GLP-1’S, LOW T, GOUT, AFIB, ROSACEA, CARPAL TUNNEL

MEDICAL NEWS BRIEFS #27

GLP-1 receptor agonists also impact FERTILITY: My goodness! What else can we expect to learn about the effects of GLP-1 drugs? Now, after regular reports of “unplanned pregnancies.…among patients using GLP-1’s,” it appears weight loss improves fertility in the subset of women who have polycystic ovary syndrome (PCOS).” Obesity is associated with irregular menstrual periods. Infertility is a consequence of menstrual irregularity. Using GLP-1’s to lose weight improves the success rate of in vitro fertilization (IVF) which is not recommended if the BMI is above 40. So the weight loss caused by injections of GLP-1 RA’s improves the fertility of certain women. GLP-1’s should be stopped at least 2 months before conception is attempted, and they can cause miscarriage, gestational diabetes, preeclampsia, and a high rate of C-section deliveries. Infant birth defects are a concern, too. Pregnancies while on GLP-1’s do occur. Contraception is recommended while on GLP-1’s, but patients with known infertility are hesitant to use contraceptives. 

Reference: O’Mary L. Are GLP-1’s the Newest Fertility Treatment? Medscape Medical News 2024 November 8. 

LOW-T: How does testosterone replacement help men with low levels? For men with hypogonadism, taking replacement testosterone causes “modest improvements in sexual function and depressive symptoms.” It does not appear to increase risk of heart attack, stroke, or cardiovascular death. It follows naturally that improving one’s sex life will help reduce depressed mood and feelings. 

Reference: AFP Clinical Answers What are the main benefits of testosterone replacement therapy for male hypogonadism? Am Fam Phys 2024 October;110(4):345.

GOUT: High baseline uric acid level is risk factor for subsequent gout flare-ups: Excess serum uric acid is related to acute attacks of gouty arthritis. A higher uric acid level during the first attack is a reliable predictor of subsequent attacks. Gout flare-ups are reported as a number per 1000 person-years. A normal uric acid is 2.5 to 6.8 mg/dl. If baseline level is 6.0, a later attack is 10.6 times more likely to occur. Levels 6.0-6.9, 40.1 times more likely, 7.0-7.9, 82 times, 8.0-8.9,101.3 times, 9.0-9.9,125.3 times, and above 10 mg/dl,132.8 times. It follows naturally that the more uric acid one has in his blood stream, the greater the chance of acute and recurrent gout attacks. 

Reference: AFP Clinical Answers. Is baseline serum urate level in adults with a history of gout accurate for predicting the risk of subsequent gout flare-ups? Am Fam Phys 2024 October;110(4):345.

A FIB: What type of blood thinner is best in patients with atrial fibrillation? Risk of stroke is greatly increased in patients with atrial fibrillation (AF). Thus, they are prescribed blood thinners to prevent such events. Experts now recommend “Direct Oral Anticoagulants” for prophylaxis. There are five such drugs on the market currently. They are Pradaxa (dabigatran), Eliquis (apixaban), Xarelto (rivaroxaban), Savaysa (edoxaban), Bevyxxa (betrixaban). These drugs no not require blood test monitoring. Warfarin/coumadin is recommended for patients with mitral valve disease or a mechanical heart valve. 

Reference: AFP Clinical Answers “What type of anticoagulation is recommended to treat atrial fibrillation?” Am Fam Phys 2024 November;110(5):463. 

ROSACEA: What is the recommended treatment for moderate to severe rosacea? A course of low dose doxycycline 40mg daily is the first choice for moderate to severe rosacea with papules and pustules (pimples). 

Reference: AFP Clinical Answers “What is the recommended systemic treatment for moderate to severe rosacea” Am Fam Phys 2024 November;110(5):463.b

Carpal Tunnel Syndrome: What drug and non-drug therapies help most? Drug Therapies—local injections of corticosteroids work up to 6 months and decrease the need for surgery. Oral prednisone (cortisone) provides short-term relief of symptoms but is less effective than cortisone injections. NSAID’s are of no help.

I would always try one or both of these methods before surgery. 

Non-drug treatments—neutral splints at night alone are as effective as splints worn all the time. 

References: AFP Clinical Answers 1. “What pharmacotherapies are recommended for carpal tunnel syndrome?” 2. “What are the recommended nonpharmacologic treatments for mild to moderate carpal tunnel syndrome?” Am Fam Phys 2024 November;110(5):463.

Bariatric Surgery Demand Declines in the Era of GLP-1 RA’s: As I’ve reported numerous times recently, glucagon-like peptide-1 receptor agonists (GLP-1 RA’s), particularly semaglutide and tirzepatide (Wegovy, Rybelsus, Ozempic and Mounjaro, Zepbound, respectively), are the drugs of the 21st century. They have been touted for controlling blood sugar in diabetics, but more so for weight loss in obese persons. Their efficacy for weight loss has brought about a complete re-structuring of the bariatric metabolic milieu. A recent report from Medscape Medical News states that GLP-1’s have caused a 25% reduction in the performance of weight-loss surgical procedures in an 18-month period from mid-2022 through 2023. During that time period, “81,092 patients were prescribed GLP-1’s and 5173 patients underwent bariatric surgery. 1,547,174 patients had neither.” The rate of use of GLP-1’s increased by 132.6% while the rate of bariatric surgery decreased by 25.6%. This is looked upon favorably since bariatric surgery is invasive and potentially problematic, while GLP-1’s are not.

Reference: Bhattacharya S. Bariatric Surgery Demand Declines in the Era of GLP-1 RA’s. Medscape Medical News 2024 December 5.