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GLP-1 Agonists Come Out on Top in Cardiovascular Comparison of Newer Diabetes Meds

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Diabetes patients adding a newcomer drug to their medications may derive cardiovascular benefits to varying degrees depending on their choice between GLP-1 agonists and SGLT-2 inhibitors, a large observational dataset suggested.

Among U.S. veterans already on metformin, sulfonylurea, or insulin treatment and without cardiovascular disease (CVD), the addition of a GLP-1 agonist, instead of a DPP-4 inhibitor, was associated with short-term reductions in major adverse cardiac events (MACE) or heart failure (HF) hospitalization (13.3 vs 17.8 events per 1,000 person-years, adjusted HR 0.82, 95% CI 0.72-0.94) upon propensity score-weighted matching.

Meanwhile, SGLT-2 inhibitors were not associated with such risk reduction in a propensity score-weighted comparison with the DPP-4 inhibitor class (12.9 vs 14.9 events per 1,000 person-years, adjusted HR 0.91, 95% CI 0.78-1.08), reported Christianne Roumie, MD, MPH, of Vanderbilt University Medical Center and Nashville VA Medical Center in Tennessee, and colleagues. Their manuscript was published in the Annals of Internal Medicine.

“These findings are hypothesis generating, and further evaluation of these medications as part of primary CVD prevention strategy is needed,” Roumie’s group stressed.

The investigators cautioned that follow-up spanned just a few months, lasting 0.58 years for each new prescription for individuals included in the GLP-1 agonist-DDP-4 inhibitor paired analysis. In the comparison between SGLT-2 inhibitors and DPP-4 inhibitors, follow-up was 0.42 years versus 0.47 years, respectively. The cumulative probability of MACE or HF hospitalization at 3.5 years was 0.9% for SGLT-2 inhibitors versus 1.1% for DPP-4 inhibitors; the cumulative probability reached 1.2% for GLP-1 agonists versus 1.7% for DPP-4 inhibitors.

With such short follow-up severely limiting any head-to-head comparisons between GLP-1 agonists and SGLT-2 inhibitors, the study authors nevertheless suggested that at least the former may have a role in primary prevention in people with diabetes, regardless of heart disease history.

“Unfortunately, this observational study has serious limitations that must be considered in the interpretation of results and that preclude reliable application to clinical decision making,” commented Steven Nissen, MD, of the Cleveland Clinic in Ohio.

“These drugs are long-term therapies, not short-term interventions, and comparing their effects over a few months is not clinically relevant … Randomized controlled trials have shown benefits for both drug classes in several trials studying mixed populations of primary and secondary prevention patients,” Nissen wrote in an accompanying editorial.

Indeed, Roumie’s team reported that a larger analysis including patients both with and without CVD showed both GLP-1 agonists and SGLT-2 inhibitors were associated with reduced MACE (i.e., acute myocardial infarction, stroke, or cardiovascular death) and HF hospitalizations compared with DPP-4 inhibitors.

For now, the exact mechanisms of the cardioprotection offered by these two medication classes remain unclear, Roumie and colleagues said.

GLP-1 agonists mimic the action of the hormone glucagon-like peptide 1 in stimulating the production of insulin when blood sugar levels rise; popularly, semaglutide (Ozempic, Wegovy), in particular, is also prescribed to induce weight loss outside the setting of diabetes.

SGLT-2 inhibitors, including empagliflozin (Jardiance) and dapagliflozin (Farxiga), employ a different mechanism to lower blood sugar in diabetes, namely preventing the kidneys from reabsorbing sugar. They have recently entered the mainstream for heart failure across the spectrum of ejection fraction.

To investigate the effects of these two drug classes in a large cohort without prior CVD, Roumie’s group probed the records of U.S. veterans receiving care from the Veterans Health Administration (VHA), with data linkage to Medicare, Medicaid, and the National Death Index.

The cohort comprised mostly white men with a median age of 67 years. Participants had diabetes for a median 8.5 years before trying one of the new medications.

After propensity score weighting, there were over 28,000 weighted pairs of new GLP-1 agonist vs DPP-4 inhibitor users; there were over 21,000 weighted pairs of new SGLT-2 inhibitor and DPP-4 inhibitor users.

Residual confounding remained possible despite statistical adjustment of the retrospective, observational study. Moreover, the investigators warned that they had not assessed DPP-4 inhibitors, GLP-1 agonists, and SGLT-2 inhibitors as first-line therapies in diabetes.

Nissen pointed out that the study lacked much valuable data, such as records of ejection fractions and micro- or macroalbuminuria. Veterans visiting clinical centers outside the VHA — for medical emergencies such as myocardial infarction and stroke, say — would have also had data incompletely captured in the investigators’ database, he said.

“Given the limitations described earlier, the observed differences in HRs (0.82 vs. 0.91) comparing [GLP-1 agonists] and [SGLT-2 inhibitors] with [DPP-4 inhibitors] are too small to derive reliable conclusions,” Nissen warned. “Caution and skepticism are appropriate when the effects are modest.”

 

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Helping people living with dementia ‘flourish’ through dance

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Dr. Pia Kontos, a Senior Scientist at UHN’s KITE Research Institute, is co-leading an initiative to help people living with dementia flourish. (Photo: Tim Fraser/UHN KITE Studio)

Dr. Pia Kontos believes in the power of the arts to support people to live well with dementia.

The Senior Scientist at UHN’s KITE Research Institute focuses on challenging policies and practices that discriminate against those living with dementia and developing and evaluating arts-based and digital knowledge translation initiatives to reduce stigma, improve social inclusion and quality of care for them.

“The predominant assumption is people living with dementia don’t have the capacity to be creative,” says Dr. Kontos, who is also a professor in the Dalla Lana School of Public Health at the University of Toronto. “However, we know through extensive research that dance…powerfully supports people living with dementia to be creative and to flourish.

“And flourishing should be a goal that we all have.”

Dr. Kontos co-produced in 2023 Dancer Not Dementia, a short documentary film. It captured the power of a dance program for seniors – Sharing Dance Older Adults (SDOA) – to challenge the stigma associated with dementia, support social inclusion and enrich lives. It’s told through the eyes of residents and staff at Alexis Lodge Dementia Care Residence and Cedarhurst Dementia Care Home in Toronto.

SDOA was jointly developed by Canada’s National Ballet School (NBS) and Baycrest Centre in 2013 for older adults with a range of physical and cognitive abilities, including dementia.

Typically, dance programs in dementia care settings are provided as a therapeutic intervention for older adults. However, SDOA’s goal is to provide a creative outlet for participants and opportunities for social interaction with other people living with dementia, staff and loved ones.

Now, Dr. Kontos will look to incorporate traditions from marginalized communities into SDOA through a $750,000 Canadian Institutes of Health Research (CIHR) Institute of Aging Implementation Science Team Grant. Dr. Rachel Bar, Director of Research and Health at NBS is co-principal applicant for the grant.

This CIHR funding supports projects that evaluate the effectiveness of existing programs, services and models of care that show promise for those impacted by cognitive impairment and dementia. An important focus is improving equitable and inclusive access to care and support.

The three-year grant to Drs. Kontos and Bar will support SDOA efforts to partner with organizations in Black, Chinese and South Asian communities to integrate their cultural practices into its programming.

Training dancers from these communities to teach the adapted program is central to these partnerships.

“People living with dementia from marginalized communities rarely have their traditions honoured with art and leisure programming,” says Dr. Kontos.

“It’s important to align dance programs with the cultural traditions of these communities. Otherwise, the music and movements wouldn’t reflect the experiences of ethno-culturally diverse populations, and the programs wouldn’t be inclusive.

“We wouldn’t be supporting their capacity to be creative or to be in relationships with others through dance. We would be falling short.”

SDOA has already partnered with Alexis Lodge, Alzheimer Society of Canada, Baycrest, NBS, Indus Community Services, Social Planning Council of Ottawa, and Yee Hong for this initiative.

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CDC: Heat may have contributed to four human cases of bird flu in Colorado

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Credit: Alexas Fotos from Pexels

Heat probably played a role in at least four cases of bird flu in poultry workers confirmed by U.S. health officials Sunday—the first cases in poultry workers in two years.

Sweltering temperatures in Colorado rose to at least 104 degrees, which is suspected to have contributed to the human cases, according to Dr. Nirav Shah, principal deputy director at the Centers for Disease Control and Prevention. The barns where poultry workers were culling chickens were “no doubt even hotter,” Shah said during a press conference on the most recent outbreak of bird flu in humans.

The new cases bring the U.S. total to at least nine cases since the first human case of the current outbreak was detected in 2022, also in a Colorado poultry worker. Eight of the nine were reported this year.

The workers were separating chickens that were going to be killed to stop the spread of the virus. The fans may also have contributed to the human infections because, while helping to keep the environment cooler, they “also spread things like feathers around which are known to carry the virus,” Shah added.

The large and strong fans also make it difficult for protective goggles and face masks to stay in place, he said.

About 60 workers at the poultry farm showed symptoms of illness and were tested for bird flu. Four tested positive for bird flu and one additional presumptive case is awaiting confirmation.

The illnesses were relatively mild, with symptoms including conjunctivitis and common respiratory infection symptoms like fever, chills, coughing, and runny nose, according to the CDC. None were hospitalized, officials said. The other U.S. cases have also been mild.

Officials said they are bracing for more cases.

The CDC says the risk to the general public remains low and the health agency is not recommending livestock workers be vaccinated against bird flu given the “mild symptoms noted thus far,” Shah said.

An initial analysis of virus samples from an infected poultry worker does not show any changes in the virus that would make it easier to spread among people and there is no evidence of person-to-person spread in the U.S.

“It’s important to note that this assessment is based on what we know today and may change,” Shah said. “CDC is constantly looking for key changes that may alter our risk assessment of the virus, such as the severity of illness that it causes, the ease with which it can transmit to humans or changes to its genetic fingerprint.”

At the request of Colorado’s officials, the CDC sent a 10-person team to Colorado to help the state manage the bird flu outbreak in humans and poultry. The team included epidemiologists, veterinarians, clinicians and industrial hygienists.

Shah also noted it was a bilingual team. Overall in the U.S., it is estimated about half of farm workers are Latino.

An analysis of the virus from an infected worker indicates that the infections at the chicken farm are “largely the same” as the strain detected in dairy herds in Colorado and other states, according to Shah. But an investigation is ongoing to determine exactly how the outbreak is spreading between wild birds, chicken and cattle.

Since 2022, a highly contagious strain of bird flu has spread across the U.S. at an unprecedented rate.

Georgia’s powerhouse poultry industry, which produces more broiler chickens than any other in the country, has mostly dodged the kinds of major outbreaks that have resulted in the deaths of more 90 million birds in commercial and backyard poultry flocks in the U.S.

About 1.8 million chickens will be killed at the Colorado poultry farm after these latest bird flu cases were detected.

In late 2023, ducks at a commercial breeding farm in Sumter County, Georgia, tested positive for H5N1. This year, in March, the virus made a jump to a mammal species that surprised many scientists: cows.

With a significant dairy industry, plus even larger beef and poultry interests, the potential arrival of the virus here threatens Georgia’s economy and the health of residents.

As of Monday, the H5N1 virus has been confirmed in 158 dairy herds in 13 states, according U.S. Agriculture Department.

So far in Georgia, there have been no bird flu cases in cattle, and there have been no human cases.

Since the unprecedented spread of H5N1 in poultry in 2022, the Georgia Department of Public Health has quietly monitored 132 people for signs of the virus, according to DPH spokeswoman Nancy Nydam. Those tracked were either first responders to one of the state’s few virus outbreaks in backyard and commercial poultry flocks or farmworkers where the infections occurred. Of those monitored, fewer than 10 people were tested for H5N1 and none came back positive.

Since the virus was discovered in cattle, a small number of first responders from Georgia who went to other states to help with investigations—fewer than 15—have also been monitored for signs of illness.

Federal officials said Tuesday they still believe they can eliminate the bird flu virus from , even as the number of herds infected continues to grow. The latest state to recently report infected dairy cattle was Oklahoma. North Carolina is the only state adjacent to Georgia to report an infected dairy herd.

Eric Deeble, acting senior adviser for the H5N1 response at the USDA, said investigations show the is spreading among cattle through cattle moved from one herd to another and the shared use of milking equipment. It can be contained through enhanced biosecurity measures such as thoroughly cleaning milking “parlors” and equipment, separating sick cows, and having dairy workers wear protective equipment.

Deeble also noted USDA scientists are also working with partners to develop a cattle-specific H5N1 vaccine—a process requires many steps and will take time.

The USDA is also exploring the possibility of developing a poultry vaccine as the number of cases soar, and outbreaks lead to the slaughter of millions of farmed birds. But USDA and industry stakeholders point to challenges that would hinder a vaccination program.

The biggest sticking point is around trade.

Mike Giles, president of the Georgia Poultry Federation, said mass vaccination would be impractical for several reasons, including the fact that the industry would lose its lucrative export market: The United States and many of its trade partners restrict the import of products or eggs from countries affected by the highly pathogenic strain or flocks that have been vaccinated against it.

“(Bird flu) has been, from an animal health standpoint, our top concern,” Giles said. “The challenge, and I think the industry has responded to it well, has been maintaining the state of preparedness and urgency and focus on biosecurity, and I think that has been accomplished.”

2024 The Atlanta Journal-Constitution. Distributed by Tribune Content Agency, LLC.

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Here is the new guidance for RSV vaccines

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Health officials recently changed the guidelines for respiratory syncytial virus vaccines. Here’s what Canadians need to know about the guidance and the virus itself.

New guidance on vaccines

As of July 12, the National Advisory Committee on Immunization (NACI) now recommends RSV vaccines for individuals who are 75 years old and older, especially those who have a greater risk of developing severe RSV.

Based on current evidence and expert opinion, NACI said in a news release, it also strongly recommends vaccines for those aged 60 and older who live in nursing homes and other chronic care facilities.

What is RSV?

RSV is a common contagious virus that often causes bronchiolitis, a lung infection, and pneumonia.

Infants face the highest risk of developing severe RSV disease, however, this risk also increases with age and with certain medical conditions, according to the Public Health Agency of Canada (PHAC). It can lead to serious complications for older people, including hospitalization and death.

What are the symptoms?

RSV typically causes mild, cold-like symptoms that usually begin two to eight days after exposure to the virus, according to PHAC.

Those with RSV may experience a runny nose, coughing, sneezing, wheezing, fever and less appetite and energy. Infants may be irritable, have trouble breathing and have less appetite and energy.

What is the treatment?

RSV infections are usually mild and last about one to two weeks. If you are infected, health officials recommend you stay home and limit contact with others.

They also recommend lots of rest and drinking plenty of fluids. Take over-the-counter products, such as acetaminophen or ibuprofen, if you have a fever. Seek immediate care or go to the hospital if you’re having trouble breathing or become dehydrated, PHAC adds.

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