased risk of bleeding, one could say, “Listen, I don’t have firm data, but observational data suggests it may be helpful.” So it’s not unreasonable.

Elizabeth: Particularly in those with all those other constellation of comorbidities.

Rick: Speaking of comorbidities, let’s go on to talk a little bit about diabetes and a medicine that is used to treat it. It’s a medicine called semaglutide and it falls into the category of medicines called a glucagon-like peptide 1 receptor agonist.

It’s a medicine that’s approved for diabetes. What’s been shown is that people that have diabetes and take this it oftentimes induces weight reduction. It’s because of its effects in the brain that affect appetite and satiety, so people that are on semaglutide actually eat less and they lose weight.

This is a medicine that’s typically given in a once-weekly injection. But if you give it in a larger dose, you get more weight reduction. But then the question is do you need to continue the medicine or could you stop it?

They had 902 participants that were receiving once-weekly injections of the higher dose and it took them 20 weeks to kind of work up to that high dose because it causes GI distress. Once they got to that 20-week period where everybody was on it, half of them, they continued the injections. The other half they gave placebo injections, and they just followed to see what happened.

With the first 20-week run-in period, those individuals all lost about 11% of their body weight. For those that went on placebo after that, unfortunately, they tended to increase their weight, but those continued on it got another 8% or 9% additional body weight reduction up to 68 weeks. By the way, this is about the same weight reduction that you get when you do gastric surgery — 20% weight reduction.

Elizabeth: Very impressive. One thing that a diabetologist here at Hopkins has said to me before about the use of medicines for diabetes in people who don’t have diabetes is a concern about hypoglycemic events. What does the data show us on that?

Rick: In this particular study, that wasn’t an issue. The major issue there wasn’t hypoglycemia. The major issue with this was GI distress. It only caused about 2% or 3% of the individuals in the study to stop it. They had to kind of work through it. That’s why they built up to that level, but once they did, they tolerated it well.

Elizabeth: What are your thoughts about something that requires an injection? For folks with weight loss desires, they would have to keep coming back in to get this.

Rick: You don’t have to keep coming in to get it — you actually take it at home. It’s just like people take insulin or other things.

Elizabeth: Let’s mention that that study is in JAMA. We’re going to stay there. We’re going to turn to a recommendation from the USPSTF, which unfortunately is an exhaustive look at the literature relative to hearing loss in older adults and says, “Hey, guess what? There’s insufficient evidence to recommend that we need to be screening older adults.”

We were talking before we started to record — and this is the part of it that I think is really the important part — about how many older adults there are with hearing loss in the United States and how important, potentially, it is going to be to ameliorate that hearing loss.

There is no data that tells us that trying to rectify that situation with use of hearing aids or hearing-assist devices is going to make any of that not happen — dementia, depression, loss of joy in activities of daily living — but we’re poised to find out, probably, because there was the passage of the Over-The-Counter Hearing Aid Act of 2017, which is yet to be implemented. But that’s going to dramatically reduce the price of these things and increase their availability, so we might see lots more people adopting them, especially if they look kind of cool, and in view of the fact that Apple’s going to be one of those folks who’s making them I suspect that they will.

I’m finding this an interesting place, where the USPSTF is panning the benefits of screening based on a paucity of data, but there are an awful lot of forces that are arrayed on the other side.

Rick: The job of the USPSTF is not to endorse. It’s just to talk to the data. What they’re saying is, “We have insufficient evidence that it actually results in anything.”

Now, there are two ways to screen. One is just to ask the simple question, “Do you have difficulty with your hearing?” That seemed to be like a pretty good way as opposed to doing what’s called tone-emitting device detection, where you play various decibels in hearing, and you’re actually more quantitative.

That simple question, by the way, costs nothing to ask, but the tone-emitting detection actually costs something. If you’re going to try to screen the millions — the 60 million individuals that are over a certain age to test for their hearing, and it costs something, and then they don’t do anything about it, then you haven’t received any benefit.

That’s part of the issue is, we don’t have any good studies that have identified those individuals and then they’ve all gotten hearing aids to see whether they have less depression, and less hospitalization, and less social isolation, and less cognitive impairment. We just don’t have any of that. Probably the best question we ought to ask after we say, “Do you have a hearing loss?” is, “Is it bothersome enough that you would do something about it?” Those are the individuals we probably ought to screen. Do you agree?

Elizabeth: I agree. I mean, I think that’s a stopgap measure. I would also say that the accumulation of the data that demonstrates that ameliorating hearing loss results in decreased rates of dementia, depression, and loss of pleasure in daily activities isn’t going to accumulate unless we get more people using hearing aids.

Rick: But the only people that are going to use them are those that are motivated. Either we bring the cost down so they’re available, there’s no stigma associated with them, they believe that there may be some benefit to it, and they’ll actually wear them. If you just detect that someone has a hearing loss and then they don’t want to do anything about it, well, you really haven’t given them really much of a service. It’s actually tone-deaf.

Elizabeth: Oh my God, you started on a pun and ending on one also. We’ll leave it there — with the caveat that we’ll talk about this again. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.

Rick: And I’m Rick Lange. Y’all listen up and make healthy choices.

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