Rapid malaria tests associated with lower mortality in children in sub-Saharan Africa. Plus, GLP-1 diaries...
That and other stories in "Five on Friday" for September 20, 2024...
Item 1: Rapid malaria tests associated with lower mortality in children.
Rapid diagnostic tests that give results within minutes without having to be sent off to a laboratory have long been under-utilized tools. There are many reasons for this, ranging from concerns over quality, to cost, to medical paternalism. The Covid-19 pandemic, however, mainstreamed the concept and there is renewed interest in their utility, both in and outside of healthcare settings.
A new study in JAMA looked at rapid diagnostic tests for malaria detection in healthcare settings in children under age 5 in sub-Saharan African countries, where around 20% of all pediatric deaths are due to malaria. Mass distribution of rapid malaria tests was associated with small but statistically significant decrease in child mortality, indicating that the rapid tests led to life-saving treatment sooner. The effect size was such that for every rapid test distributed, mortality went down by around 1 out of every 3,000 children per year in the study. That’s either a small change or a massive one, depending on your perspective.
The findings, however, hinged on malaria prevalence. Nations with higher malaria prevalence (like Nigeria, Uganda and Zambia) benefited more than those with lower malaria prevalence (like Chad, Ethiopia, and Madagascar). Notably, in lower prevalence areas, rapid tests were more often negative—which makes sense. In the face of a child with a fever and a negative malaria test at the point of care (i.e., in the clinic), providers often chalked the illness up to something else, like a bacterial infection. That led to higher antibiotic use, and often inappropriate prescriptions. The trouble is that these prescriptions didn’t help the children and contributed to antibiotic resistance, a major problem. Researchers are not sure what to do here because some of these kids needed antibiotics, while most did not. It sounds like a problem that could be addressed by…another kind of rapid test.
Item 2: GLP-1 diaries. Cost effectiveness, pills, pediatric use, and liver disease
Glucagon-like receptor-1 agonists (GLP-1s) power drugs like Ozempic, Wegovy, and Mounjaro. (There are so many stories and studies about these important drugs, that one could devote an entire newsletter to them. Instead, I’ll use this space to keep tabs.)
This week, four stories about GLP-1s caught my eye.
Pills. Wouldn’t it be nice if people who needed GLP-1s could take a pill, instead of an injection? While there are oral formulations, they are less-well studied. We don’t know whether they have the same amazing disease-decreasing, life-saving abilities as the injectable formulations. A story on CNN provided some interesting context. First, the pills have to be taken daily, rather than a weekly injection. Second, because of how the drugs are metabolized, higher doses are needed in the oral formulations, leading to higher rates of side effects. That said, if some patients do well with them, it might be a nice alternative in the long run for people who do not wish to do weekly injections. If and when pills can replace injections, the costs will also come down.
Speaking of costs, a new analysis in the Annals of Internal Medicine estimates that the fiscal implications of Medicare’s 2024 decision to cover semaglutide (Ozempic and Wegovy) for patients meeting the criteria of the blockbuster SELECT trial—the one we’ve discussed that showed a mortality benefit for patients with serious cardiovascular disease and a body mass index above 27. The researchers calculate that this could cost Medicare between $34-$145 billion per year. Of course, that is at current prices, prices which are bound to come down. In addition, we keep learning about more ways in which these drugs help patients, including in ways that could save money down the road. Leading us to….
GLP-1 use was associated with a decrease in new diagnoses of cirrhosis of the liver in patients at high risk of developing that condition, according to a new observational study in JAMA Internal Medicine. If this holds, it could mean a reduction in patients with liver failure, saving the needs to organ transplantation, and saving lives. Our understanding of the effects that GLP-1s have in this area are still early, but it could also save money, as the management of liver disease can be very costly.
Kids and GLP-1s. What if adults were healthier to begin with? One way to achieve that is to raise kids with fewer risks. A double-blinded placebo-control randomized trial enrolled children under age 12 (average age 10) to receive either liraglutide (a somewhat older GLP-1 than the compound powering Ozempic and Wegovy) or placebo for just over a year of treatment and followed them for another 26 weeks. (Both groups also received lifestyle modification interventions based on a “healthy diet and regular physical activity.”) At the end of the study, the liraglutde recipients had a 5.8% decrease in the body mass index (BMI), while the placebo recipients gained around 1.6% in their BMI. Notably, the children who received liraglutide initially lost weight. But at around 16 weeks into treatment, their weights began increasing again—but not their BMIs. In other words, the kids lost weight, but then resumed what appears to be normal healthy growth. (Remember, if a healthy kid isn’t slowly gaining weight as they grow, something is wrong!) The difference amounted to a couple of BMI points (~29 down from 31). This is a big difference in a small period of time. What we don’t know is what this portends for their future. Will the liraglutide recipients go on to be healthier adults who do not need GLP-1s? Time will tell. But if we can create a healthier young adult population, the longer-term implications are obvious.
Item 3: FDA green lights over-the-counter hearing aids software.
The US FDA approved the first over-the-counter hearing aids software last week. This is actually a big deal. Around 30 million US adults have some degree of hearing loss, and hearing aids can slow the pace of cognitive decline and depression. Of note, what the FDA approved here was software that turns Apple AirPods (headphones) into hearing aids.
Since 2022, the FDA has permitted OTC hearing aids devices (i.e., specific hardware). So what does this new policy really add? Possibly a lot. Maybe it will lower the bar to “try” the technology for people who are resistant to the notion of needing some help with hearing. I know a fair number of highly functional older people who are tech savvy enough to have Apple AirPods and also self-conscious enough to never want to try a hearing aid, due to stigma. Hopefully, easier access to this new technology will nudge people to try an OTC hearing aid at all, which may in turn lead to them seeking out better, smaller, and less visible ones.
Item 4: Instagram unveils new teen-focused tools to improve online safety…and real-life sleep.
In response to growing concerns from Congress and the US Surgeon General, Instagram unveiled a substantial new set of policies designed to protect teens. The changes affect privacy settings (making accounts of user under age 18 private by default) and allow parents to monitor the identity of incoming messages. Another interesting intervention is that notifications will be silenced from 10pm to 7am, in an effort to help teen sleep better.
Earlier this summer, I spoke with US Surgeon General Dr. Vivek Murthy about this very issue, as Dr. Murthy had identified social media use as a powerful influence on youth mental health. While I agree, top of mind for me was how safety tools on social media would actually work in practice. While it’s difficult to know how effective these new tools will be, an expert in a New York Times story about the changes called the moves “significant.” So, Instagram’s effort here seems like a step in the right direction.
Item 5: Poll of the Week.
Here are the results from the last poll. Thanks for your votes! The correct answer is that the active ingredient in Adderall was originally developed as a weight loss drug.
Item 5a: Poll of the Week for this week!
Medical trivia time. No Google or other resources allowed (other than any hints you may have noticed from reading today’s Five on Friday)…
Malaria killed over 608,000 people in 2022. Most of this calamity occurred in Africa.
That’s it. Your “Friday Five!” Questions? Comments? Please chime in!
Feedback! Have any ideas for next week’s Poll of the Week? Any great articles you have read elsewhere that you want to share with the Inside Medicine community?
1) possibly rhetorical, a pos. rapid-test for malaria would be f/u with blood screening? This being said (asked) antimalarial Rx should be initiated upon a pos result.
2) item 4...statistics being my challenge (admitted coincidentally on a seperate Substack post today) how many children were enrolled?
3) Android phone & not tech savvy yet I have a new Motorola phone (kids at work LOL)... yesterday had the ear-molds switched out on my new hearing aids...yep vanity