Monday, 4 February 2019

What’s new with the flu shot?

The American College of Cardiology and the American Heart Association certainly grabbed the attention of us busy primary care physicians with the recent release of their updated blood pressure guidelines. These organizations had piqued interest by declaring the release date and labeling it as “highly anticipated.” I pooh-poohed all that drama, but upon reading through the 114-page executive summary PDF with 21 authors and almost a thousand references, I have to say, I am duly impressed.

The definition of the diagnosis of high blood pressure and the decision-making process surrounding treatment have traditionally been quite individualized (read: all over the place). Personally, I invite these stricter measures, because they are accompanied by solid research, logistical guidance, and useful management strategies.

However, a whole heck of a lot of people just got pulled into a significant medical diagnosis.

Let’s review what’s new.
A new definition of high blood pressure (hypertension)

(Please note that all numbers refer to mm Hg, or, millimeters of mercury.) The guidelines, in a nutshell, state that normal blood pressure is under 120/80, whereas up until Monday, normal was under 140/90.

Now, elevated blood pressure (without a diagnosis of hypertension) is systolic blood pressure (the top number) between 120 and 129. That used to be a vague category called “prehypertension.”

Stage 1 high blood pressure (a diagnosis of hypertension) is now between 130 and 139 systolic or between 80 and 89 diastolic (the bottom number).

Stage 2 high blood pressure is now over 140 systolic or 90 diastolic.

The measurements must have been obtained from at least two careful readings on at least two different occasions. What does careful mean? The guidelines provide a six-step tutorial on how, exactly, to correctly measure a blood pressure, which, admittedly, is sorely needed. My patients often have their first blood pressure taken immediately after they have rushed in through downtown traffic, as they’re sipping a large caffeinated beverage. While we always knew this could result in a falsely elevated measurement, it is now officially poor clinical technique resulting in an invalid reading.
New recommendations on monitoring blood pressure

The new guidelines also encourage additional monitoring, using a wearable digital monitor that continually takes blood pressure readings as you go about your life, or checked with your own cuff at home. This additional monitoring can help to tease out masked hypertension (when the blood pressure is normal in our office, but high the rest of the time) or white coat hypertension (when the blood pressure is high in our office, but normal the rest of the time). There are clear, helpful directions for setting patients up with a home blood pressure monitor, including a recommendation to give people specific instructions on when not to check blood pressure (within 30 minutes of smoking, drinking coffee, or exercising) and how to take a measurement correctly (seated comfortably, using the correct size cuff). The home blood pressure cuff should first be validated (checked in the office, for accuracy).
If you now have high blood pressure, you may not need meds… yet

The guidelines also outline very clearly when a diet-and-lifestyle approach is the recommended, first-line treatment, and when medications are simply just what you have to do. Thankfully, the decision is largely based on facts and statistics. For the elevated blood pressure category, medications are actually not recommended; rather, a long list of evidence-based, non-drug interventions are. What are these interventions? Things that really work: a diet high in fruits and vegetables (such as the DASH diet, which is naturally high in potassium); decreased salt and bad fats; more activity; weight loss if one is overweight or obese; and no more than two alcoholic drinks per day for men, and one for women. Simply changing what you eat can bring down systolic blood pressure by as much as 11 points, and each additional healthy habit you adopt can bring it down another four to five points.

For people with stage 1 hypertension who don’t have cardiovascular disease and are at low risk for developing it (less than 10% risk of an event within 10 years), lifestyle changes are still the way to go. (Risk is determined using a well-researched, widely used formula available here.)

However, if a patient has any kind of cardiovascular disease and stage 1 hypertension (a blood pressure over 130 systolic or 80 diastolic), or no existing cardiovascular disease but a significant risk of developing it (over 10% risk within the next 10 years), then lifestyle changes plus medications are recommended. And, even if someone has less than a 10% risk, if their blood pressure is over 140 systolic or 90 diastolic, which is now stage 2 high blood pressure, they ought to be treated with medication as well.
Optimizing treatment of high blood pressure

The authors bring several evidence-based yet progressive concepts into the guidelines, the first of which is that high blood pressure should be treated using a team approach. This makes sense, as science supports more and better patient education around self-monitoring, nutrition, and lifestyle changes, as well as stress management. Telehealth is emphasized as a cost-effective method of ongoing monitoring that is more convenient for patients than frequent office visits.
And why should this all matter to you?

Mountains of research over time have shown a very clear link between high blood pressure and cardiovascular disease. A 20-point higher systolic blood pressure or a 10-point higher diastolic blood pressure is associated with double your risk of death from a heart attack, stroke, or other cardiovascular complication (like abdominal aortic aneurysm or heart failure). What many people don’t realize is that those who survive these events find their lives permanently altered by disability and medical complications.

Much is being made of the fact that the new definitions of high blood pressure will mean roughly half of all US citizens will be considered to have high blood pressure, but when you really look at the numbers, as cardiologists already have, not that many more people will actually be advised to take medications. Although the public has good reason to be suspicious of “big pharma,” that’s not what this is about.

Diet and lifestyle changes are powerful medicine. Even if your blood pressure is normal now, you can help to prevent it from becoming elevated starting today. Eat more fruits, veggies, and whole grains, and limit foods high in sodium and unhealthy fats. Be as physically active as possible.
Be physically active. Exercise busts stress, boosts the mood, and elevates our energy level, not to mention the heart health benefits. Believe it or not, you can exercise just about anywhere, anytime. It doesn’t have to be at the gym. It doesn’t have to be a scheduled class. And it doesn’t have to be more than a few minutes a day. All activity counts. I encourage patients to think of an activity that they enjoy. Anything. Think about how that enjoyable activity can fit into your life: maybe you can ride your bike to work, or take your kids on an easy hike, or get the whole family to rake leaves with you. Let’s brainstorm about activities that will fit into your life: Maybe make your next meeting a walking one, or take a brisk walk at lunchtime. Try a few minutes on the exercise bike in the kitchen, or dancing around your living room in your socks. On my very busy days, I make sure I take the stairs whenever I have the option. I park farther away than I need to and walk a little more. If I’m going to the grocery store and I only need a few things, I use a hand basket instead of a cart. It. All. Counts. And the more, the better.

Eat well. That means eat healthy. The mountain of studies supporting a whole-foods, plant-based diet for our health is almost as large as the exercise one. Stay away from inflammatory, sugar-spiking, insulin-releasing foods like processed carbohydrates (think all added sugars and anything made with flour). Aim for things that grew on plants or trees. The more colorful the fruits or vegetables, the more vitamins, minerals, and antioxidants they have and the healthier they are. Vitamin pills and other supplements just don’t work as well. Not going vegetarian to save your life? Got it. Just get colorful fruits and veggies into your diet wherever you can. We don’t have to be perfect, but the more plant-based our diets are, the better.

Calm your mind. We all have stressors in our lives. What varies is how much we let the stressors stress us. What can we do? Yes, meditation works. The relaxation response works. Yoga works. But for those patients who stare at me blankly when I mention these, I talk about other calming activities. This can mean knitting, baking, walking, swimming. Anything quiet and peaceful, when one can take deep breaths and be calmly, enjoyably focused. Me? I try to do a few favorite yoga stretches at the end of the day, right before bed. This is usually after the kids fall asleep, and I can’t even be bothered to find my yoga mat. I just get right to it on the carpet in my daughter’s room: downward dog, plank, cobra, and then some of my own moves, to stretch out my back.

Sleep well. Aim for a refreshing amount of sleep. While this will differ for everyone, generally it’s about eight hours. It’s tempting to stay up late to cram in those last household chores or answer email, but really, the world won’t end if the laundry is dirty for another day, or the dishes are piled up in the sink. Sleep deprivation causes irritability, poor cognition, impaired reflexes and response time (think: car accidents!), and chronic sleep deprivation can contribute to depression and anxiety. Create a short, easy bedtime routine. Stretching or yoga, prayer, or reading a book can be relaxing. But stay away from your smartphone, tablet, or laptop, as the light interferes and interrupts the natural sleep onset. Alcohol near bedtime also interferes with sleep, and is a common cause of nighttime or early-morning awakening. As a neuroscientist I have been trained to think in a certain way, almost like a car mechanic, who “looks under the hood” at the brains of laboratory rats exposed to drugs. If we can figure out exactly which genes, proteins, brain regions, and neural connections go awry in substance use disorders (SUDs), we can fix those “broken” parts in the brain and design better long-term approaches to addiction treatment. While there is great promise in this approach, it’s not so easy to get under the hood of people who desperately need help with a SUD. It’s very different from working with lab rats. And it can take a long time — often decades — between discovering a way to redirect the addicted brain and an approved treatment.
Neuroscientists and practicing clinicians need to be partners in advancing treatment for SUDs

Obviously medical and mental health clinicians treat SUDs from the perspective of patient care. They are presented with real people who have very real, very immediate needs. These individuals have often lost their families, their jobs, and their basic health. Their lives may be in jeopardy because of the risk of overdose. The goal is to first detoxify the patients, then work with them, through initial recovery from the crisis and beyond, to prevent relapse. This is critically important work, but so is searching for potentially permanent solutions to SUDs. And the place to start is the brain.

Over the past 30-plus years, basic laboratory and translational research has expanded our understanding of the brain’s reward circuitry — specifically how dopamine, a neurotransmitter that is important in both our ability to feel pleasure and our brain’s ability to learn strong associations between cues in our daily lives that predict pleasure, operates. We now understand that the brain’s reward circuitry regulates both the “feel good” effects of a drug as well as the extreme physical and emotional discomfort experienced during withdrawal. The emotional signs of withdrawal can flare up for months or even years after attempts to quit, and these factors play into drug taking, craving, and relapse.
Neuroscience has already contributed to SUD treatment

Here are two examples of SUD treatments that regulate, directly or indirectly, dopamine’s role in the brain reward pathway.

Buprenorphine (Subutex): Like methadone, buprenorphine is considered an opioid replacement therapy because it activates the same parts of the brain that opioids like heroin and oxycodone do. The difference is that it activates at a much lower level and doesn’t jolt the brain’s reward pathway, causing a surge of dopamine release like heroin or oxycodone would. It can help ease withdrawal symptoms and can be used for both initial recovery periods and maintenance of abstinence.

Bupropion (Wellbutrin, Zyban): It has several pharmacological actions in the brain, all of which combine to make bupropion an effective treatment for nicotine addiction (e.g., smoking or chewing tobacco). Its main action is to increase levels of available dopamine in the brain. Since a drop in dopamine is partly responsible for symptoms of nicotine withdrawal, bupropion can prevent this drop, and thus mitigate the strong cravings people experience when they try to quit smoking.
And neuroscience holds promise for better and safer treatments

Here are examples of newer approaches:

Transcranial magnetic stimulation (TMS): TMS uses magnetic fields to strategically stimulate parts of the brain. The FDA approved TMS for some neurological conditions in 2009. Since then the number of conditions for which TMS has shown positive effects has skyrocketed. For people with SUDs, the prefrontal cortex, the part of the brain that helps us not act on every impulse, is often sluggish. Scientists have shown that an underactive prefrontal cortex can set the stage for impulsive and compulsive behavior observed in SUDs. Recently, it was shown that using TMS to stimulate the prefrontal cortex of the human brain might help quell those insatiable urges to take a drug.

Kappa opioid receptor antagonists: These compounds, which block the actions of the naturally occurring neuropeptide dynorphin, can help prevent drug withdrawal from causing low dopamine levels. Here’s how: many drugs that can lead to substance use disorders, if taken long enough, increase dynorphin in the dopamine reward system, which inhibits dopamine release in the brain’s reward circuitry — and the person doesn’t feel good. However, blocking dynorphin receptors with synthetically designed compounds prevents this effect. Currently there are several ongoing clinical trials testing kappa receptor antagonists in SUDs.
Where do we go from here?

The good news is that carefully collected and analyzed laboratory data from preclinical studies have led to numerous treatment options for people with SUDs. But in real life, it’s never as simple as in the laboratory. Each person struggling with a substance use disorder has his or her unique constellation of social, genetic, and psychological factors that make some treatments more or less effective than others. But the better we understand the brain science of addiction, the more likely we will come up with an array of treatments that can help a broader range of those with SUDs.

To me, this means my brain-mechanic work looking under the hood of the brains of rats exposed to drugs is essential to the ultimate process of helping people suffering from SUDs, but only if I take the time to look up and discuss my findings with clinical colleagues. Likewise, the clinicians’ overwhelming job of helping people with immediate, life-threatening needs is essential, but only if they pause periodically to listen to our new brain discoveries that might revolutionize SUD treatments. Should you get the influenza (flu) vaccine this year? The short, quick answer (barring any medical reasons you shouldn’t, such as severe allergies), is yes! But recent research raises another important question: When should you get the shot?
Why a flu shot every year in the first place?

Getting infected with the flu can be dangerous — we’ve seen patients in the ICU who were previously healthy but had a horrible response to a strain of the virus and became very sick.

Every year the Centers for Disease Control and Prevention (CDC) and other agencies release flu vaccination guidelines in late summer to early fall. The flu vaccines are usually available by the end of the summer season. Figuring out exactly which strains of flu viruses the vaccine should protect against is often complicated. Basically, experts look at the influenza virus strains that were making trouble in previous years, and attempt to predict which strains are likely to cause the flu in the upcoming season.

The inactivated flu vaccine is the form of flu vaccine that is most commonly injected and contains parts of the virus but no live virus. Therefore, you should not be infected with the flu from the vaccine itself. Some people may feel “sick” after the vaccine with symptoms such as mild fever, pain in the injection site, fatigue — all of which may just be your body mounting an expected immune response against the foreign virus particles. For the 2017-18 season, the CDC and Advisory Committee on Immunization Practices (ACIP) have recommended against the alternative intranasal live attenuated vaccine, due to concerns about its ineffectiveness during the previous seasons.
Get your flu shot as soon as possible? Maybe not…

Recent studies have suggested that the flu vaccines may not be as effective when given too early. The US Influenza Vaccine Effectiveness Network compiled data on patients seeking care at outpatient clinics during the four previous flu seasons from 2011-12 to 2014-15. Although the data varied for different influenza strains, it did show that the vaccine was most effective at approximately two weeks after it was given. Protection against the flu then decreases every month. There could be many explanations for this: people may lose immunity during the season; different patient populations receive vaccines at different times; the virus may mutate during the course of the flu season, etc. This decrease in protection over time may even account for why some people who did get a flu shot go on to get the flu later on in the season (February or March). However, more research needs to be conducted to evaluate this further.
It gets even trickier

The problem is that we cannot predict exactly when the flu season will begin each year. In clinics and in the emergency department, we often see the flu season starting around December and lasting until the spring. And the flu shot is not 100% effective. Over the past few seasons, studies have shown that the vaccine reduced the risk of flu infection by 40% to 60%. For patients who are immunocompromised or have chronic medical conditions, it may still make sense to receive the vaccine earlier so that your body is protected against the virus whenever the season comes. But if you’re generally healthy, it may make sense to get the vaccine a little later in the fall.

But, as physicians, we really aren’t sure yet.
So, what should you do?

We need more research to determine the optimal timing of influenza immunization. Until we have more information, I still recommend getting the flu vaccine each year before the flu season starts, especially if you have other health problems, have a weakened immune system, or if your child is young enough to require two doses. Even if you are exposed to the flu virus later in the season and your immunity is not as strong against it, your body may still be able to fight off the virus quicker and more effectively than if you did not receive the vaccine at all. For those who are healthier and have access to primary care physicians, you could consider holding off until later in the fall; however, you may risk getting the flu if the season comes early.

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