Health Newsfeed – Johns Hopkins Medicine Podcasts

Medicare developed a program to rein in the costs of cancer treatment, but the results were disappointing, a new study reveals, with this comprehensive approach reducing costs by about 1%. William Nelson, director of the Kimmel Cancer Center at Johns Hopkins, says newer therapies may eventually result in lower costs for cancer care.

Nelson: Thirty percent of the costs of this were for the drugs themselves. I wonder whether the progress towards drugs that are less toxic, hair doesn’t fall out, white blood cell counts don’t drop. Many of them are taken orally, so the expense of delivery is not going to be as great. If we get more people treated earlier in the course of the disease with less toxic therapies, that the other main driver of cost, which is the need for people to show up in emergency rooms, be hospitalized for treatment complications, won’t slowly but surely be less and less. :31

As cancer cases rise worldwide, developing approaches to contain costs is critical. At Johns Hopkins, I’m Elizabeth Tracey.

The Covid-19 spike protein allows it to attach to cells and infect them, and it’s been a primary target for vaccines and antibodies. Now a new monoclonal antibody directed against a region of this protein that really doesn’t change very much has been developed, and Brian Garibaldi, a critical care medicine expert at Johns Hopkins, says that’s great, but there are still barriers to treatment.

Garibaldi: While its easier to administer something subq or intramuscular, you still have to watch people for potential infusion or injection site reactions and the biggest challenge right now is space and staff.  We’ve seen critical shortages at all levels of healthcare. Remember these are all for the most part patients who are going to have Covid. So you have to have a designated space in an already busy healthcare environment to administer that drug. I think that’s led to a lot of health systems not being able to keep up with the demand.  :28

Garibaldi says this antibody should be useful against more variants of Covid-19. At Johns Hopkins, I’m Elizabeth Tracey.

Another monoclonal antibody against Covid-19 has been developed and appears to work in reducing severe disease and hospitalization. This one is unique, however, according to Brian Garibaldi, a critical care medicine expert at Johns Hopkins.

Garibaldi: The interesting thing about the new monoclonal antibody, sotrovimab, this monoclonal antibody was developed using antibodies from individuals who were infected with Sars-CoV1. It targets a more conserved region of the spike protein and the hope would be that this type of monoclonal antibody would be less likely to come across viruses that are resistant to its action. So far we have not seen delta being resistant to the other currently available monoclonals but you can imagine that we might encounter a variant down the road that might be.  :29

Garibaldi says monoclonal antibodies are still limited to those who come forward for treatment within a few days of infection, and must be administered in settings that allow for observation as well as protection of others from Covid-19. At Johns Hopkins, I’m Elizabeth Tracey.

Monoclonal antibodies remain a treatment option for those in early stages of Covid infection, even in the face of new oral medications that likely will be available soon. Brian Garibaldi, a critical care medicine expert at Johns Hopkins, says the data are persuasive.

Garibaldi: High risk individuals who are household contacts of people who have documented Covid, they got randomized to getting subcutaneous administration of monoclonals versus placebo. At a month it was about 80% effective in symptomatic infection. Eight months after that initial prophylactic infusion protection still holds to about 80%. So it’s likely that people who get monoclonal antibodies these antibodies are going to circulate at pretty high concentrations for months. We currently recommend that you don’t get vaccinated until 90 days past your initial monoclonal antibody infusion.  :31

Garibaldi notes that monoclonals are not a substitute for vaccination, however, so when you are eligible to receive the vaccine you should do so. And monoclonals require supervised administration and observation afterward. At Johns Hopkins, I’m Elizabeth Tracey.

Both Pfizer and Merck have recently revealed promising data on oral medicines for early Covid-19 infection, with both companies on the threshold of widespread use of the drugs. Brian Garibaldi, a critical care medicine expert at Johns Hopkins, says he hopes people don’t see these new medicines as a reason to forgo vaccination.

Garibaldi: I have lost the ability to predict how people are going to respond to different therapies, and the reason I say this is that there are many people who were not willing to get vaccinated but have no problem taking a monoclonal antibody. If you’re going to follow the science, millions and millions of people have gotten the different mRNA vaccines, and the Johnson and Johnson vaccine. It doesn’t make sense to choose to forgo a vaccine, take the risk of getting ill and if you get ill I’m going to take this other therapy that’s also brand new for Covid that’s been tested on less people.  :27

Garibaldi says these new oral medicines have even less of a record, so vaccination is still the best strategy to protect yourself and others. At Johns Hopkins, I’m Elizabeth Tracey.

Pfizer has asked the FDA to approve its new oral medication for Covid-19, called Paxlovid, for people in the early stages of infection. Brian Garibaldi, a critical care medicine expert at Johns Hopkins, reviews the data.

Garibaldi: From symptom onset to receipt of drug within about three days they had about 750 or so patients enrolled. This drug reduced hospitalization by almost 90%, three people who got the drug got hospitalized compared to 27 who got placebo. There were seven deaths in the placebo group and no deaths in the group that got the Pfizer drug. And then when they extended that population to look at people who got it within five days of symptoms they had similar benefits. If this pans out, having an oral treatment that can reduce hospitalizations and death would be an unbelievable addition to what we currently do for Covid outpatients.  :34

Such a medication would be a boon for low and middle income countries, where vaccines have been difficult or impossible to obtain. At Johns Hopkins, I’m Elizabeth Tracey.

More expensive analog insulins are used by the majority of people with diabetes who use insulin, a study by Rita Kalyani, a diabetes expert at Johns Hopkins, and colleagues has shown. Is this practice based in any professional society recommendations? Kalyani comments.

Kalyani: None of them preferentially recommend use of the newer analog insulins over the human insulins. So the question is why are they being prescribed so often? Some of them act much faster at mealtimes, some are much longer acting, so you have less hypoglycemia during the day and less injections during the day. So we see that the newer insulins allow greater flexibility to match the daily patterns of people with diabetes, whether its their meals or their activity, with less hypoglycemia.   :32

Kalyani notes that these conveniences do come at a price, but less hypoglycemia or low blood sugar may also avoid hospitalizations. At Johns Hopkins, I’m Elizabeth Tracey.

When someone is taking insulin for diabetes, it’s important to monitor and manage its use, but during the pandemic, that didn’t happen. That’s according to research by Rita Kalyani, a diabetes expert at Johns Hopkins, and colleagues.

Kalyani: We saw that between 2019 and 2020, when the pandemic hit, that there was an 18% decrease in visits for insulin, and as we talk about access to care during the pandemic this suggests that perhaps people using insulin weren’t coming to see their provider as often as before though they could have still been taking it at home but perhaps not having as aggressive titration or changes to their insulin regimen as they should have been.    :28

Kalyani urges anyone who postponed visits to the clinician managing their diabetes during the pandemic to try to be seen, even if it’s a telemedicine visit. People with diabetes are at higher risk for severe Covid-19 disease that may be impacted by very good blood sugar control. At Johns Hopkins, I’m Elizabeth Tracey.

Insulin costs have been cited as a case in point for out of control pharmaceutical prices. Now a study by Rita Kalyani, a diabetes expert at Johns Hopkins, and colleagues, shows that in fact, a survey of insulin use over the last five years reveals that the most expensive formulations are being used most often.

Kalyani: What we found during this five year period was that more than 80% were for analog insulin use, over the past five years. We know that analog insulins are also associated with higher costs, they are the insulins that have been found to be main drivers of price increases for insulin over the past few years. We found that insulin glargine represented the majority throughout this time period as well. And that biosimilar insulins, which have been introduced over the past two to three years have been slowly gaining in the number of insulin users.  :33

Kalyani says there are compelling reasons to use the newer insulins for many, but that cost must be weighed. At Johns Hopkins, I’m Elizabeth Tracey.

What is the data to show that electronic cigarettes help people to stop smoking combustible cigarettes? Michael Blaha, a cardiologist at Johns Hopkins and antismoking activist, explains.

Blaha: The randomized control trial data shows moderate evidence that e-cigarettes can help with smoking cessation. However they also show people who start e-cigarettes to quit smoking but fail to quit, tend to become long term users of both products. Also the people who quit smoking using e-cigarettes tend to become long term users of e-cigarettes. In other words they don’t get rid of their nicotine addiction, they just have shifted their nicotine addiction to a product that may be less toxic.    :26

Blaha says the data that convinced the FDA to allow one brand of electronic cigarette to market itself as helpful in smoking cessation hasn’t been revealed but that a wealth of other studies are in the public venue. He notes that the data also show that quit attempts are much more successful when a constellation of methods are employed. At Johns Hopkins, I’m Elizabeth Tracey.