TTHealthWatch is a weekly podcast from Texas Tech. In it, Elizabeth Tracey, director of electronic media for Johns Hopkins Medicine in Baltimore, and Rick Lange, MD, president of the Texas Tech University Health Sciences Center in El Paso, look at the top medical stories of the week.
This week’s topics include long COVID, mix-and-match COVID vaccines, the WHO living guideline on outpatient treatment for COVID, and aspirin for primary prevention of heart disease.
0:50 Clinical characteristics of long COVID
1:55 28% on mechanical ventilation
2:55 Minority fully recovered
3:59 Mix-and-match COVID vaccines
4:58 4 million completed
5:56 Many don’t have a choice
6:30 WHO living guideline on COVID drugs
7:30 Use in patients at highest risk for hospitalization
8:30 Paxlovid trade name
9:22 Update from USPSTF on aspirin
10:22 Evolving story
11:20 Increased risk for mortality
Elizabeth Tracey: What does it look like following people who have had COVID 1 year later?
Rick Lange, MD: Should we be mixing or matching COVID booster shots?
Elizabeth: What’s the current state of using medications to treat COVID?
Rick: Who should be receiving aspirin to prevent cardiovascular disease?
Elizabeth: That’s what we’re talking about this week on TTHealthWatch, your weekly look at the medical headlines from Texas Tech University Health Sciences Center in El Paso. I’m Elizabeth Tracey, a Baltimore-based medical journalist.
Rick: I’m Rick Lange, president of Texas Tech University Health Sciences Center in El Paso, where I’m also dean of the Paul L. Foster School of Medicine.
Elizabeth: Chagrined to note, of course, that we are returning to largely COVID material this week. Why don’t we start? Part of the reason that we’re doing that is because the European Infectious Disease Society meeting is going on right now. There is just an enormous amount of information that’s coming out of that particular meeting, largely published in the Lancet Respiratory Medicine.
Why don’t we first look at what are the clinical characteristics with inflammation profiling of long COVID and its association with 1-year recovery following hospitalization in the U.K.? In this case, they were looking at post-hospitalization COVID-19 people, looking at their recovery 1 year later.
It was assessed using patient-reported outcome measures, physical performance, organ function at 5 months and 1 year after hospital discharge. They also did inflammatory protein profiling at the 5-month visit.
They started out with 2,300+ participants and they ended up assessing at 5 months after discharge and at this 12-month visit, 807. Of that number, 279 were women. Their mean age was just shy of 59 years; 28% of those had been on invasive mechanical ventilation during their hospitalization.
The proportion, unfortunately, of patients, who reported a full recovery was unchanged between 5 months and 1 year. Factors that were associated with being more likely to have so-called long COVID were female sex, obesity, and having received invasive mechanical ventilation. They also noted that there were increased inflammatory mediators of tissue damage and repair in both the very severe and the moderate folks. It’s sort of unsurprising in some ways, and I’m not sure exactly what the action points are here.
Rick: Well, Elizabeth, the thing that was most surprising to me is that the number of people that reported a full recovery 5 months and 1 year after hospitalization for COVID was 30% or less. The most common symptoms were fatigue, muscle pain, people physically slowing down, poor sleep, and breathlessness. I have to admit the thing that was most striking to me was the fact that it was the minority of individuals that fully recovered and if there wasn’t recovery at 5 months, very few of those recovered even at 1 year.
Elizabeth: One of the things that I have queried about this, as this pandemic has gone on, is how does this compare to post-ICU syndromes that we see in lots of other people who are also critically ill? Because we know that that sequelae syndrome is really common.
Rick: It’s hard to know and that’s because what they noted was that the recovery was tied to the severity of symptoms, but more importantly to a number of different inflammatory markers. I’m not sure that the post-ICU syndrome has been. If we address this inflammation, can we alleviate some of the long COVID symptoms? I think that’s where we’re headed.
Elizabeth: Right, and they note that this upregulation of IL-6 suggests that these anti-IL-6 biologics that were successful when patients were admitted to the hospital might also be used in the treatment of long COVID.
Rick: And it’s a great hypothesis. Will that relieve the long COVID symptoms? I think that’s what future studies will address.
Elizabeth: Let’s turn, since we are in the Lancet, to yours. This is looking at should we mix and match vaccines for best efficacy.
Rick: This has really been a topic that I continue to address. “Okay. I need to get a COVID booster. Should I get the same booster as the original vaccine or should I get something different?”
This was a really well done study that involved over 11 million individuals that had been vaccinated in Chile. Most of them had received as their initial vaccine the Sinovac Biotech called CoronaVac. It’s an inactivated virus vaccine. Then as their booster, they either got another dose of the Sinovac or they received the AstraZeneca/Oxford vaccine, or they received the Pfizer vaccine.
They compared the outcomes. Did they prevent either symptomatic COVID cases or the COVID-19 outcomes — such as hospitalization, or admission to the ICU, or death — both for just the vaccines versus unvaccinated and then for the mixed versus those that matched.
What they found is that of the 11 million individuals who were eligible for this study, over 4 million had completed their primary immunization and they received their booster during that study period. About 45% of them had received the AstraZeneca, about 50% received the Pfizer, and about 5% had received the CoronaVac.
If you received the same booster as you did originally, it’s about 80% effective. But if you received a different one, it was closer to about 95% effective. By the way, the numbers are very similar looking at COVID-related hospitalization, ICU admission, or death, in that getting vaccines and booster was clearly much more effective than not getting anything. But if you received a different vaccine, it was even better.
Elizabeth: It makes a lot of sense to me because they all vary slightly and so producing this greater breadth of antibodies just seems like an effective thing to do. I would just note that I did that.
Rick: Many of us have, Elizabeth. This was before the data became available. Unfortunately, many people don’t have the option to have a choice. They have to receive what’s available. What I would say to our listeners, especially those around the globe, is that the most important thing is to get your primary vaccine and a booster. If you have the opportunity to choose what that booster is, I would mix it rather than match it. But the most important thing is to make sure that people are primarily immunized and boosted.
Elizabeth: More to come on that, no doubt. As we have noted, lots and lots of different kinds of vaccines that are on the threshold right now. I’m sure we are going to be hearing a good deal more about it.
Turning to The BMJ, what we’re looking at is not a study, which is unusual for us, but we’re looking at the WHO’s living guideline on drugs for COVID-19. I applaud this attempt by the WHO to try to go ahead and take the data from randomized clinical trials as soon as it becomes available and employ it in this living document, this continuous update that they are attempting to do, and get it put out there.
This is merely their latest attempt at this, and I am definitely going to refer everyone to it because I found by far the most useful part of this to be the schematic. They are looking at two particular drugs really largely, one that’s called nirmatrelvir-ritonavir, which we are familiar with ritonavir already; that’s an HIV med. They have two randomized clinical trials, 3,100 participants, they are basing their recommendations on. Then remdesivir, five randomized clinical trials and 2,700+ participants.
Basically for the first one, the combination, they issue a strong recommendation for its use in patients who are at highest risk of hospitalization. Remdesivir, a conditional recommendation for its use in patients at highest risk of hospitalization. The first combination drugs, the nirmatrelvir-ritonavir, is good because it’s oral. The remdesivir, of course, they were looking at the IV preparation for this, and you and I have discussed before that they do have an oral formulation of it that is on board that may render it a little bit more useful.
They continue also in this recommendation to look at steroids and other things. They recommend against convalescent plasma for virtually everybody.
Rick: This particular update is targeting outpatient treatment to help get them out of the hospital, to decrease their time on the ventilator. Currently, especially with the variants that we have seen in high-risk people, it’s keeping them out of the hospital and that’s really what you’d prefer.
What this update tells us is this oral medication called Paxlovid — that’s the trade name for it — it received FDA approval [Editor’s note: Paxlovid is authorized, not approved, by the FDA] for children over the age of 12, at least 88 lb, and it’s used for high-risk individuals, people over the age of 65, people that have diabetes, obesity, or cancer, and it’s 90% effective in keeping them out of the hospital. It’s a five-day regimen. You take the medication twice a day. Now, the remdesivir does require IV therapy over 3 days and it’s probably only about 30% effective.
Elizabeth: Let’s just note that Paxlovid is also not easy to get in this country, with many people saying, “Oops, I tested positive. I went out and looked for Paxlovid, and I couldn’t find it.”
Rick: They’re ramping it up. I just heard a report this morning where they have substantially increased the production. But you’re right, there’s limited availability right now.
Elizabeth: Let’s turn to our one thing that’s non-COVID this week.
Rick: It’s an update from the USPSTF about which patients should take aspirin for primary cardiovascular prevention. These are individuals that don’t have known cardiovascular disease, but they may be at risk for it. They may have high blood pressure or diabetes, or other conditions, or just because of their age.
The recommendations now are very different than when they were first established years ago in 1989. The newest recommendations changed in three ways. They are saying individuals over the age of 60 don’t need to be started on aspirin in general. Those between the ages of 40 and 60 should be considered if they are at high risk, if there is a 10-year risk of having a heart attack, or a stroke that approaches 20%, and the individuals over the age of 75 should probably stop their aspirin because of the risk of gastrointestinal bleeding.
Elizabeth: Let’s note that these are in JAMA. We have talked about aspirin, I believe, more than any other drug that we have talked about. Would you say that’s true?
Rick: I think that’s true. It’s an evolving story. You say, “Well, what’s the harm in taking aspirin?” Well, there is an increased risk of gastrointestinal bleeding, fatal bleeding, and intracranial hemorrhage.
The other thing that we have done a very good job at is we have reduced the cardiovascular risk by introducing statins for primary prevention. We have lowered that risk. If someone takes an aspirin for primary prevention and they are not in that high-risk group that I mentioned, there is a benefit, but it’s really small.
Elizabeth: I would also note that we have talked before about aspirin in the cancer prevention realm. My suspicion is that we are not done with this.
Rick: No. In fact, they said, “Well, gosh, maybe we should recommend it,” not because of cardiovascular but for cancer prevention, colorectal cancer prevention specifically. Although that looks like it may be the case in observational studies, when they looked at these individuals — and again, there is only about a 5-year follow up — they really didn’t see a benefit. In fact, there was an increased risk in mortality for those that had colorectal cancer and those who were taking aspirin. They say, “Gosh, no benefit for cardiovascular disease compared to the risk and no benefit regarding colorectal cancer as far as we can tell.”
Elizabeth: Again, let me ask you to recall that big study that was done in Australia that looked at the role of aspirin in skin cancer prevention. I don’t know if the jury is in on that one.
Rick: I suspect we’ll be reporting this for years to come. I know that many of my patients are listeners, and I’m going to be getting some phone calls and some emails saying, “Oh, gosh. I’m over the age of 75,” or “I’m 60 and really should I be taking aspirin?” Based upon these recommendations, I’m probably going to recommend to them some different strategies than we have previously employed.
Elizabeth: Okay. The ongoing story. That’s a look at this week’s medical headlines from Texas Tech. I’m Elizabeth Tracey.
Rick: I’m Rick Lange. Y’all listen up and make healthy choices.
Source : MedPageToday