Each January, the AGA Nominating Committee meets to complete a very important task — namely, selection of new members of AGA’s Governing Board, pending approval by the membership.

Having served on this committee in the past, I can attest to how challenging a task it is to select these leaders from such a talented and committed pool of candidates, each of whom have served the organization in numerous impactful roles over the course of many years.

University of Michigan

This year’s recently announced additions to the Governing Board, who will assume their roles this summer, include Dr. Byron Cryer (incoming Vice President), Dr. Shahnaz Sultan (Clinical Research Councillor), and Dr. Jonathan Rosenberg (Practice Councillor). I have had the pleasure of working with each of them over the years from my very early days at AGA and am confident that AGA will continue to thrive under their leadership. Please join me in congratulating Byron, Shahnaz, and Jonathan on their new roles!

In this month’s issue of GIHN, we highlight a phase 3 RCT from NEJM demonstrating the efficacy of seladelpar, an alternative to ursodeoxycholic acid in patients with PBC with refractory pruritus. From the CGH Practice Management section, Dr. Michelle Kim (Cleveland Clinic) and colleagues provide helpful tips on how to optimize EHR use in GI practice, including by incorporating novel tools based on AI, natural language processing, and speech recognition. In our April Member Spotlight, we are excited to feature gastroenterologist and stand-up comedienne Dr. Shida Haghighat of UCLA, who shares her passion for addressing health disparities and highlights how humor helped her cope with the demands of medical training. We hope you enjoy these, and all the stories included in our April issue.
 

Megan A. Adams, MD, JD, MSc

Editor-in-Chief

Each January, the AGA Nominating Committee meets to complete a very important task — namely, selection of new members of AGA’s Governing Board, pending approval by the membership.

Having served on this committee in the past, I can attest to how challenging a task it is to select these leaders from such a talented and committed pool of candidates, each of whom have served the organization in numerous impactful roles over the course of many years.

University of Michigan

This year’s recently announced additions to the Governing Board, who will assume their roles this summer, include Dr. Byron Cryer (incoming Vice President), Dr. Shahnaz Sultan (Clinical Research Councillor), and Dr. Jonathan Rosenberg (Practice Councillor). I have had the pleasure of working with each of them over the years from my very early days at AGA and am confident that AGA will continue to thrive under their leadership. Please join me in congratulating Byron, Shahnaz, and Jonathan on their new roles!

In this month’s issue of GIHN, we highlight a phase 3 RCT from NEJM demonstrating the efficacy of seladelpar, an alternative to ursodeoxycholic acid in patients with PBC with refractory pruritus. From the CGH Practice Management section, Dr. Michelle Kim (Cleveland Clinic) and colleagues provide helpful tips on how to optimize EHR use in GI practice, including by incorporating novel tools based on AI, natural language processing, and speech recognition. In our April Member Spotlight, we are excited to feature gastroenterologist and stand-up comedienne Dr. Shida Haghighat of UCLA, who shares her passion for addressing health disparities and highlights how humor helped her cope with the demands of medical training. We hope you enjoy these, and all the stories included in our April issue.
 

Megan A. Adams, MD, JD, MSc

Editor-in-Chief

Each January, the AGA Nominating Committee meets to complete a very important task — namely, selection of new members of AGA’s Governing Board, pending approval by the membership.

Having served on this committee in the past, I can attest to how challenging a task it is to select these leaders from such a talented and committed pool of candidates, each of whom have served the organization in numerous impactful roles over the course of many years.

University of Michigan

This year’s recently announced additions to the Governing Board, who will assume their roles this summer, include Dr. Byron Cryer (incoming Vice President), Dr. Shahnaz Sultan (Clinical Research Councillor), and Dr. Jonathan Rosenberg (Practice Councillor). I have had the pleasure of working with each of them over the years from my very early days at AGA and am confident that AGA will continue to thrive under their leadership. Please join me in congratulating Byron, Shahnaz, and Jonathan on their new roles!

In this month’s issue of GIHN, we highlight a phase 3 RCT from NEJM demonstrating the efficacy of seladelpar, an alternative to ursodeoxycholic acid in patients with PBC with refractory pruritus. From the CGH Practice Management section, Dr. Michelle Kim (Cleveland Clinic) and colleagues provide helpful tips on how to optimize EHR use in GI practice, including by incorporating novel tools based on AI, natural language processing, and speech recognition. In our April Member Spotlight, we are excited to feature gastroenterologist and stand-up comedienne Dr. Shida Haghighat of UCLA, who shares her passion for addressing health disparities and highlights how humor helped her cope with the demands of medical training. We hope you enjoy these, and all the stories included in our April issue.
 

Megan A. Adams, MD, JD, MSc

Editor-in-Chief

Growing up in a household where GI issues dominated conversations, it’s no surprise that Shida Haghighat, MD, chose gastroenterology as her area of study in medicine.

She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.

University of Miami

As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.

Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
 

Q: What practice challenges have you faced in your career?

Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have. 

Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.

Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”

So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.

We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
 

Q: Can you discuss some health disparity studies you’ve done in this area?

Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.

I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups. 

A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer . 

We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening. 
 

Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?

Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.

My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
 

Q: What types of things do you talk about during your stand-up act?

Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.

Lightning Round

Texting or talking?

Text

Favorite city in U.S. besides the one you live in?

Denver

Cat or dog person

Dog

Best place you went on vacation

Patagonia

Favorite sport

Basketball

Favorite ice cream

Rocky Road

What song do you have to sing along with when you hear it?

Celine Dion’s My Heart Will Go On

Growing up in a household where GI issues dominated conversations, it’s no surprise that Shida Haghighat, MD, chose gastroenterology as her area of study in medicine.

She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.

University of Miami

As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.

Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
 

Q: What practice challenges have you faced in your career?

Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have. 

Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.

Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”

So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.

We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
 

Q: Can you discuss some health disparity studies you’ve done in this area?

Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.

I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups. 

A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer . 

We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening. 
 

Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?

Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.

My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
 

Q: What types of things do you talk about during your stand-up act?

Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.

Lightning Round

Texting or talking?

Text

Favorite city in U.S. besides the one you live in?

Denver

Cat or dog person

Dog

Best place you went on vacation

Patagonia

Favorite sport

Basketball

Favorite ice cream

Rocky Road

What song do you have to sing along with when you hear it?

Celine Dion’s My Heart Will Go On

Growing up in a household where GI issues dominated conversations, it’s no surprise that Shida Haghighat, MD, chose gastroenterology as her area of study in medicine.

She watched her father suffer from the complications of Crohn’s disease and her brother struggle with irritable bowel syndrome. “We always needed to know where the nearest bathroom was. I grew up with that around me, and I was always just fascinated by the gut and the digestive system,” said Dr. Haghighat, who just finished up her fellowship at the University of Miami and is now a gastroenterologist at University of California, Los Angeles. She also serves as social media editor for AGA’s Gastro Hep Advances.

University of Miami

As she got to know the personalities of the GI department in the first year of medical school, “I realized that our senses of humor and personalities kind of aligned, and I was like, ‘Oh yeah, this is where I’m supposed to be,’ ” said Dr. Haghighat, who can be found on X @DoctorShida.

Humor is something Dr. Haghighat has reached for throughout her life and career. She eventually channeled her gift for satire onto the stage and the internet, as a stand-up comedian. In an interview with GI & Hepatology News, she spoke about the connection between GI medicine and humor, and the creative ways she has helped promote cancer screening in underserved populations.
 

Q: What practice challenges have you faced in your career?

Dr. Haghighat: I trained in a county hospital, so I’ve always worked with underserved and vulnerable populations. One of the challenges has been just navigation of care, especially as it pertains to cancer diagnoses or cancer screening. A lot of the time, patients don’t understand why they have to do a test or something invasive like a colonoscopy for symptoms they don’t have. 

Q: A focus of yours has been improving uptake of screening in underserved communities. Please talk about the work you’ve done in this area.

Dr. Haghighat: I was at Los Angeles General Medical Center — a county hospital in Los Angeles — for residency, where we treated underserved, uninsured patients. I noticed in our primary care clinics a very low uptake of colon cancer screening. Patients didn’t want to bring the stool tests back or get colonoscopies. I surveyed a bunch of the patients and asked: How can we make colon cancer screening easier for you? About a third of the patients said, “If I can do it in the clinic before I go home, that would be great.”

So, I started this initiative called “Go Before You Go.” We would ask patients, “Hey, do you need to go to the bathroom right now, if you can?” Our nurses handed them the stool test to do in the bathroom before they left the clinic after their doctor visits.

We saw really good results with that. Surprisingly, a lot of people can go on demand. We saw increased screening rates, and that quality improvement project went on to win multiple first place awards in research competitions. So that’s what got me interested, and that’s where I had my beginnings of increasing preventative services in underserved communities on the ground.
 

Q: Can you discuss some health disparity studies you’ve done in this area?

Dr. Haghighat: As a GI at Jackson Memorial Hospital in Miami, I was seeing cancer disparities firsthand every day. I wanted to approach these disparities from a research funding standpoint on a federal level. I was particularly interested in gastric cancer because it’s not common enough in the United States to warrant universal screening, but it’s very common among certain racial and ethnic minorities, which would warrant targeted screening.

I evaluated cancer funding allocation from the National Cancer Institute among the most common cancers in the United States and found that cancer afflicting a higher proportion of racial and ethnic minorities was receiving lower funding. One of those cancers was stomach cancer. This study basically highlighted that, to decrease these disparities, a top-down policy approach is necessary to distribute cancer research funding equitably across these groups. 

A lot of stomach cancer comes from a bacteria called Helicobacter pylori, which can be more prevalent in certain countries. In another study, I looked at country of birth as a risk factor for stomach cancer, specifically for gastric intestinal metaplasia, which is a precursor for gastric cancer . 

We found that country of birth is a key risk factor for gastric intestinal metaplasia and that it should be incorporated into risk stratification for targeted screening. 
 

Q: Outside of medicine, you perform as a stand-up comedian. You have a popular satirical alias on social media. How did you get interested in stand-up comedy?

Dr. Haghighat: I gave my medical school’s commencement speech, and I had sprinkled a few jokes in there. Afterward, multiple people approached me and said, “You should really consider stand-up comedy. Your timing and delivery are great.” A few months later, I started my intern year in Los Angeles and simultaneously took stand-up comedy classes. I started performing at local clubs around town throughout residency, and I had two or three good sets that I could rely on. And so that’s how I got into stand-up comedy.

My intern year is also when I started this social media satire account. It was a way to cope with the anxieties and stress of residency. Before I knew it, the account gained multitudes of followers, doctors, and other medical professionals. And I joke that the more hours I work in a week, the more memes I make, the more posts I make. It’s kind of a creative outlet for me after a long day.
 

Q: What types of things do you talk about during your stand-up act?

Dr. Haghighat: A lot of it is about growing up in an immigrant household as a first-generation Iranian American. One of my favorite jokes is, my parents gave me so many options for a career. They said I could be a family doctor, a surgeon, a plastic surgeon, and if I worked hard, even a wife of a surgeon. But I talk a lot about being a woman in medicine. That always gets a lot of laughs. And now that I’ve graduated GI fellowship, I’m excited to incorporate some GI jokes because it turns out people love poop jokes.

Lightning Round

Texting or talking?

Text

Favorite city in U.S. besides the one you live in?

Denver

Cat or dog person

Dog

Best place you went on vacation

Patagonia

Favorite sport

Basketball

Favorite ice cream

Rocky Road

What song do you have to sing along with when you hear it?

Celine Dion’s My Heart Will Go On

A recent study, published in the March 2024 issue of Sleep Medicine, identified shift work as one of the risk factors for headache and migraine. The researchers conducted a meta-analysis, including seven studies and involving 422,869 participants. The authors defined shift work as characterized by individuals or teams working consecutively to exceed the standard 8-hour day. They reported that the pooled analysis revealed a significant association between shift work and an increased risk for headache. Specifically, they determined that "individuals working night shifts had a 44% higher risk of developing headaches and a higher incidence of migraines." The authors stated that this association did not establish any causal relationship, and they suggested that future research should investigate the impact of genetics or health behaviors, which could be considered shared risk factors.

An article that had been published in 2019 in Headache included two case reports detailing the effects of shift work on patients with migraine. The authors of the case reports stated that "in the two cases presented, shift work appeared to be associated with chronification of migraine and higher headache-related disability, despite optimal headache management and good patient adherence."^[1] They observed that "a switch to only day shifts promoted transition to an episodic, less disabling pattern of migraine."^[1] These publications both support the idea that, while patients may have an underlying predisposition to migraine, certain lifestyle factors can play a role in exacerbating symptoms.

Erenumab, one of the relatively new therapies for migraine, was found to have a potential link to worsening hypertension. According to an article published in February in Headache: The Journal of Head and Face Pain, there has not been evidence of hypertension in preclinical models or clinical trials, yet postmarketing data suggest that erenumab may be associated with hypertension. The authors conducted an observational retrospective cohort study that included 335 patients who had been seen at a tertiary headache or neurology department. At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The researchers observed that 23.3% (78/335) of the patients were found to have worsening hypertension, and 13 patients of the 225 who continued on erenumab experienced an improvement in their blood pressure. The authors noted that there was no association between worsening hypertension and preexisting hypertension, sex, body mass index, or age, but patients with atrial fibrillation were more likely to develop worsening hypertension (odds ratio 4.9; 95% CI 1.12-21.4; P = .035).

Consideration of a relationship between hypertension and anti-calcitonin gene–related peptide migraine (CGRP) therapies has been found in other studies as well. Results of a retrospective study conducted at the University Hospital of Modena, to explore the rate of hypertension among patients treated with anti-CGRP monoclonal antibodies, were published in April 2024 in Neurological Sciences (published online November 6, 2023). Those authors reported that no significant increase in blood pressure was detected overall, yet 5.7% of the patients developed a significant increase in their blood pressure.^[2] Specifically, the researchers reported that patients with preexisting hypertension were more likely to have a significant increase in blood pressure.^[2] The study authors of the Neurological Sciences publication suggested that patients with preexisting hypertension should be cautiously monitored for signs of hypertension. A more recent publication noted that "CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension," which could explain these findings. As the two studies noted different underlying risk factors for hypertension for patients taking anti-CGRP migraine therapies, it is important to monitor patients for signs of hypertension regardless of their underlying cardiovascular status.

Migraine was also noted to potentially be associated with an increased risk for cerebrovascular disease and stroke among women who have underlying cardiovascular disease risk factors. According to a cross-sectional analysis whose results were published in Mayo Clinic Proceedings in May 2023, women with migraine were significantly more likely to have severe hot flashes compared with women without migraine.^[3] Additionally, the authors stated that migraine was associated with a diagnosis of hypertension.^[3]

Results of a secondary data analysis of a subset of 1954 women in the Coronary Artery Risk Development in Young Adults (CARDIA) study were published in the April 2024 issue of Menopause. After adjustment for age, race, estrogen use, oophorectomy, and hysterectomy, women with histories of migraine and persistent vasomotor symptoms were found to have a greater risk for cerebrovascular disease (hazard ratio [HR] 2.25; 95% CI 1.15-4.38), and stroke (HR 3.15; 95% CI 1.35-7.34), compared with women without migraine histories and with minimal vasomotor symptoms. After adjustment for cerebrovascular disease risk factors, the associations between migraine/vasomotor symptoms and cerebrovascular disease were attenuated (HR 1.51; 95% CI 0.73-3.10), and associations between migraine/vasomotor symptoms and stroke were similarly attenuated (HR 1.70; 95% CI 0.66-4.38). The authors of this research article concluded that migraine and persistent vasomotor symptoms are jointly associated with greater risk for cerebrovascular disease and stroke, particularly for women who already have traditional risk factors for cerebrovascular disease.

This new research brings the importance of managing migraine risk factors and symptoms to the forefront. Patients who experience migraine may have a higher risk for cerebrovascular disease. Minimizing migraine risk factors could potentially help reduce this risk for cerebrovascular disease for some patients, and effectively treating migraines may also play a role in reducing the risk for cerebrovascular disease. Some migraine therapies could worsen cardiovascular disease for some patients, however — particularly patients who already have underlying risk factors. Therefore, it is crucial for physicians to approach migraine care with a comprehensive strategy to reduce risk factors, assess underlying disease, and monitor for comorbidities.

Additional References

1. Sandoe CH, Sasikumar S, Lay C, Lawler V. The impact of shift work on migraine: A case series and narrative review. Headache. 2019;59:1631-1640. doi: 10.1111/head.13622  Source

2. Guerzoni S, Castro FL, Brovia D, Baraldi C, Pani L. Evaluation of the risk of hypertension in patients treated with anti-CGRP monoclonal antibodies in a real-life study. Neurol Sci. 2024;45:1661-1668. doi: 10.1007/s10072-023-07167-z Source

3. Faubion SS, Smith T, Thielen J, et al. Association of migraine and vasomotor symptoms. Mayo Clin Proc. 2023;98:701-712. doi: 10.1016/j.mayocp.2023.01.010 Source

A recent study, published in the March 2024 issue of Sleep Medicine, identified shift work as one of the risk factors for headache and migraine. The researchers conducted a meta-analysis, including seven studies and involving 422,869 participants. The authors defined shift work as characterized by individuals or teams working consecutively to exceed the standard 8-hour day. They reported that the pooled analysis revealed a significant association between shift work and an increased risk for headache. Specifically, they determined that "individuals working night shifts had a 44% higher risk of developing headaches and a higher incidence of migraines." The authors stated that this association did not establish any causal relationship, and they suggested that future research should investigate the impact of genetics or health behaviors, which could be considered shared risk factors.

An article that had been published in 2019 in Headache included two case reports detailing the effects of shift work on patients with migraine. The authors of the case reports stated that "in the two cases presented, shift work appeared to be associated with chronification of migraine and higher headache-related disability, despite optimal headache management and good patient adherence."^[1] They observed that "a switch to only day shifts promoted transition to an episodic, less disabling pattern of migraine."^[1] These publications both support the idea that, while patients may have an underlying predisposition to migraine, certain lifestyle factors can play a role in exacerbating symptoms.

Erenumab, one of the relatively new therapies for migraine, was found to have a potential link to worsening hypertension. According to an article published in February in Headache: The Journal of Head and Face Pain, there has not been evidence of hypertension in preclinical models or clinical trials, yet postmarketing data suggest that erenumab may be associated with hypertension. The authors conducted an observational retrospective cohort study that included 335 patients who had been seen at a tertiary headache or neurology department. At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The researchers observed that 23.3% (78/335) of the patients were found to have worsening hypertension, and 13 patients of the 225 who continued on erenumab experienced an improvement in their blood pressure. The authors noted that there was no association between worsening hypertension and preexisting hypertension, sex, body mass index, or age, but patients with atrial fibrillation were more likely to develop worsening hypertension (odds ratio 4.9; 95% CI 1.12-21.4; P = .035).

Consideration of a relationship between hypertension and anti-calcitonin gene–related peptide migraine (CGRP) therapies has been found in other studies as well. Results of a retrospective study conducted at the University Hospital of Modena, to explore the rate of hypertension among patients treated with anti-CGRP monoclonal antibodies, were published in April 2024 in Neurological Sciences (published online November 6, 2023). Those authors reported that no significant increase in blood pressure was detected overall, yet 5.7% of the patients developed a significant increase in their blood pressure.^[2] Specifically, the researchers reported that patients with preexisting hypertension were more likely to have a significant increase in blood pressure.^[2] The study authors of the Neurological Sciences publication suggested that patients with preexisting hypertension should be cautiously monitored for signs of hypertension. A more recent publication noted that "CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension," which could explain these findings. As the two studies noted different underlying risk factors for hypertension for patients taking anti-CGRP migraine therapies, it is important to monitor patients for signs of hypertension regardless of their underlying cardiovascular status.

Migraine was also noted to potentially be associated with an increased risk for cerebrovascular disease and stroke among women who have underlying cardiovascular disease risk factors. According to a cross-sectional analysis whose results were published in Mayo Clinic Proceedings in May 2023, women with migraine were significantly more likely to have severe hot flashes compared with women without migraine.^[3] Additionally, the authors stated that migraine was associated with a diagnosis of hypertension.^[3]

Results of a secondary data analysis of a subset of 1954 women in the Coronary Artery Risk Development in Young Adults (CARDIA) study were published in the April 2024 issue of Menopause. After adjustment for age, race, estrogen use, oophorectomy, and hysterectomy, women with histories of migraine and persistent vasomotor symptoms were found to have a greater risk for cerebrovascular disease (hazard ratio [HR] 2.25; 95% CI 1.15-4.38), and stroke (HR 3.15; 95% CI 1.35-7.34), compared with women without migraine histories and with minimal vasomotor symptoms. After adjustment for cerebrovascular disease risk factors, the associations between migraine/vasomotor symptoms and cerebrovascular disease were attenuated (HR 1.51; 95% CI 0.73-3.10), and associations between migraine/vasomotor symptoms and stroke were similarly attenuated (HR 1.70; 95% CI 0.66-4.38). The authors of this research article concluded that migraine and persistent vasomotor symptoms are jointly associated with greater risk for cerebrovascular disease and stroke, particularly for women who already have traditional risk factors for cerebrovascular disease.

This new research brings the importance of managing migraine risk factors and symptoms to the forefront. Patients who experience migraine may have a higher risk for cerebrovascular disease. Minimizing migraine risk factors could potentially help reduce this risk for cerebrovascular disease for some patients, and effectively treating migraines may also play a role in reducing the risk for cerebrovascular disease. Some migraine therapies could worsen cardiovascular disease for some patients, however — particularly patients who already have underlying risk factors. Therefore, it is crucial for physicians to approach migraine care with a comprehensive strategy to reduce risk factors, assess underlying disease, and monitor for comorbidities.

Additional References

1. Sandoe CH, Sasikumar S, Lay C, Lawler V. The impact of shift work on migraine: A case series and narrative review. Headache. 2019;59:1631-1640. doi: 10.1111/head.13622  Source

2. Guerzoni S, Castro FL, Brovia D, Baraldi C, Pani L. Evaluation of the risk of hypertension in patients treated with anti-CGRP monoclonal antibodies in a real-life study. Neurol Sci. 2024;45:1661-1668. doi: 10.1007/s10072-023-07167-z Source

3. Faubion SS, Smith T, Thielen J, et al. Association of migraine and vasomotor symptoms. Mayo Clin Proc. 2023;98:701-712. doi: 10.1016/j.mayocp.2023.01.010 Source

A recent study, published in the March 2024 issue of Sleep Medicine, identified shift work as one of the risk factors for headache and migraine. The researchers conducted a meta-analysis, including seven studies and involving 422,869 participants. The authors defined shift work as characterized by individuals or teams working consecutively to exceed the standard 8-hour day. They reported that the pooled analysis revealed a significant association between shift work and an increased risk for headache. Specifically, they determined that "individuals working night shifts had a 44% higher risk of developing headaches and a higher incidence of migraines." The authors stated that this association did not establish any causal relationship, and they suggested that future research should investigate the impact of genetics or health behaviors, which could be considered shared risk factors.

An article that had been published in 2019 in Headache included two case reports detailing the effects of shift work on patients with migraine. The authors of the case reports stated that "in the two cases presented, shift work appeared to be associated with chronification of migraine and higher headache-related disability, despite optimal headache management and good patient adherence."^[1] They observed that "a switch to only day shifts promoted transition to an episodic, less disabling pattern of migraine."^[1] These publications both support the idea that, while patients may have an underlying predisposition to migraine, certain lifestyle factors can play a role in exacerbating symptoms.

Erenumab, one of the relatively new therapies for migraine, was found to have a potential link to worsening hypertension. According to an article published in February in Headache: The Journal of Head and Face Pain, there has not been evidence of hypertension in preclinical models or clinical trials, yet postmarketing data suggest that erenumab may be associated with hypertension. The authors conducted an observational retrospective cohort study that included 335 patients who had been seen at a tertiary headache or neurology department. At baseline, 20.9% (70/335) of patients had a prior diagnosis of hypertension. The researchers observed that 23.3% (78/335) of the patients were found to have worsening hypertension, and 13 patients of the 225 who continued on erenumab experienced an improvement in their blood pressure. The authors noted that there was no association between worsening hypertension and preexisting hypertension, sex, body mass index, or age, but patients with atrial fibrillation were more likely to develop worsening hypertension (odds ratio 4.9; 95% CI 1.12-21.4; P = .035).

Consideration of a relationship between hypertension and anti-calcitonin gene–related peptide migraine (CGRP) therapies has been found in other studies as well. Results of a retrospective study conducted at the University Hospital of Modena, to explore the rate of hypertension among patients treated with anti-CGRP monoclonal antibodies, were published in April 2024 in Neurological Sciences (published online November 6, 2023). Those authors reported that no significant increase in blood pressure was detected overall, yet 5.7% of the patients developed a significant increase in their blood pressure.^[2] Specifically, the researchers reported that patients with preexisting hypertension were more likely to have a significant increase in blood pressure.^[2] The study authors of the Neurological Sciences publication suggested that patients with preexisting hypertension should be cautiously monitored for signs of hypertension. A more recent publication noted that "CGRP is involved in the regulation of vasomotor tone under physiologic and pathologic conditions, including hypertension," which could explain these findings. As the two studies noted different underlying risk factors for hypertension for patients taking anti-CGRP migraine therapies, it is important to monitor patients for signs of hypertension regardless of their underlying cardiovascular status.

Migraine was also noted to potentially be associated with an increased risk for cerebrovascular disease and stroke among women who have underlying cardiovascular disease risk factors. According to a cross-sectional analysis whose results were published in Mayo Clinic Proceedings in May 2023, women with migraine were significantly more likely to have severe hot flashes compared with women without migraine.^[3] Additionally, the authors stated that migraine was associated with a diagnosis of hypertension.^[3]

Results of a secondary data analysis of a subset of 1954 women in the Coronary Artery Risk Development in Young Adults (CARDIA) study were published in the April 2024 issue of Menopause. After adjustment for age, race, estrogen use, oophorectomy, and hysterectomy, women with histories of migraine and persistent vasomotor symptoms were found to have a greater risk for cerebrovascular disease (hazard ratio [HR] 2.25; 95% CI 1.15-4.38), and stroke (HR 3.15; 95% CI 1.35-7.34), compared with women without migraine histories and with minimal vasomotor symptoms. After adjustment for cerebrovascular disease risk factors, the associations between migraine/vasomotor symptoms and cerebrovascular disease were attenuated (HR 1.51; 95% CI 0.73-3.10), and associations between migraine/vasomotor symptoms and stroke were similarly attenuated (HR 1.70; 95% CI 0.66-4.38). The authors of this research article concluded that migraine and persistent vasomotor symptoms are jointly associated with greater risk for cerebrovascular disease and stroke, particularly for women who already have traditional risk factors for cerebrovascular disease.

This new research brings the importance of managing migraine risk factors and symptoms to the forefront. Patients who experience migraine may have a higher risk for cerebrovascular disease. Minimizing migraine risk factors could potentially help reduce this risk for cerebrovascular disease for some patients, and effectively treating migraines may also play a role in reducing the risk for cerebrovascular disease. Some migraine therapies could worsen cardiovascular disease for some patients, however — particularly patients who already have underlying risk factors. Therefore, it is crucial for physicians to approach migraine care with a comprehensive strategy to reduce risk factors, assess underlying disease, and monitor for comorbidities.

Additional References

1. Sandoe CH, Sasikumar S, Lay C, Lawler V. The impact of shift work on migraine: A case series and narrative review. Headache. 2019;59:1631-1640. doi: 10.1111/head.13622  Source

2. Guerzoni S, Castro FL, Brovia D, Baraldi C, Pani L. Evaluation of the risk of hypertension in patients treated with anti-CGRP monoclonal antibodies in a real-life study. Neurol Sci. 2024;45:1661-1668. doi: 10.1007/s10072-023-07167-z Source

3. Faubion SS, Smith T, Thielen J, et al. Association of migraine and vasomotor symptoms. Mayo Clin Proc. 2023;98:701-712. doi: 10.1016/j.mayocp.2023.01.010 Source

For anyone (physicians included) concerned about whether generative artificial intelligence (AI) tools will take your job, the likely answer is no—but those who use generative AI will have an advantage, according to Faranak (Fara) Kamangar, MD, Department Chair, Palo Alto Medical Foundation, who presented on AI at the 2024 Annual Meeting of the American Academy of Dermatology, San Diego, California.

Dr. Kamangar is a dermatologist and inventor of DermGPT, an AI tool created specifically to help health care providers with clinical tasks to increase productivity. According to Dr. Kamangar, “For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the [electronic health record].” Her advice is to use AI when you can to complete clinical tasks and move on.

DermGPT utilizes a learned language model that is based on dermatology knowledge acquired from more than 3000 peer-reviewed articles and texts (eg, systematic literature reviews, other published sources in the field of dermatology). Search output includes citations so that users can confirm that the answers and sources are accurate. “Still, with all of these safeguards, all AI models can create inaccuracies and it is important to proofread all content,” says Dr. Kamangar.

During her presentation, Dr. Kamangar gave the following examples of potentially useful DermGPT prompts for dermatologists:

• Can you help me write a response to a denial letter to an insurance company for upadacitinib in a patient with atopic dermatitis?
• I am seeing a patient with blisters. What is the differential diagnosis?
• I am prescribing bimekizumab. What labs do I need to check?

Other potential time-saving uses for a dermatologist include:

• prior authorization letters
• coding support
• responses to common patient messages
• letters of recommendation
• information on new treatments.

In Dr. Kamangar’s practice, they have been able to save at least 30 to 60 minutes at the end of the day that is usually spent updating the electronic health record. “This allows us to complete the clinic day much earlier and does not leave work that will spill over to the next day,” she shares. “During my workday, I have [DermGPT] open on my computer, and as clinical tasks arise, if they require more information or assistance, I turn to DermGPT to help de-escalate the task from a moderate to difficult level to an easy task that can be easily managed.”

The next stage of health technology—AI—is here, and physicians are understandably cautious. Board-certified dermatologists, dermatology residents, fellows, and medical students can try DermGPT for free at https://www.dermgpt.com/.

Dr. Kamangar is the founder of DermGPT.

Melissa Sears is the Director, Editorial, of Cutis.

For anyone (physicians included) concerned about whether generative artificial intelligence (AI) tools will take your job, the likely answer is no—but those who use generative AI will have an advantage, according to Faranak (Fara) Kamangar, MD, Department Chair, Palo Alto Medical Foundation, who presented on AI at the 2024 Annual Meeting of the American Academy of Dermatology, San Diego, California.

Dr. Kamangar is a dermatologist and inventor of DermGPT, an AI tool created specifically to help health care providers with clinical tasks to increase productivity. According to Dr. Kamangar, “For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the [electronic health record].” Her advice is to use AI when you can to complete clinical tasks and move on.

DermGPT utilizes a learned language model that is based on dermatology knowledge acquired from more than 3000 peer-reviewed articles and texts (eg, systematic literature reviews, other published sources in the field of dermatology). Search output includes citations so that users can confirm that the answers and sources are accurate. “Still, with all of these safeguards, all AI models can create inaccuracies and it is important to proofread all content,” says Dr. Kamangar.

During her presentation, Dr. Kamangar gave the following examples of potentially useful DermGPT prompts for dermatologists:

• Can you help me write a response to a denial letter to an insurance company for upadacitinib in a patient with atopic dermatitis?
• I am seeing a patient with blisters. What is the differential diagnosis?
• I am prescribing bimekizumab. What labs do I need to check?

Other potential time-saving uses for a dermatologist include:

• prior authorization letters
• coding support
• responses to common patient messages
• letters of recommendation
• information on new treatments.

In Dr. Kamangar’s practice, they have been able to save at least 30 to 60 minutes at the end of the day that is usually spent updating the electronic health record. “This allows us to complete the clinic day much earlier and does not leave work that will spill over to the next day,” she shares. “During my workday, I have [DermGPT] open on my computer, and as clinical tasks arise, if they require more information or assistance, I turn to DermGPT to help de-escalate the task from a moderate to difficult level to an easy task that can be easily managed.”

The next stage of health technology—AI—is here, and physicians are understandably cautious. Board-certified dermatologists, dermatology residents, fellows, and medical students can try DermGPT for free at https://www.dermgpt.com/.

Dr. Kamangar is the founder of DermGPT.

Melissa Sears is the Director, Editorial, of Cutis.

For anyone (physicians included) concerned about whether generative artificial intelligence (AI) tools will take your job, the likely answer is no—but those who use generative AI will have an advantage, according to Faranak (Fara) Kamangar, MD, Department Chair, Palo Alto Medical Foundation, who presented on AI at the 2024 Annual Meeting of the American Academy of Dermatology, San Diego, California.

Dr. Kamangar is a dermatologist and inventor of DermGPT, an AI tool created specifically to help health care providers with clinical tasks to increase productivity. According to Dr. Kamangar, “For every 8 hours of scheduled patient time, ambulatory physicians spend more than 5 hours on the [electronic health record].” Her advice is to use AI when you can to complete clinical tasks and move on.

DermGPT utilizes a learned language model that is based on dermatology knowledge acquired from more than 3000 peer-reviewed articles and texts (eg, systematic literature reviews, other published sources in the field of dermatology). Search output includes citations so that users can confirm that the answers and sources are accurate. “Still, with all of these safeguards, all AI models can create inaccuracies and it is important to proofread all content,” says Dr. Kamangar.

During her presentation, Dr. Kamangar gave the following examples of potentially useful DermGPT prompts for dermatologists:

• Can you help me write a response to a denial letter to an insurance company for upadacitinib in a patient with atopic dermatitis?
• I am seeing a patient with blisters. What is the differential diagnosis?
• I am prescribing bimekizumab. What labs do I need to check?

Other potential time-saving uses for a dermatologist include:

• prior authorization letters
• coding support
• responses to common patient messages
• letters of recommendation
• information on new treatments.

In Dr. Kamangar’s practice, they have been able to save at least 30 to 60 minutes at the end of the day that is usually spent updating the electronic health record. “This allows us to complete the clinic day much earlier and does not leave work that will spill over to the next day,” she shares. “During my workday, I have [DermGPT] open on my computer, and as clinical tasks arise, if they require more information or assistance, I turn to DermGPT to help de-escalate the task from a moderate to difficult level to an easy task that can be easily managed.”

The next stage of health technology—AI—is here, and physicians are understandably cautious. Board-certified dermatologists, dermatology residents, fellows, and medical students can try DermGPT for free at https://www.dermgpt.com/.

Dr. Kamangar is the founder of DermGPT.

Melissa Sears is the Director, Editorial, of Cutis.

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Short-term exposure to high outdoor temperatures is associated with an increased inflammatory response and reduction in infection-fighting cells, new research showed.

In this study, blood work from volunteers was examined for immune biomarkers, and the findings mapped against environmental data.

“With rising global temperatures, the association between heat exposure and a temporarily weakened response from the immune system is a concern because temperature and humidity are known to be important environmental drivers of infectious, airborne disease transmission,” lead author Daniel W. Riggs, PhD, with the Christina Lee Brown Envirome Institute, University of Louisville in Louisville, Kentucky, said in a news release.

“In this study, even exposure to relatively modest increases in temperature were associated with acute changes in immune system functioning indexed by low-grade inflammation known to be linked to cardiovascular disorders, as well as potential secondary effects on the ability to optimally protect against infection,” said Rosalind J. Wright, MD, MPH, who wasn’t involved in the study.

“Further elucidation of the effects of both acute and more prolonged heat exposures (heat waves) on immune signaling will be important given potential broad health implications beyond the heart,” said Dr. Wright, dean of public health and professor and chair, Department of Public Health, Mount Sinai Health System.

The study was presented at the American Heart Association (AHA) Epidemiology and Prevention | Lifestyle and Cardiometabolic Scientific Sessions 2024.

High Temps Hard on Multiple Organs

Extreme-heat events have been shown to increase mortality, and excessive deaths due to heat waves are overwhelmingly cardiovascular in origin. Many prior studies only considered ambient temperature, which fails to capture the actual heat stress experienced by individuals, Dr. Riggs and colleagues wrote.

They designed their study to gauge how short-term heat exposures are related to markers of inflammation and the immune response.

They recruited 624 adults (mean age 49 years, 59% women) from a neighborhood in Louisville during the summer months, when median temperatures over 24 hours were 24.5 °C (76 °F).

They obtained blood samples to measure circulating cytokines and immune cells during clinic visits. Heat metrics, collected on the same day as blood draws, included 24-hour averages of temperature, net effective temperature, and the Universal Thermal Climate Index (UTCI), a metric that incorporates temperature, humidity, wind speed, and ultraviolet radiation, to determine the physiological comfort of the human body under specific weather conditions.

The results were adjusted for multiple factors, including sex, age, race, education, body mass index, smoking status, anti-inflammatory medication use, and daily air pollution (PM 2.5).

In adjusted analyses, for every five-degree increase in UTCI, there was an increase in levels of several inflammatory markers, including monocytes (4.2%), eosinophils (9.5%), natural killer T cells (9.9%), and tumor necrosis factor-alpha (7.0%) and a decrease in infection-fighting B cells (−6.8%).

Study Raises Important Questions

“We’re finding that heat is associated with health effects across a wide range of organ systems and outcomes, but this study helps start to get at the ‘how,’” said Perry E. Sheffield, MD, MPH, with the Departments of Pediatrics and Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai in New York City, who wasn’t involved in the study.

Dr. Sheffield said the study raises “important questions like, Does the timing of heat exposure matter (going in and out of air-conditioned spaces for example)? and Could some people be more vulnerable than others based on things like what they eat, whether they exercise, or their genetics?”

The study comes on the heels of a report released earlier this month from the World Meteorological Organization noting that climate change indicators reached record levels in 2023.

“The most critical challenges facing medicine are occurring at the intersection of climate and health, underscoring the urgent need to understand how climate-related factors, such as exposure to more extreme temperatures, shift key regulatory systems in our bodies to contribute to disease,” Dr. Wright told this news organization.

The study was supported by grants from the National Institute of Environmental Health Sciences. Dr. Riggs, Dr. Wright, and Sheffield had no relevant disclosures.

A version of this article appeared on Medscape.com.

Short-term exposure to high outdoor temperatures is associated with an increased inflammatory response and reduction in infection-fighting cells, new research showed.

In this study, blood work from volunteers was examined for immune biomarkers, and the findings mapped against environmental data.

“With rising global temperatures, the association between heat exposure and a temporarily weakened response from the immune system is a concern because temperature and humidity are known to be important environmental drivers of infectious, airborne disease transmission,” lead author Daniel W. Riggs, PhD, with the Christina Lee Brown Envirome Institute, University of Louisville in Louisville, Kentucky, said in a news release.

“In this study, even exposure to relatively modest increases in temperature were associated with acute changes in immune system functioning indexed by low-grade inflammation known to be linked to cardiovascular disorders, as well as potential secondary effects on the ability to optimally protect against infection,” said Rosalind J. Wright, MD, MPH, who wasn’t involved in the study.

“Further elucidation of the effects of both acute and more prolonged heat exposures (heat waves) on immune signaling will be important given potential broad health implications beyond the heart,” said Dr. Wright, dean of public health and professor and chair, Department of Public Health, Mount Sinai Health System.

The study was presented at the American Heart Association (AHA) Epidemiology and Prevention | Lifestyle and Cardiometabolic Scientific Sessions 2024.

High Temps Hard on Multiple Organs

Extreme-heat events have been shown to increase mortality, and excessive deaths due to heat waves are overwhelmingly cardiovascular in origin. Many prior studies only considered ambient temperature, which fails to capture the actual heat stress experienced by individuals, Dr. Riggs and colleagues wrote.

They designed their study to gauge how short-term heat exposures are related to markers of inflammation and the immune response.

They recruited 624 adults (mean age 49 years, 59% women) from a neighborhood in Louisville during the summer months, when median temperatures over 24 hours were 24.5 °C (76 °F).

They obtained blood samples to measure circulating cytokines and immune cells during clinic visits. Heat metrics, collected on the same day as blood draws, included 24-hour averages of temperature, net effective temperature, and the Universal Thermal Climate Index (UTCI), a metric that incorporates temperature, humidity, wind speed, and ultraviolet radiation, to determine the physiological comfort of the human body under specific weather conditions.

The results were adjusted for multiple factors, including sex, age, race, education, body mass index, smoking status, anti-inflammatory medication use, and daily air pollution (PM 2.5).

In adjusted analyses, for every five-degree increase in UTCI, there was an increase in levels of several inflammatory markers, including monocytes (4.2%), eosinophils (9.5%), natural killer T cells (9.9%), and tumor necrosis factor-alpha (7.0%) and a decrease in infection-fighting B cells (−6.8%).

Study Raises Important Questions

“We’re finding that heat is associated with health effects across a wide range of organ systems and outcomes, but this study helps start to get at the ‘how,’” said Perry E. Sheffield, MD, MPH, with the Departments of Pediatrics and Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai in New York City, who wasn’t involved in the study.

Dr. Sheffield said the study raises “important questions like, Does the timing of heat exposure matter (going in and out of air-conditioned spaces for example)? and Could some people be more vulnerable than others based on things like what they eat, whether they exercise, or their genetics?”

The study comes on the heels of a report released earlier this month from the World Meteorological Organization noting that climate change indicators reached record levels in 2023.

“The most critical challenges facing medicine are occurring at the intersection of climate and health, underscoring the urgent need to understand how climate-related factors, such as exposure to more extreme temperatures, shift key regulatory systems in our bodies to contribute to disease,” Dr. Wright told this news organization.

The study was supported by grants from the National Institute of Environmental Health Sciences. Dr. Riggs, Dr. Wright, and Sheffield had no relevant disclosures.

A version of this article appeared on Medscape.com.

Short-term exposure to high outdoor temperatures is associated with an increased inflammatory response and reduction in infection-fighting cells, new research showed.

In this study, blood work from volunteers was examined for immune biomarkers, and the findings mapped against environmental data.

“With rising global temperatures, the association between heat exposure and a temporarily weakened response from the immune system is a concern because temperature and humidity are known to be important environmental drivers of infectious, airborne disease transmission,” lead author Daniel W. Riggs, PhD, with the Christina Lee Brown Envirome Institute, University of Louisville in Louisville, Kentucky, said in a news release.

“In this study, even exposure to relatively modest increases in temperature were associated with acute changes in immune system functioning indexed by low-grade inflammation known to be linked to cardiovascular disorders, as well as potential secondary effects on the ability to optimally protect against infection,” said Rosalind J. Wright, MD, MPH, who wasn’t involved in the study.

“Further elucidation of the effects of both acute and more prolonged heat exposures (heat waves) on immune signaling will be important given potential broad health implications beyond the heart,” said Dr. Wright, dean of public health and professor and chair, Department of Public Health, Mount Sinai Health System.

The study was presented at the American Heart Association (AHA) Epidemiology and Prevention | Lifestyle and Cardiometabolic Scientific Sessions 2024.

High Temps Hard on Multiple Organs

Extreme-heat events have been shown to increase mortality, and excessive deaths due to heat waves are overwhelmingly cardiovascular in origin. Many prior studies only considered ambient temperature, which fails to capture the actual heat stress experienced by individuals, Dr. Riggs and colleagues wrote.

They designed their study to gauge how short-term heat exposures are related to markers of inflammation and the immune response.

They recruited 624 adults (mean age 49 years, 59% women) from a neighborhood in Louisville during the summer months, when median temperatures over 24 hours were 24.5 °C (76 °F).

They obtained blood samples to measure circulating cytokines and immune cells during clinic visits. Heat metrics, collected on the same day as blood draws, included 24-hour averages of temperature, net effective temperature, and the Universal Thermal Climate Index (UTCI), a metric that incorporates temperature, humidity, wind speed, and ultraviolet radiation, to determine the physiological comfort of the human body under specific weather conditions.

The results were adjusted for multiple factors, including sex, age, race, education, body mass index, smoking status, anti-inflammatory medication use, and daily air pollution (PM 2.5).

In adjusted analyses, for every five-degree increase in UTCI, there was an increase in levels of several inflammatory markers, including monocytes (4.2%), eosinophils (9.5%), natural killer T cells (9.9%), and tumor necrosis factor-alpha (7.0%) and a decrease in infection-fighting B cells (−6.8%).

Study Raises Important Questions

“We’re finding that heat is associated with health effects across a wide range of organ systems and outcomes, but this study helps start to get at the ‘how,’” said Perry E. Sheffield, MD, MPH, with the Departments of Pediatrics and Environmental Medicine and Public Health, Icahn School of Medicine at Mount Sinai in New York City, who wasn’t involved in the study.

Dr. Sheffield said the study raises “important questions like, Does the timing of heat exposure matter (going in and out of air-conditioned spaces for example)? and Could some people be more vulnerable than others based on things like what they eat, whether they exercise, or their genetics?”

The study comes on the heels of a report released earlier this month from the World Meteorological Organization noting that climate change indicators reached record levels in 2023.

“The most critical challenges facing medicine are occurring at the intersection of climate and health, underscoring the urgent need to understand how climate-related factors, such as exposure to more extreme temperatures, shift key regulatory systems in our bodies to contribute to disease,” Dr. Wright told this news organization.

The study was supported by grants from the National Institute of Environmental Health Sciences. Dr. Riggs, Dr. Wright, and Sheffield had no relevant disclosures.

A version of this article appeared on Medscape.com.

Experts worry a recent rise in long COVID cases — fueled by a spike in winter holiday infections and a decline in masking and other measures — could continue into this year.

A sudden rise in long COVID in January has persisted into a second month. About 17.6% of those surveyed by the Census Bureau in January said they have experienced long COVID. The number for February was 17.4.

Compare these new numbers to October 2023 and earlier, when long COVID numbers hovered between 14% and 15% of the US adult population as far back as June 2022.

The Census Bureau and the Centers for Disease Control and Prevention (CDC) regularly query about 70,000 people as part of its ongoing Pulse Survey.

It’s Not Just the Federal Numbers

Independently, advocates, researchers, and clinicians also reported seeing an increase in the number of people who have developed long COVID after a second or third infection.

John Baratta, MD, who runs the COVID Recovery Clinic at the University of North Carolina, said the increase is related to a higher rate of acute cases in the fall and winter of 2023.

In January, the percentage of North Carolinians reporting ever having had long COVD jumped from 12.5% to 20.2% in January and fell to 16.8% in February.

At the same time, many cases are either undetected or unreported by people who tested positive for COVID-19 at home or are not aware they have had it.

Hannah Davis, a member of the Patient-Led Research Collaborative, also linked the increase in long COVID to the wave of new infections at the end of 2023 and the start of 2024.

“It’s absolutely real,” she said via email. “There have been many new cases in the past few months, and we see those new folks in our communities as well.”

Wastewater Remains the Best Indicator

“This results in many cases of COVID flying under the radar,” Dr. Baratta said. “However, we do know from the wastewater monitoring that there was a pretty substantial rise.”

Testing wastewater for COVID levels is becoming one of the most reliable measures of estimating infection, he said. Nationally, viral measure of wastewater followed a similar path: The viral rate started creeping up in October and peaked on December 30, according to CDC measures.

RNA extracted from concentrated wastewater samples offer a good measure of SARS-CoV-2 in the community. In North Carolina and elsewhere, the state measures the virus by calculating gene copies in wastewater per capita — how many for each resident. For most of 2023, North Carolina reported fewer than 10 million viral gene copies per state resident. In late July, that number shot up to 25 million and reached 71 million per capita in March 2023 before starting to go down.

Repeat Infections, Vaccine Apathy Driving Numbers

Dr. Baratta said COVID remains a problem in rural areas. In Maine, wastewater virus counts have been much higher than the national average. There, the percentage of people who reported currently experiencing long COVID rose from 5.7% in October to 9.2% in January. The percentage reporting ever experiencing long COVID rose from 13.8% to 21% in that period.

Other factors play a role. Dr. Baratta said he is seeing patients with long COVID who have refused the vaccine or developed long COVID after a second or third infection.

He said he thinks that attitudes toward the pandemic have resulted in relaxed protection and prevention efforts.

“There is low booster vaccination rate and additional masking is utilized less that before,” he said. About 20% of the population has received the latest vaccine booster, according to the Kaiser Family Foundation.

The increase in long COVID has many causes including “infection, reinfection (eg, people getting COVID after a second, third, or fourth infection), low vaccination rates, waning immunity, and decline in the use of antivirals (such as Paxlovid),” said Ziyad Al-Aly, MD, chief of research at Veterans Affairs St. Louis Health Care and clinical epidemiologist at Washington University in St. Louis, St. Louis, Missouri.

“All of these could contribute to the rise in burden of long COVID,” he said.

Not all states reported an increase. Massachusetts and Hawaii saw long COVD rates drop slightly, according to the CDC.

A version of this article appeared on Medscape.com.

Experts worry a recent rise in long COVID cases — fueled by a spike in winter holiday infections and a decline in masking and other measures — could continue into this year.

A sudden rise in long COVID in January has persisted into a second month. About 17.6% of those surveyed by the Census Bureau in January said they have experienced long COVID. The number for February was 17.4.

Compare these new numbers to October 2023 and earlier, when long COVID numbers hovered between 14% and 15% of the US adult population as far back as June 2022.

The Census Bureau and the Centers for Disease Control and Prevention (CDC) regularly query about 70,000 people as part of its ongoing Pulse Survey.

It’s Not Just the Federal Numbers

Independently, advocates, researchers, and clinicians also reported seeing an increase in the number of people who have developed long COVID after a second or third infection.

John Baratta, MD, who runs the COVID Recovery Clinic at the University of North Carolina, said the increase is related to a higher rate of acute cases in the fall and winter of 2023.

In January, the percentage of North Carolinians reporting ever having had long COVD jumped from 12.5% to 20.2% in January and fell to 16.8% in February.

At the same time, many cases are either undetected or unreported by people who tested positive for COVID-19 at home or are not aware they have had it.

Hannah Davis, a member of the Patient-Led Research Collaborative, also linked the increase in long COVID to the wave of new infections at the end of 2023 and the start of 2024.

“It’s absolutely real,” she said via email. “There have been many new cases in the past few months, and we see those new folks in our communities as well.”

Wastewater Remains the Best Indicator

“This results in many cases of COVID flying under the radar,” Dr. Baratta said. “However, we do know from the wastewater monitoring that there was a pretty substantial rise.”

Testing wastewater for COVID levels is becoming one of the most reliable measures of estimating infection, he said. Nationally, viral measure of wastewater followed a similar path: The viral rate started creeping up in October and peaked on December 30, according to CDC measures.

RNA extracted from concentrated wastewater samples offer a good measure of SARS-CoV-2 in the community. In North Carolina and elsewhere, the state measures the virus by calculating gene copies in wastewater per capita — how many for each resident. For most of 2023, North Carolina reported fewer than 10 million viral gene copies per state resident. In late July, that number shot up to 25 million and reached 71 million per capita in March 2023 before starting to go down.

Repeat Infections, Vaccine Apathy Driving Numbers

Dr. Baratta said COVID remains a problem in rural areas. In Maine, wastewater virus counts have been much higher than the national average. There, the percentage of people who reported currently experiencing long COVID rose from 5.7% in October to 9.2% in January. The percentage reporting ever experiencing long COVID rose from 13.8% to 21% in that period.

Other factors play a role. Dr. Baratta said he is seeing patients with long COVID who have refused the vaccine or developed long COVID after a second or third infection.

He said he thinks that attitudes toward the pandemic have resulted in relaxed protection and prevention efforts.

“There is low booster vaccination rate and additional masking is utilized less that before,” he said. About 20% of the population has received the latest vaccine booster, according to the Kaiser Family Foundation.

The increase in long COVID has many causes including “infection, reinfection (eg, people getting COVID after a second, third, or fourth infection), low vaccination rates, waning immunity, and decline in the use of antivirals (such as Paxlovid),” said Ziyad Al-Aly, MD, chief of research at Veterans Affairs St. Louis Health Care and clinical epidemiologist at Washington University in St. Louis, St. Louis, Missouri.

“All of these could contribute to the rise in burden of long COVID,” he said.

Not all states reported an increase. Massachusetts and Hawaii saw long COVD rates drop slightly, according to the CDC.

A version of this article appeared on Medscape.com.

Experts worry a recent rise in long COVID cases — fueled by a spike in winter holiday infections and a decline in masking and other measures — could continue into this year.

A sudden rise in long COVID in January has persisted into a second month. About 17.6% of those surveyed by the Census Bureau in January said they have experienced long COVID. The number for February was 17.4.

Compare these new numbers to October 2023 and earlier, when long COVID numbers hovered between 14% and 15% of the US adult population as far back as June 2022.

The Census Bureau and the Centers for Disease Control and Prevention (CDC) regularly query about 70,000 people as part of its ongoing Pulse Survey.

It’s Not Just the Federal Numbers

Independently, advocates, researchers, and clinicians also reported seeing an increase in the number of people who have developed long COVID after a second or third infection.

John Baratta, MD, who runs the COVID Recovery Clinic at the University of North Carolina, said the increase is related to a higher rate of acute cases in the fall and winter of 2023.

In January, the percentage of North Carolinians reporting ever having had long COVD jumped from 12.5% to 20.2% in January and fell to 16.8% in February.

At the same time, many cases are either undetected or unreported by people who tested positive for COVID-19 at home or are not aware they have had it.

Hannah Davis, a member of the Patient-Led Research Collaborative, also linked the increase in long COVID to the wave of new infections at the end of 2023 and the start of 2024.

“It’s absolutely real,” she said via email. “There have been many new cases in the past few months, and we see those new folks in our communities as well.”

Wastewater Remains the Best Indicator

“This results in many cases of COVID flying under the radar,” Dr. Baratta said. “However, we do know from the wastewater monitoring that there was a pretty substantial rise.”

Testing wastewater for COVID levels is becoming one of the most reliable measures of estimating infection, he said. Nationally, viral measure of wastewater followed a similar path: The viral rate started creeping up in October and peaked on December 30, according to CDC measures.

RNA extracted from concentrated wastewater samples offer a good measure of SARS-CoV-2 in the community. In North Carolina and elsewhere, the state measures the virus by calculating gene copies in wastewater per capita — how many for each resident. For most of 2023, North Carolina reported fewer than 10 million viral gene copies per state resident. In late July, that number shot up to 25 million and reached 71 million per capita in March 2023 before starting to go down.

Repeat Infections, Vaccine Apathy Driving Numbers

Dr. Baratta said COVID remains a problem in rural areas. In Maine, wastewater virus counts have been much higher than the national average. There, the percentage of people who reported currently experiencing long COVID rose from 5.7% in October to 9.2% in January. The percentage reporting ever experiencing long COVID rose from 13.8% to 21% in that period.

Other factors play a role. Dr. Baratta said he is seeing patients with long COVID who have refused the vaccine or developed long COVID after a second or third infection.

He said he thinks that attitudes toward the pandemic have resulted in relaxed protection and prevention efforts.

“There is low booster vaccination rate and additional masking is utilized less that before,” he said. About 20% of the population has received the latest vaccine booster, according to the Kaiser Family Foundation.

The increase in long COVID has many causes including “infection, reinfection (eg, people getting COVID after a second, third, or fourth infection), low vaccination rates, waning immunity, and decline in the use of antivirals (such as Paxlovid),” said Ziyad Al-Aly, MD, chief of research at Veterans Affairs St. Louis Health Care and clinical epidemiologist at Washington University in St. Louis, St. Louis, Missouri.

“All of these could contribute to the rise in burden of long COVID,” he said.

Not all states reported an increase. Massachusetts and Hawaii saw long COVD rates drop slightly, according to the CDC.

A version of this article appeared on Medscape.com.

TOPLINE:

A study involving more than 260,000 patients found that neither text messages nor reminders in patient portals significantly increased rates of influenza vaccination.

METHODOLOGY:

• The study was conducted from September 2022 to April 2023 in the University of California, Los Angeles (UCLA) health system, involving 262,085 patients across 79 primary care practices.
• Patients were randomly assigned to one of three groups: A control group that received usual care, a group that received reminders through the patient portal, and a group that received reminders via text message.
• The primary outcome was the influenza vaccination rate by April 30, 2023, including vaccinations from pharmacies and other sources.

TAKEAWAY:

• Neither intervention significantly improved influenza vaccination rates, which remained around 47% for all the groups.
• Preappointment text reminders appeared to have a slight effect on unvaccinated patients who had scheduled appointments, suggesting potential for targeted use in this population, according to the researchers.

IN PRACTICE:

“Health systems should consider the potential opportunity costs of sending reminders for influenza vaccination and may decide on other, more intensive interventions, such as improving access to vaccinations (eg, Saturday or after-hour clinics) or communication training for clinicians to address vaccine hesitancy,” the authors of the study wrote.

SOURCE:

The study was led by Peter G. Szilagyi, MD, MPH, with the Department of Pediatrics at UCLA Mattel Children’s Hospital, University of California, Los Angeles. It was published online in JAMA Internal Medicine.

LIMITATIONS:

The study was confined to a single health system and did not assess patients’ reasons for not getting vaccinated.

DISCLOSURES:

The study was supported by grants from the National Institutes of Health. Coauthors disclosed financial ties to pharmacy and pharmaceutical companies and the Pediatric Infectious Disease Society.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

TOPLINE:

A study involving more than 260,000 patients found that neither text messages nor reminders in patient portals significantly increased rates of influenza vaccination.

METHODOLOGY:

• The study was conducted from September 2022 to April 2023 in the University of California, Los Angeles (UCLA) health system, involving 262,085 patients across 79 primary care practices.
• Patients were randomly assigned to one of three groups: A control group that received usual care, a group that received reminders through the patient portal, and a group that received reminders via text message.
• The primary outcome was the influenza vaccination rate by April 30, 2023, including vaccinations from pharmacies and other sources.

TAKEAWAY:

• Neither intervention significantly improved influenza vaccination rates, which remained around 47% for all the groups.
• Preappointment text reminders appeared to have a slight effect on unvaccinated patients who had scheduled appointments, suggesting potential for targeted use in this population, according to the researchers.

IN PRACTICE:

“Health systems should consider the potential opportunity costs of sending reminders for influenza vaccination and may decide on other, more intensive interventions, such as improving access to vaccinations (eg, Saturday or after-hour clinics) or communication training for clinicians to address vaccine hesitancy,” the authors of the study wrote.

SOURCE:

The study was led by Peter G. Szilagyi, MD, MPH, with the Department of Pediatrics at UCLA Mattel Children’s Hospital, University of California, Los Angeles. It was published online in JAMA Internal Medicine.

LIMITATIONS:

The study was confined to a single health system and did not assess patients’ reasons for not getting vaccinated.

DISCLOSURES:

The study was supported by grants from the National Institutes of Health. Coauthors disclosed financial ties to pharmacy and pharmaceutical companies and the Pediatric Infectious Disease Society.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

TOPLINE:

A study involving more than 260,000 patients found that neither text messages nor reminders in patient portals significantly increased rates of influenza vaccination.

METHODOLOGY:

• The study was conducted from September 2022 to April 2023 in the University of California, Los Angeles (UCLA) health system, involving 262,085 patients across 79 primary care practices.
• Patients were randomly assigned to one of three groups: A control group that received usual care, a group that received reminders through the patient portal, and a group that received reminders via text message.
• The primary outcome was the influenza vaccination rate by April 30, 2023, including vaccinations from pharmacies and other sources.

TAKEAWAY:

• Neither intervention significantly improved influenza vaccination rates, which remained around 47% for all the groups.
• Preappointment text reminders appeared to have a slight effect on unvaccinated patients who had scheduled appointments, suggesting potential for targeted use in this population, according to the researchers.

IN PRACTICE:

“Health systems should consider the potential opportunity costs of sending reminders for influenza vaccination and may decide on other, more intensive interventions, such as improving access to vaccinations (eg, Saturday or after-hour clinics) or communication training for clinicians to address vaccine hesitancy,” the authors of the study wrote.

SOURCE:

The study was led by Peter G. Szilagyi, MD, MPH, with the Department of Pediatrics at UCLA Mattel Children’s Hospital, University of California, Los Angeles. It was published online in JAMA Internal Medicine.

LIMITATIONS:

The study was confined to a single health system and did not assess patients’ reasons for not getting vaccinated.

DISCLOSURES:

The study was supported by grants from the National Institutes of Health. Coauthors disclosed financial ties to pharmacy and pharmaceutical companies and the Pediatric Infectious Disease Society.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.

A version of this article appeared on Medscape.com.

Treatment decisions about the care of patients with non–small cell lung cancer (NSCLC) that has metastasized to the brain should always be made by a multidisciplinary team, according to a lung cancer research specialist.

The care of these patients can be quite complex, and the brain is still largely terra incognita, said Lizza Hendriks, MD, PhD, during a case-based session at the European Lung Cancer Congress (ELCC) 2024 in Prague, Czech Republic.

The approach to patients with NSCLC metastatic to the brain and central nervous system was the subject of the session presented by Dr. Hendriks of Maastricht University Medical Center in Maastricht, the Netherlands. During this session, she outlined what is known, what is believed to be true, and what is still unknown about the treatment of patients with NSCLC that has spread to the CNS.

“Immunotherapy has moderate efficacy in the brain, but it can result in long-term disease control,” she said. She added that the best treatment strategy using these agents, whether immunotherapy alone or combined with chemotherapy, is still unknown, even when patients have high levels of programmed death protein 1 (PD-1) in their tumors.

“Also, we don’t know the best sequence of treatments, and we really need more preclinical research regarding the tumor microenvironment in the CNS,” she said.

Next-generation tyrosine kinase inhibitors (TKIs) generally have good intracranial efficacy, except for KRAS G12C inhibitors, which need to be tweaked for better effectiveness in the brain. The optimal sequence for TKIs also still needs to be determined, she continued.
 

Decision Points

Dr. Hendriks summarized decision points for the case of a 60-year-old female patient, a smoker, who in February of 2021 was evaluated for multiple asymptomatic brain metastases. The patient, who had good performance status, had a diagnosis of stage IVB NSCLC of adenocarcinoma histology, with a tumor positive for a KRAS G12C mutation and with 50% of tumor cells expressing PD-1.

The patient was treated with whole-brain radiation therapy and single-agent immunotherapy, and, 8 months later, in October 2021, was diagnosed with extracranial progressive disease and was then started on the KRAS G12c inhibitor sotorasib (Lumakras).

In May 2023 the patient was diagnosed with CNS oligoprogressive disease (that is, isolated progressing lesions) and underwent stereotactic radiotherapy. In June 2023 the patient was found to have progressive disease and was then started on platinum-based chemotherapy, with disease progression again noted in December of that year. The patient was still alive at the time of the presentation.

The first decision point in this case, Dr. Hendriks said, was whether to treat the patient at the time of diagnosis of brain metastases with upfront systemic or local therapy for the metastases.

At the time of extracranial progressive disease, should the treatment be another immumotherapy, chemotherapy, or a targeted agent?

“And the last decision is what should we do [in the event of] CNS oligoprogression?,” she said.
 

First Decision

For cases such as that described by Dr. Hendriks the question is whether upfront local therapy is needed if the patient is initially asymptomatic. Other considerations concerning early local therapy include the risks for late toxicities and whether there is also extracranial disease that needs to be controlled.

If systemic therapy is considered at this point, clinicians need to consider intracranial response rates to specific agents, time to onset of response, risk of pseudoprogression, and the risk of toxicity if radiotherapy is delayed until later in the disease course.

“I think all of these patients with brain metastases really deserve multidisciplinary team decisions in order to maintain or to [move] to new treatments, improve the quality of life, and improve survival,” she said.

In the case described here, the patient had small but numerous metastases that indicated the need for extracranial control, she said.

European Society of Medical Oncology (ESMO) guidelines recommend that asymptomatic patients or those with oligosymptomatic NSCLC brain metastases with an oncogenic driver receive a brain-penetrating TKI. Those with no oncogenic drive but high PD-1 expression should receive upfront immunotherapy alone, while those with PD-1 ligand 1 (PD-L1) expression below 50% receive chemoimmunotherapy.

The joint American Society of Clinical Oncology (ASCO), Society for Neuro-Oncology (SNO), and American Society for Radiation Oncology (ASTRO) guideline for treatment of brain metastases recommends a CNS-penetrating TKI for patients with asymptomatic NSCLC brain metastases bearing EGFR or ALK alterations. If there is no oncogenic driver, the guideline recommends the option of pembrolizumab (Keytruda) with or without chemotherapy.

Both the US and European guidelines recommend initiating local treatment for patients with symptomatic metastases. The level of evidence for these recommendations is low, however.

Clinicians still need better evidence about the potential for upfront immunotherapy for these patients, more information about the NSCLC brain metastases immune environment and tumor microenvironment, data on the best treatment sequence, and new strategies for improving CNS penetration of systemic therapy, Dr. Hendriks said.
 

Second Decision

At the time of CNS progression, the question becomes whether patients would benefit from targeted therapy or chemotherapy.

“We quite often say that chemotherapy doesn’t work in the brain, but that’s not entirely true,” Dr. Hendriks said, noting that, depending on the regimen range, brain response rates range from 23% to as high as 50% in patients with previously untreated asymptomatic brain metastases, although the median survival times are fairly low, on the order of 4 to almost 13 months.

There is also preclinical evidence that chemotherapy uptake is higher for larger brain metastases, compared with normal tissue and cerebrospinal fluid, “so the blood-brain barrier opens if you have the larger brain metastases,” she said.

KRAS-positive NSCLC is associated with a high risk for brain metastases, and these metastases share the same mutation as the primary cancer, suggesting potential efficacy of KRAS G12c inhibitors. There is preclinical evidence that adagrasib (Krazati) has CNS penetration, and there was evidence for intracranial efficacy of the drug in the KRYSTAL-1b trial, Dr. Hendriks noted.

There are fewer data for the other Food and Drug Administration (FDA)–approved inhibitor, sotorasib, but there is evidence to suggest that its brain activity is restricted by ABCB1, a gene encoding for a transporter protein that shuttles substances out of cells.
 

Third Decision

For patients with CNS oligoprogression, the question is whether to adapt systemic therapy or use local therapy.

There is some evidence to support dose escalation for patients with oligoprogression of tumors with EGFR or ALK alterations, but no data to support such a strategy for those with KRAS alterations, she said.

In these situations, data support dose escalation of osimertinib (Tagrisso), especially for patients with leptomeningeal disease, and brigatinib (Alunbrig), but there is very little evidence to support dose escalation for any other drugs that might be tried, she said.

In the question-and-answer part of the session, Antonin Levy, MD, from Gustave Roussy in Villejuif, France, who also presented during the session, asked Dr. Hendriks what she would recommend for a patient with a long-term response to chemoimmunotherapy for whom treatment cessation may be recommended, but who still has oligopersistent brain metastases.

“The difficulty is that with immunotherapy patients can have persistent lesions without any tumor activity, and in the brain I think there is no reliable technique to evaluate this type of thing,” she said.

Dr. Hendriks added that she would continue to follow the patient, but also closely evaluate disease progression by reviewing all scans over the course of therapy to determine whether the tumor is truly stable, follow the patient with brain imaging, and then “don’t do anything.”

Dr. Hendriks disclosed grants/research support and financial relationships with multiple companies. Dr. Levy disclosed research grants from Beigene, AstraZeneca, PharmaMar, and Roche.

Treatment decisions about the care of patients with non–small cell lung cancer (NSCLC) that has metastasized to the brain should always be made by a multidisciplinary team, according to a lung cancer research specialist.

The care of these patients can be quite complex, and the brain is still largely terra incognita, said Lizza Hendriks, MD, PhD, during a case-based session at the European Lung Cancer Congress (ELCC) 2024 in Prague, Czech Republic.

The approach to patients with NSCLC metastatic to the brain and central nervous system was the subject of the session presented by Dr. Hendriks of Maastricht University Medical Center in Maastricht, the Netherlands. During this session, she outlined what is known, what is believed to be true, and what is still unknown about the treatment of patients with NSCLC that has spread to the CNS.

“Immunotherapy has moderate efficacy in the brain, but it can result in long-term disease control,” she said. She added that the best treatment strategy using these agents, whether immunotherapy alone or combined with chemotherapy, is still unknown, even when patients have high levels of programmed death protein 1 (PD-1) in their tumors.

“Also, we don’t know the best sequence of treatments, and we really need more preclinical research regarding the tumor microenvironment in the CNS,” she said.

Next-generation tyrosine kinase inhibitors (TKIs) generally have good intracranial efficacy, except for KRAS G12C inhibitors, which need to be tweaked for better effectiveness in the brain. The optimal sequence for TKIs also still needs to be determined, she continued.
 

Decision Points

Dr. Hendriks summarized decision points for the case of a 60-year-old female patient, a smoker, who in February of 2021 was evaluated for multiple asymptomatic brain metastases. The patient, who had good performance status, had a diagnosis of stage IVB NSCLC of adenocarcinoma histology, with a tumor positive for a KRAS G12C mutation and with 50% of tumor cells expressing PD-1.

The patient was treated with whole-brain radiation therapy and single-agent immunotherapy, and, 8 months later, in October 2021, was diagnosed with extracranial progressive disease and was then started on the KRAS G12c inhibitor sotorasib (Lumakras).

In May 2023 the patient was diagnosed with CNS oligoprogressive disease (that is, isolated progressing lesions) and underwent stereotactic radiotherapy. In June 2023 the patient was found to have progressive disease and was then started on platinum-based chemotherapy, with disease progression again noted in December of that year. The patient was still alive at the time of the presentation.

The first decision point in this case, Dr. Hendriks said, was whether to treat the patient at the time of diagnosis of brain metastases with upfront systemic or local therapy for the metastases.

At the time of extracranial progressive disease, should the treatment be another immumotherapy, chemotherapy, or a targeted agent?

“And the last decision is what should we do [in the event of] CNS oligoprogression?,” she said.
 

First Decision

For cases such as that described by Dr. Hendriks the question is whether upfront local therapy is needed if the patient is initially asymptomatic. Other considerations concerning early local therapy include the risks for late toxicities and whether there is also extracranial disease that needs to be controlled.

If systemic therapy is considered at this point, clinicians need to consider intracranial response rates to specific agents, time to onset of response, risk of pseudoprogression, and the risk of toxicity if radiotherapy is delayed until later in the disease course.

“I think all of these patients with brain metastases really deserve multidisciplinary team decisions in order to maintain or to [move] to new treatments, improve the quality of life, and improve survival,” she said.

In the case described here, the patient had small but numerous metastases that indicated the need for extracranial control, she said.

European Society of Medical Oncology (ESMO) guidelines recommend that asymptomatic patients or those with oligosymptomatic NSCLC brain metastases with an oncogenic driver receive a brain-penetrating TKI. Those with no oncogenic drive but high PD-1 expression should receive upfront immunotherapy alone, while those with PD-1 ligand 1 (PD-L1) expression below 50% receive chemoimmunotherapy.

The joint American Society of Clinical Oncology (ASCO), Society for Neuro-Oncology (SNO), and American Society for Radiation Oncology (ASTRO) guideline for treatment of brain metastases recommends a CNS-penetrating TKI for patients with asymptomatic NSCLC brain metastases bearing EGFR or ALK alterations. If there is no oncogenic driver, the guideline recommends the option of pembrolizumab (Keytruda) with or without chemotherapy.

Both the US and European guidelines recommend initiating local treatment for patients with symptomatic metastases. The level of evidence for these recommendations is low, however.

Clinicians still need better evidence about the potential for upfront immunotherapy for these patients, more information about the NSCLC brain metastases immune environment and tumor microenvironment, data on the best treatment sequence, and new strategies for improving CNS penetration of systemic therapy, Dr. Hendriks said.
 

Second Decision

At the time of CNS progression, the question becomes whether patients would benefit from targeted therapy or chemotherapy.

“We quite often say that chemotherapy doesn’t work in the brain, but that’s not entirely true,” Dr. Hendriks said, noting that, depending on the regimen range, brain response rates range from 23% to as high as 50% in patients with previously untreated asymptomatic brain metastases, although the median survival times are fairly low, on the order of 4 to almost 13 months.

There is also preclinical evidence that chemotherapy uptake is higher for larger brain metastases, compared with normal tissue and cerebrospinal fluid, “so the blood-brain barrier opens if you have the larger brain metastases,” she said.

KRAS-positive NSCLC is associated with a high risk for brain metastases, and these metastases share the same mutation as the primary cancer, suggesting potential efficacy of KRAS G12c inhibitors. There is preclinical evidence that adagrasib (Krazati) has CNS penetration, and there was evidence for intracranial efficacy of the drug in the KRYSTAL-1b trial, Dr. Hendriks noted.

There are fewer data for the other Food and Drug Administration (FDA)–approved inhibitor, sotorasib, but there is evidence to suggest that its brain activity is restricted by ABCB1, a gene encoding for a transporter protein that shuttles substances out of cells.
 

Third Decision

For patients with CNS oligoprogression, the question is whether to adapt systemic therapy or use local therapy.

There is some evidence to support dose escalation for patients with oligoprogression of tumors with EGFR or ALK alterations, but no data to support such a strategy for those with KRAS alterations, she said.

In these situations, data support dose escalation of osimertinib (Tagrisso), especially for patients with leptomeningeal disease, and brigatinib (Alunbrig), but there is very little evidence to support dose escalation for any other drugs that might be tried, she said.

In the question-and-answer part of the session, Antonin Levy, MD, from Gustave Roussy in Villejuif, France, who also presented during the session, asked Dr. Hendriks what she would recommend for a patient with a long-term response to chemoimmunotherapy for whom treatment cessation may be recommended, but who still has oligopersistent brain metastases.

“The difficulty is that with immunotherapy patients can have persistent lesions without any tumor activity, and in the brain I think there is no reliable technique to evaluate this type of thing,” she said.

Dr. Hendriks added that she would continue to follow the patient, but also closely evaluate disease progression by reviewing all scans over the course of therapy to determine whether the tumor is truly stable, follow the patient with brain imaging, and then “don’t do anything.”

Dr. Hendriks disclosed grants/research support and financial relationships with multiple companies. Dr. Levy disclosed research grants from Beigene, AstraZeneca, PharmaMar, and Roche.

Treatment decisions about the care of patients with non–small cell lung cancer (NSCLC) that has metastasized to the brain should always be made by a multidisciplinary team, according to a lung cancer research specialist.

The care of these patients can be quite complex, and the brain is still largely terra incognita, said Lizza Hendriks, MD, PhD, during a case-based session at the European Lung Cancer Congress (ELCC) 2024 in Prague, Czech Republic.

The approach to patients with NSCLC metastatic to the brain and central nervous system was the subject of the session presented by Dr. Hendriks of Maastricht University Medical Center in Maastricht, the Netherlands. During this session, she outlined what is known, what is believed to be true, and what is still unknown about the treatment of patients with NSCLC that has spread to the CNS.

“Immunotherapy has moderate efficacy in the brain, but it can result in long-term disease control,” she said. She added that the best treatment strategy using these agents, whether immunotherapy alone or combined with chemotherapy, is still unknown, even when patients have high levels of programmed death protein 1 (PD-1) in their tumors.

“Also, we don’t know the best sequence of treatments, and we really need more preclinical research regarding the tumor microenvironment in the CNS,” she said.

Next-generation tyrosine kinase inhibitors (TKIs) generally have good intracranial efficacy, except for KRAS G12C inhibitors, which need to be tweaked for better effectiveness in the brain. The optimal sequence for TKIs also still needs to be determined, she continued.
 

Decision Points

Dr. Hendriks summarized decision points for the case of a 60-year-old female patient, a smoker, who in February of 2021 was evaluated for multiple asymptomatic brain metastases. The patient, who had good performance status, had a diagnosis of stage IVB NSCLC of adenocarcinoma histology, with a tumor positive for a KRAS G12C mutation and with 50% of tumor cells expressing PD-1.

The patient was treated with whole-brain radiation therapy and single-agent immunotherapy, and, 8 months later, in October 2021, was diagnosed with extracranial progressive disease and was then started on the KRAS G12c inhibitor sotorasib (Lumakras).

In May 2023 the patient was diagnosed with CNS oligoprogressive disease (that is, isolated progressing lesions) and underwent stereotactic radiotherapy. In June 2023 the patient was found to have progressive disease and was then started on platinum-based chemotherapy, with disease progression again noted in December of that year. The patient was still alive at the time of the presentation.

The first decision point in this case, Dr. Hendriks said, was whether to treat the patient at the time of diagnosis of brain metastases with upfront systemic or local therapy for the metastases.

At the time of extracranial progressive disease, should the treatment be another immumotherapy, chemotherapy, or a targeted agent?

“And the last decision is what should we do [in the event of] CNS oligoprogression?,” she said.
 

First Decision

For cases such as that described by Dr. Hendriks the question is whether upfront local therapy is needed if the patient is initially asymptomatic. Other considerations concerning early local therapy include the risks for late toxicities and whether there is also extracranial disease that needs to be controlled.

If systemic therapy is considered at this point, clinicians need to consider intracranial response rates to specific agents, time to onset of response, risk of pseudoprogression, and the risk of toxicity if radiotherapy is delayed until later in the disease course.

“I think all of these patients with brain metastases really deserve multidisciplinary team decisions in order to maintain or to [move] to new treatments, improve the quality of life, and improve survival,” she said.

In the case described here, the patient had small but numerous metastases that indicated the need for extracranial control, she said.

European Society of Medical Oncology (ESMO) guidelines recommend that asymptomatic patients or those with oligosymptomatic NSCLC brain metastases with an oncogenic driver receive a brain-penetrating TKI. Those with no oncogenic drive but high PD-1 expression should receive upfront immunotherapy alone, while those with PD-1 ligand 1 (PD-L1) expression below 50% receive chemoimmunotherapy.

The joint American Society of Clinical Oncology (ASCO), Society for Neuro-Oncology (SNO), and American Society for Radiation Oncology (ASTRO) guideline for treatment of brain metastases recommends a CNS-penetrating TKI for patients with asymptomatic NSCLC brain metastases bearing EGFR or ALK alterations. If there is no oncogenic driver, the guideline recommends the option of pembrolizumab (Keytruda) with or without chemotherapy.

Both the US and European guidelines recommend initiating local treatment for patients with symptomatic metastases. The level of evidence for these recommendations is low, however.

Clinicians still need better evidence about the potential for upfront immunotherapy for these patients, more information about the NSCLC brain metastases immune environment and tumor microenvironment, data on the best treatment sequence, and new strategies for improving CNS penetration of systemic therapy, Dr. Hendriks said.
 

Second Decision

At the time of CNS progression, the question becomes whether patients would benefit from targeted therapy or chemotherapy.

“We quite often say that chemotherapy doesn’t work in the brain, but that’s not entirely true,” Dr. Hendriks said, noting that, depending on the regimen range, brain response rates range from 23% to as high as 50% in patients with previously untreated asymptomatic brain metastases, although the median survival times are fairly low, on the order of 4 to almost 13 months.

There is also preclinical evidence that chemotherapy uptake is higher for larger brain metastases, compared with normal tissue and cerebrospinal fluid, “so the blood-brain barrier opens if you have the larger brain metastases,” she said.

KRAS-positive NSCLC is associated with a high risk for brain metastases, and these metastases share the same mutation as the primary cancer, suggesting potential efficacy of KRAS G12c inhibitors. There is preclinical evidence that adagrasib (Krazati) has CNS penetration, and there was evidence for intracranial efficacy of the drug in the KRYSTAL-1b trial, Dr. Hendriks noted.

There are fewer data for the other Food and Drug Administration (FDA)–approved inhibitor, sotorasib, but there is evidence to suggest that its brain activity is restricted by ABCB1, a gene encoding for a transporter protein that shuttles substances out of cells.
 

Third Decision

For patients with CNS oligoprogression, the question is whether to adapt systemic therapy or use local therapy.

There is some evidence to support dose escalation for patients with oligoprogression of tumors with EGFR or ALK alterations, but no data to support such a strategy for those with KRAS alterations, she said.

In these situations, data support dose escalation of osimertinib (Tagrisso), especially for patients with leptomeningeal disease, and brigatinib (Alunbrig), but there is very little evidence to support dose escalation for any other drugs that might be tried, she said.

In the question-and-answer part of the session, Antonin Levy, MD, from Gustave Roussy in Villejuif, France, who also presented during the session, asked Dr. Hendriks what she would recommend for a patient with a long-term response to chemoimmunotherapy for whom treatment cessation may be recommended, but who still has oligopersistent brain metastases.

“The difficulty is that with immunotherapy patients can have persistent lesions without any tumor activity, and in the brain I think there is no reliable technique to evaluate this type of thing,” she said.

Dr. Hendriks added that she would continue to follow the patient, but also closely evaluate disease progression by reviewing all scans over the course of therapy to determine whether the tumor is truly stable, follow the patient with brain imaging, and then “don’t do anything.”

Dr. Hendriks disclosed grants/research support and financial relationships with multiple companies. Dr. Levy disclosed research grants from Beigene, AstraZeneca, PharmaMar, and Roche.

Can brown fat tissue be targeted for fat burning? Current findings on this topic were presented at the 67th German Congress of Endocrinology. Some statistics highlighted the need. Approximately 53% of the German population (almost 47% of women and 60% of men) are overweight (including obesity). Obesity is present in 19% of adults. The condition not only results in a shorter life expectancy but also increases the risk for cancer, diabetes, and cardiovascular diseases.

“The current treatment focuses on reducing energy intake, for example, through GLP-1 [glucagon-like peptide 1] agonists, which induce a feeling of satiety and significantly reduce body weight,” explained PD Tim Hollstein, MD, of the Institute of Diabetes and Clinical Metabolic Research at the University Hospital Schleswig-Holstein in Kiel, Germany. But the effect of weight loss injections only lasts for the duration of their application, and they are expensive.

“A potentially more sustainable treatment option would be to increase energy expenditure,” said Dr. Hollstein. He explained the role of brown fat tissue at a press conference for the German Society of Endocrinology (DGE) Congress.

While white fat tissue stores energy and can make up to 50% of a person’s body mass, brown fat tissue (brown adipose tissue [BAT]) burns energy to generate heat. The many mitochondria in brown fat tissue give it its characteristic brown color. “Brown fat tissue is like a heater for our body and kicks in when we are cold,” said Dr. Hollstein.

Brown fat tissue is primarily found in babies who cannot generate heat through muscle shivering. It has only been known for about 15 years that adults also possess brown fat. PET scans have shown that women generally have a higher amount of BAT and a higher energy intake capacity. The chance of discovering brown fat tissue was lower in older patients (P < .001), at higher outside temperatures (P = .02), in older patients with higher body mass index (P = .007), and if the patients were taking beta-blockers (P < .001).

Two Metabolic Types

An average person has about 100-300 g of brown fat tissue, mainly around the neck and collarbone and along the spine. Interestingly, just 50 g of active BAT can burn up to 300 kcal/d. “That’s roughly equivalent to a chocolate brownie,” said Dr. Hollstein. Lean individuals have more active BAT than overweight people, suggesting that BAT plays a role in our body weight.

In addition to its “heating function,” BAT also produces hormones, so-called “batokines,” which influence metabolism and organs such as the heart and liver. An example of a batokine is the hormone fibroblast growth factor 21, which promotes fat burning in the liver and can protect against fatty liver.

Recent studies have shown that BAT is activated not only by cold but also by food intake. BAT thus contributes to so-called “diet-induced thermogenesis,” which is the energy the body needs for digestion. Some people have a higher digestive energy than others, despite having the same food intake. They burn excess calories and can thus protect themselves from being overweight.

“There are people who have a more wasteful metabolism and people who have a more economical metabolic type, meaning they have less brown fat,” explained Dr. Hollstein. Interestingly, BAT also seems to induce a feeling of satiety in the brain, which could be significant for regulating food intake.
 

Activating Brown Fat

According to Dr. Hollstein, batokines probably have diverse effects and influence not only satiety and inflammatory processes but also cardiovascular diseases, diabetes, and fatty liver. It is important to research what distinguishes patients who have a lot of brown fat tissue from those who have little.

BAT can be trained and increased through regular cold exposure, which subsequently melts body fat. In a Japanese study, acute cold exposure (19 °C) for 2 hours increased energy consumption. Cold-induced increases in energy consumption correlated strongly with BAT activity, regardless of age and fat-free mass. Daily 2-hour cold exposure at 17 °C for 6 weeks led to a parallel increase in BAT activity.

“You can train brown fat tissue through cold exposure, which also leads to improvements in metabolism and a slight loss of fat mass, but the effect is very small,” explained Dr. Hollstein. The changes in metabolism are significant. Blood lipid levels improve, insulin sensitivity increases, and inflammation values decrease, according to Dr. Hollstein.

Evidence also indicates that capsaicin contained in chili peppers can activate brown fat tissue. However, the effects are small, and so far, there is no evidence that consumption can help with weight loss.
 

Medications Activate Brown Fat

Because permanent cold and daily consumption of chili peppers are not a real option, especially because the effects on BAT are rather small, research is being conducted to find drugs that activate brown fat tissue.

Preliminary results come from the United States. Mirabegron, originally developed for an overactive bladder, can selectively activate BAT and boost metabolism. A single injection of mirabegron activated BAT and increased energy consumption in the short term. Plasma levels of high-density lipoproteins cholesterol and apolipoprotein A1 increased, as did the total amount of bile acids.

The hormone adiponectin, which has antidiabetic and anti-inflammatory properties, also increased and was 35% higher after the study’s completion. An intravenous glucose tolerance test showed higher insulin sensitivity, glucose efficiency, and insulin secretion.

After 4 weeks of therapy in healthy women, brown fat tissue increased, but the participants did not lose weight or body fat.

New studies have also identified the widely used drug salbutamol as a BAT activator. However, the problem with both drugs is that they have side effects such as a faster heartbeat and increased blood pressure.

As Dr. Hollstein reported, attempts have also been made to transplant brown fat tissue into overweight mice. However, in most cases, the brown fat tissue was converted into white fat.

In Dr. Hollstein’s estimation, BAT offers enormous potential in the treatment of obesity and related metabolic diseases, and its activation could make a significant contribution to combating the obesity epidemic. “I believe that brown fat tissue will occupy us even more in the future. In combination with weight loss injections, increased energy consumption through brown fat tissue could have synergistic effects,” he concluded.

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Can brown fat tissue be targeted for fat burning? Current findings on this topic were presented at the 67th German Congress of Endocrinology. Some statistics highlighted the need. Approximately 53% of the German population (almost 47% of women and 60% of men) are overweight (including obesity). Obesity is present in 19% of adults. The condition not only results in a shorter life expectancy but also increases the risk for cancer, diabetes, and cardiovascular diseases.

“The current treatment focuses on reducing energy intake, for example, through GLP-1 [glucagon-like peptide 1] agonists, which induce a feeling of satiety and significantly reduce body weight,” explained PD Tim Hollstein, MD, of the Institute of Diabetes and Clinical Metabolic Research at the University Hospital Schleswig-Holstein in Kiel, Germany. But the effect of weight loss injections only lasts for the duration of their application, and they are expensive.

“A potentially more sustainable treatment option would be to increase energy expenditure,” said Dr. Hollstein. He explained the role of brown fat tissue at a press conference for the German Society of Endocrinology (DGE) Congress.

While white fat tissue stores energy and can make up to 50% of a person’s body mass, brown fat tissue (brown adipose tissue [BAT]) burns energy to generate heat. The many mitochondria in brown fat tissue give it its characteristic brown color. “Brown fat tissue is like a heater for our body and kicks in when we are cold,” said Dr. Hollstein.

Brown fat tissue is primarily found in babies who cannot generate heat through muscle shivering. It has only been known for about 15 years that adults also possess brown fat. PET scans have shown that women generally have a higher amount of BAT and a higher energy intake capacity. The chance of discovering brown fat tissue was lower in older patients (P < .001), at higher outside temperatures (P = .02), in older patients with higher body mass index (P = .007), and if the patients were taking beta-blockers (P < .001).

Two Metabolic Types

An average person has about 100-300 g of brown fat tissue, mainly around the neck and collarbone and along the spine. Interestingly, just 50 g of active BAT can burn up to 300 kcal/d. “That’s roughly equivalent to a chocolate brownie,” said Dr. Hollstein. Lean individuals have more active BAT than overweight people, suggesting that BAT plays a role in our body weight.

In addition to its “heating function,” BAT also produces hormones, so-called “batokines,” which influence metabolism and organs such as the heart and liver. An example of a batokine is the hormone fibroblast growth factor 21, which promotes fat burning in the liver and can protect against fatty liver.

Recent studies have shown that BAT is activated not only by cold but also by food intake. BAT thus contributes to so-called “diet-induced thermogenesis,” which is the energy the body needs for digestion. Some people have a higher digestive energy than others, despite having the same food intake. They burn excess calories and can thus protect themselves from being overweight.

“There are people who have a more wasteful metabolism and people who have a more economical metabolic type, meaning they have less brown fat,” explained Dr. Hollstein. Interestingly, BAT also seems to induce a feeling of satiety in the brain, which could be significant for regulating food intake.
 

Activating Brown Fat

According to Dr. Hollstein, batokines probably have diverse effects and influence not only satiety and inflammatory processes but also cardiovascular diseases, diabetes, and fatty liver. It is important to research what distinguishes patients who have a lot of brown fat tissue from those who have little.

BAT can be trained and increased through regular cold exposure, which subsequently melts body fat. In a Japanese study, acute cold exposure (19 °C) for 2 hours increased energy consumption. Cold-induced increases in energy consumption correlated strongly with BAT activity, regardless of age and fat-free mass. Daily 2-hour cold exposure at 17 °C for 6 weeks led to a parallel increase in BAT activity.

“You can train brown fat tissue through cold exposure, which also leads to improvements in metabolism and a slight loss of fat mass, but the effect is very small,” explained Dr. Hollstein. The changes in metabolism are significant. Blood lipid levels improve, insulin sensitivity increases, and inflammation values decrease, according to Dr. Hollstein.

Evidence also indicates that capsaicin contained in chili peppers can activate brown fat tissue. However, the effects are small, and so far, there is no evidence that consumption can help with weight loss.
 

Medications Activate Brown Fat

Because permanent cold and daily consumption of chili peppers are not a real option, especially because the effects on BAT are rather small, research is being conducted to find drugs that activate brown fat tissue.

Preliminary results come from the United States. Mirabegron, originally developed for an overactive bladder, can selectively activate BAT and boost metabolism. A single injection of mirabegron activated BAT and increased energy consumption in the short term. Plasma levels of high-density lipoproteins cholesterol and apolipoprotein A1 increased, as did the total amount of bile acids.

The hormone adiponectin, which has antidiabetic and anti-inflammatory properties, also increased and was 35% higher after the study’s completion. An intravenous glucose tolerance test showed higher insulin sensitivity, glucose efficiency, and insulin secretion.

After 4 weeks of therapy in healthy women, brown fat tissue increased, but the participants did not lose weight or body fat.

New studies have also identified the widely used drug salbutamol as a BAT activator. However, the problem with both drugs is that they have side effects such as a faster heartbeat and increased blood pressure.

As Dr. Hollstein reported, attempts have also been made to transplant brown fat tissue into overweight mice. However, in most cases, the brown fat tissue was converted into white fat.

In Dr. Hollstein’s estimation, BAT offers enormous potential in the treatment of obesity and related metabolic diseases, and its activation could make a significant contribution to combating the obesity epidemic. “I believe that brown fat tissue will occupy us even more in the future. In combination with weight loss injections, increased energy consumption through brown fat tissue could have synergistic effects,” he concluded.

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.

Can brown fat tissue be targeted for fat burning? Current findings on this topic were presented at the 67th German Congress of Endocrinology. Some statistics highlighted the need. Approximately 53% of the German population (almost 47% of women and 60% of men) are overweight (including obesity). Obesity is present in 19% of adults. The condition not only results in a shorter life expectancy but also increases the risk for cancer, diabetes, and cardiovascular diseases.

“The current treatment focuses on reducing energy intake, for example, through GLP-1 [glucagon-like peptide 1] agonists, which induce a feeling of satiety and significantly reduce body weight,” explained PD Tim Hollstein, MD, of the Institute of Diabetes and Clinical Metabolic Research at the University Hospital Schleswig-Holstein in Kiel, Germany. But the effect of weight loss injections only lasts for the duration of their application, and they are expensive.

“A potentially more sustainable treatment option would be to increase energy expenditure,” said Dr. Hollstein. He explained the role of brown fat tissue at a press conference for the German Society of Endocrinology (DGE) Congress.

While white fat tissue stores energy and can make up to 50% of a person’s body mass, brown fat tissue (brown adipose tissue [BAT]) burns energy to generate heat. The many mitochondria in brown fat tissue give it its characteristic brown color. “Brown fat tissue is like a heater for our body and kicks in when we are cold,” said Dr. Hollstein.

Brown fat tissue is primarily found in babies who cannot generate heat through muscle shivering. It has only been known for about 15 years that adults also possess brown fat. PET scans have shown that women generally have a higher amount of BAT and a higher energy intake capacity. The chance of discovering brown fat tissue was lower in older patients (P < .001), at higher outside temperatures (P = .02), in older patients with higher body mass index (P = .007), and if the patients were taking beta-blockers (P < .001).

Two Metabolic Types

An average person has about 100-300 g of brown fat tissue, mainly around the neck and collarbone and along the spine. Interestingly, just 50 g of active BAT can burn up to 300 kcal/d. “That’s roughly equivalent to a chocolate brownie,” said Dr. Hollstein. Lean individuals have more active BAT than overweight people, suggesting that BAT plays a role in our body weight.

In addition to its “heating function,” BAT also produces hormones, so-called “batokines,” which influence metabolism and organs such as the heart and liver. An example of a batokine is the hormone fibroblast growth factor 21, which promotes fat burning in the liver and can protect against fatty liver.

Recent studies have shown that BAT is activated not only by cold but also by food intake. BAT thus contributes to so-called “diet-induced thermogenesis,” which is the energy the body needs for digestion. Some people have a higher digestive energy than others, despite having the same food intake. They burn excess calories and can thus protect themselves from being overweight.

“There are people who have a more wasteful metabolism and people who have a more economical metabolic type, meaning they have less brown fat,” explained Dr. Hollstein. Interestingly, BAT also seems to induce a feeling of satiety in the brain, which could be significant for regulating food intake.
 

Activating Brown Fat

According to Dr. Hollstein, batokines probably have diverse effects and influence not only satiety and inflammatory processes but also cardiovascular diseases, diabetes, and fatty liver. It is important to research what distinguishes patients who have a lot of brown fat tissue from those who have little.

BAT can be trained and increased through regular cold exposure, which subsequently melts body fat. In a Japanese study, acute cold exposure (19 °C) for 2 hours increased energy consumption. Cold-induced increases in energy consumption correlated strongly with BAT activity, regardless of age and fat-free mass. Daily 2-hour cold exposure at 17 °C for 6 weeks led to a parallel increase in BAT activity.

“You can train brown fat tissue through cold exposure, which also leads to improvements in metabolism and a slight loss of fat mass, but the effect is very small,” explained Dr. Hollstein. The changes in metabolism are significant. Blood lipid levels improve, insulin sensitivity increases, and inflammation values decrease, according to Dr. Hollstein.

Evidence also indicates that capsaicin contained in chili peppers can activate brown fat tissue. However, the effects are small, and so far, there is no evidence that consumption can help with weight loss.
 

Medications Activate Brown Fat

Because permanent cold and daily consumption of chili peppers are not a real option, especially because the effects on BAT are rather small, research is being conducted to find drugs that activate brown fat tissue.

Preliminary results come from the United States. Mirabegron, originally developed for an overactive bladder, can selectively activate BAT and boost metabolism. A single injection of mirabegron activated BAT and increased energy consumption in the short term. Plasma levels of high-density lipoproteins cholesterol and apolipoprotein A1 increased, as did the total amount of bile acids.

The hormone adiponectin, which has antidiabetic and anti-inflammatory properties, also increased and was 35% higher after the study’s completion. An intravenous glucose tolerance test showed higher insulin sensitivity, glucose efficiency, and insulin secretion.

After 4 weeks of therapy in healthy women, brown fat tissue increased, but the participants did not lose weight or body fat.

New studies have also identified the widely used drug salbutamol as a BAT activator. However, the problem with both drugs is that they have side effects such as a faster heartbeat and increased blood pressure.

As Dr. Hollstein reported, attempts have also been made to transplant brown fat tissue into overweight mice. However, in most cases, the brown fat tissue was converted into white fat.

In Dr. Hollstein’s estimation, BAT offers enormous potential in the treatment of obesity and related metabolic diseases, and its activation could make a significant contribution to combating the obesity epidemic. “I believe that brown fat tissue will occupy us even more in the future. In combination with weight loss injections, increased energy consumption through brown fat tissue could have synergistic effects,” he concluded.

This story was translated from the Medscape German edition using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication. A version of this article appeared on Medscape.com.