Glucagon-Like Peptide-1 Receptor Agonists and Risk for Gastroesophageal Reflux Disease in Patients With Type 2 Diabetes: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 178, No 9

Background: Glucagon-like peptide-1 receptor agonists (GLP-1 RAs), medications used to treat type 2 diabetes and obesity, are associated with delayed gastric emptying, which is a risk factor for gastroesophageal reflux disease (GERD). However, evidence linking these drugs to GERD is limited. Objective: To estimate the effect of GLP-1 RAs compared with sodium–glucose cotransporter-2 (SGLT-2) inhibitors on the risk for GERD and its complications among patients with type 2 diabetes. Design: Active-comparator new-user cohort study emulating a target trial. Setting: U.K. Clinical Practice Research Datalink. Participants: Adults aged 18 years or older with type 2 diabetes initiating GLP-1 RAs or SGLT-2 inhibitors between 1 January 2013 and 31 December 2021, with follow-up until 31 March 2022. Measurements: The primary outcome was incident GERD, and the secondary outcome was its complications. Three-year risk differences (RDs) and risk ratios (RRs) were estimated and weighted using propensity score fine stratification. Results: The study included 24 708 new users of GLP-1 RAs and 89 096 new users of SGLT-2 inhibitors. Over a median follow-up of 3.0 years, the RRs were 1.27 (95% CI, 1.14 to 1.42) for GERD, with an RD of 0.7 per 100 patients, and 1.55 (95% CI, 1.12 to 2.29) for its complications, with an RD of 0.8 per 1000 patients, among GLP-1 RA users compared with SGLT-2 inhibitor users. Limitation: Residual confounding due to lack of information on dietary or lifestyle factors. Conclusion: The estimated effect of GLP-1 RAs compared with SGLT-2 inhibitors suggested a higher risk for GERD and its complications in patients with type 2 diabetes. Clinicians should be aware of this potential adverse effect to provide timely prevention and treatment strategies. Primary Funding Source: Canadian Institutes of Health Research.

Diet and Risk for Incident Diverticulitis in Women: A Prospective Cohort Study: Annals of Internal Medicine: Vol 178, No 6

Background: Patients with diverticulitis often attempt to control their diet with a particular focus on avoiding nuts and seeds. However, whether dietary patterns or dietary intake of nuts and seeds are associated with diverticulitis risk is poorly studied, particularly in women. Objective: To determine whether select diets affect incident diverticulitis risk in women. Design: Prospective cohort study. Setting: Cohort study in the United States and Puerto Rico. Participants: Women aged 35 to 74 years at enrollment who responded to food frequency and diverticulitis questionnaires and had no history of inflammatory bowel disease, cancer, or diverticulitis (n = 29 916). Intervention: Food frequency questionnaires were used to calculate dietary index scores and to assess intake of nuts, seeds, and corn. Measurements: Cox proportional hazards regression was used to estimate adjusted hazard ratios (aHRs) and 95% CIs for the associations between each dietary component or dietary index and diverticulitis risk. Results: 1531 cases of incident diverticulitis for 415 103 person-years of follow-up were identified. Intake of peanuts, nuts, and seeds (aHR,1.07 [95% CI, 0.91 to 1.25]) and fresh fruits with edible seeds (aHR,1.06 [CI, 0.90 to 1.24]) was not associated with incident diverticulitis. There was a reduced risk for incident diverticulitis in women in the highest quartile of healthy diets compared with the lowest quartile: the Dietary Approaches to Stop Hypertension diet (aHR, 0.77 [CI, 0.65 to 0.90]), the Healthy Eating Index (aHR, 0.78 [CI, 0.66 to 0.91]), the Alternative Healthy Eating Index (aHR, 0.81 [CI, 0.69 to 0.95]), and the Alternative Mediterranean diet (aHR, 0.91 [CI, 0.78 to 1.06]). Limitation: Confounding, selection bias, and measurement bias are possible. Conclusion: Healthy diets were associated with a reduced risk for incident diverticulitis in women. Consumption of nuts and seeds was not associated with diverticulitis risk. Primary Funding Source: National Institutes of Health.

Fecal Microbiota Transplantation Versus Vancomycin for Primary Clostridioides difficile Infection: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 7

Background: Fecal microbiota transplantation (FMT) is recommended for recurrent Clostridioides difficile infection (CDI), but its role in primary CDI is unclear. Objective: To investigate the efficacy and safety of FMT in primary CDI. Design: Randomized, open-label, noninferiority, multicenter trial. (ClinicalTrials.gov: NCT03796650) Setting: Hospitals and primary care facilities in Norway. Patients: Adults with CDI (C difficile toxin in stool and ≥3 loose stools daily) and no previous CDI within 365 days before enrollment. Intervention: FMT without antibiotic pretreatment versus oral vancomycin, 125 mg 4 times daily for 10 days. Measurements: The primary end point was clinical cure (firm stools or <3 bowel movements daily) at day 14 and no disease recurrence within 60 days with the assigned treatment alone. Results: Of 104 randomly assigned patients, 100 received FMT or the first dose of vancomycin and were eligible for analysis. Clinical cure and no disease recurrence within 60 days without additional treatment was observed in 34 of 51 patients (66.7%) with FMT versus 30 of 49 (61.2%) with vancomycin (difference, 5.4 percentage points [95.2% CI, −13.5 to 24.4 percentage points]; P for noninferiority < 0.001, rejecting the hypothesis that response to FMT is 25 percentage points lower than response to vancomycin). Eleven patients in the FMT group and 4 in the vancomycin group had additional C difficile treatment. Clinical cure at day 14 and no recurrence with or without additional treatment was observed in 40 of 51 patients (78.4%) with FMT and 30 of 49 (61.2%) with vancomycin (difference, 17.2 percentage points [95.2% CI, −0.7 to 35.1 percentage points]). No significant differences in adverse events were observed between groups. Limitations: Open-label design and reliance on clinical end points. Conclusion: FMT may be considered as first-line therapy in primary CDI. Primary Funding Source: South-East Norway Health Trust.

Diagnostic performance of 5 FITs varied for detection of advanced colorectal neoplasia

Source Citation Levy BT, Xu Y, Daly JM, et al. Comparative performance of common fecal immunochemical tests: a cross-sectional study. Ann Intern Med. 2024;177:1350-1360. 39222513

Trends in Mortality From Chronic Liver Disease Before, During, and After the COVID-19 Pandemic, 2015 to 2023

Effect of Personalized Risk Messages on Uptake of Colorectal Cancer Screening: A Randomized Controlled Trial: Annals of Internal Medicine: Vol 178, No 10

Background: Providing personalized risk information to patients and their providers could improve colorectal cancer (CRC) screening. Objective: To determine whether providing information on patient risk for advanced colorectal neoplasia (ACN; which includes CRC and advanced precancerous lesions) to patients and providers affects screening uptake, and to identify effect moderators. Design: Randomized controlled trial (2 × 2 factorial design). (ClinicalTrials.gov: NCT04683731) Setting: Primary care clinics in 2 health care systems. Participants: 214 providers and 1084 average-risk patients due for screening. Intervention: Participants were randomly assigned to view a CRC screening decision aid with or without a personalized message about ACN risk. Providers were randomly assigned to receive notifications that the patient was due for screening, with or without a personalized message about the patient’s ACN risk. Measurements: Screening test completion by 6 months. Logistic regression was used to estimate intervention effects. Results: Overall, there were no differences in screening uptake or test completion for the provider notification (predicted probabilities, 41.5% vs. 36.4% for personalized vs. generic; difference, 5.1 [95% CI, −1.6 to 11.8] percentage points) or decision aid (predicted probabilities, 36.8% vs. 41.0% for personalized vs. generic; difference, −4.1 [CI, −10.2 to 1.9] percentage points) interventions. Health system was an effect moderator for stool testing. For one health system, the stool testing rate was higher for personalized versus generic provider notification (predicted probabilities, 21.1% vs. 7.9%; difference, 13.2 [CI, 1.6 to 24.8] percentage points) when the decision aid was generic. The stool testing rate was higher for the personalized versus the generic decision aid (predicted probabilities, 21.4% vs. 7.9%; difference, 13.5 [CI, 2.4 to 24.5] percentage points) when the provider notification was generic. Limitations: Few participants had high-average ACN risk. Non–English-speaking patients were excluded. Conclusion: Although including personalized risk for ACN in a decision aid or provider notification had no overall effect, it increased uptake of stool testing in one health system. Primary Funding Source: Patient-Centered Outcomes Research Institute (PCORI).

Metabolic Dysfunction–Associated Steatotic Liver Disease

Metabolic dysfunction–associated steatotic liver disease (MASLD) is the most common chronic liver disease in the United States. It is characterized by steatosis in the liver and is potentially reversible. Risk factors include obesity, type 2 mellitus, and other metabolic disorders. Metabolic dysfunction–associated steatohepatitis (MASH), a more severe form of MASLD, puts patients at risk for cirrhosis, liver decompensation, and liver cancer. Diet, exercise, and weight loss are the cornerstones of management. Although only 1 medication has been approved for treatment of MASH, other pharmacotherapies and surgeries that aid weight loss and optimize metabolic risk factors can be used. Early diagnosis and intervention are important to prevent progression to cirrhosis and its complications, including cancer.

How Would You Manage This Patient With Gastroesophageal Reflux Symptoms? Grand Rounds Discussion From Beth Israel Deaconess Medical Center

Gastroesophageal reflux disease (GERD) is a common medical condition presenting with heartburn, regurgitation, cough, hoarseness, and/or wheezing. Patients with classic GERD symptoms often do not require diagnostic studies before empirical treatment is initiated. However, if atypical features are present, including alarm symptoms for malignancy, or if symptoms do not respond to conventional treatment, upper endoscopy may be necessary. The optimal management of GERD, which is the subject of debate, depends on the frequency and severity of symptoms. In 2021, the American College of Gastroenterology published updated recommendations for diagnosis and management of GERD. In addition to histamine-2 receptor antagonist or proton-pump inhibitor therapy, which may be prescribed as needed or continuously, lifestyle and dietary modification are often advised. Here, 2 physicians, a primary care practitioner and a gastroenterologist, debate how to manage a patient with GERD symptoms. They discuss the diagnosis of this condition, its initial management, indications for upper endoscopy, and how to care for the patient whose condition does not respond to empirical therapy.

Red-Tape Roadblocks: How Prior Authorization Intermediaries Delay Optimal Patient Care

In active ulcerative colitis, risankizumab induced and maintained remission

Source Citation Louis E, Schreiber S, Panaccione R, et al; INSPIRE and COMMAND Study Group. Risankizumab for ulcerative colitis: two randomized clinical trials. JAMA. 2024;332:881-897. 39037800