Gout: An Update (Maniscalco, 5/6/26)

A recording of this presentation is available HERE.

Thanks to Dr. David Maniscalco, SMGR Endocrinologist, for an update on Management of Gout. 

1st MTP

Common signs/symptoms

• 80% of gout is monoarticular process (single ankle, knee, 1st MTP, wrist, olecranon bursa)

• significant pain ("cannot even let a bedsheet touch it")

• red/hot/swollen

• flares commonly overnight and early morning (pts may describe this)

polyarticular gout (<20%) becomes an issue in pts with longstanding gout that hasn't been treated, can be seen in hospitalized patients, can be associated with fever, can mimic sepsis
tophaceous gout: pts who haven't received care as outpatient, develop significant tophi, pain can hit critical point with severe pain

Diagnosis

• ideal: presence of uric acid crystals on synovial fluid analysis (crystal-proven gout)

• less ideal: often diagnosed on typical clinical presentation + hyperuricemia

NOTE: serum uric acid level can be erroneously low when a patient is in the midst of a gout flare, so don't be fooled (should recheck uric acid after flare resolves)

Management
Based on 2020 American College of Rheumatology Guidelines for Management of Gout
Indications for urate lowering therapy:

• 2 or more gout flares within a year

• no need to start after first attack>> monitor and see if repeated attacks

• tophaceous gout (rheum should manage)

• radiographic damage attributable to gout (erosions on x-ray)

• hx multiple flares over time (even if <2/year)

• first gout flare with CKD >3

• uric acid >9 (significantly high) or hx nephrolithiasis

no need to start with incidental elevation of uric acid in the absence of gout symptoms
Urate lowering therapy:

• Allopurinol is PREFERRED first-line agent

• recommended including for pts with CKD>3 (safe)

• allopurinol does not cause kidney injury (safe in AKI as well)>> decreased GFR can increase risk of side effects, e.g. severe cutaneous reactions (Stevens Johnson, DRESS), which are rare but do happen>> lower dose if rash develops

• in pts of southeast Asian descent (Han Chinese, Korean, Thai) and African American>> check for alelle HLA B5801 before starting allopurinol

• Feboxostat is used as an alternative to allopurinol

• previously concerned recommended for patients with CKD>> now no longer an indication

• used rarely

• per current guidelines, contraindicated in pts with hx CVD (increases risk of CV death, mixed data)

start lowest dose and titrate up monthly, need serial uric acid measurements to titrate
Goal uric acid <6mg/dl (for non-tophaceous) <5mg/dl (for tophaceous, managed by rheum)

• starting dose: allopurinol 100mg daily (lowest dose), feboxostat 40mg daily (lowest dose)

• decreases risk of hypersensitivity reactions, decreased risk of flares with initiation

• there is no inherent danger in increasing allopurinol>> max dose 800mg

• max dose of feboxostat is 80mg

• about 1/3 of patients will be at goal with 300mg allopurinol

• for pts with CKD3, start with 50mg allopurinol (titrate up by 50 mg/month until goal uric acid)

• There is NO need to stop allopurinol in AKI in hospitalized patients

• can lead to gout flares and do not worsen AKI

Acute flare management
Colchicine is first line most effective within first 36 hours of flare (doesn't work better if started after): 1.2mg, followed by 0.6 mg 1 hour later, then 0.6mg BID until flare resolves
If not resolving, transition to prednisone
If attack is going >48 hours, choose something other than colchicine (prednisone preferred)
Prednisone: 0.5mg/kg 2-5 days, then taper over 7-10 days
NSAID: naproxen 500mg BID, indomethacin okay (often cannot be used due to comorbidities)
ICE!!!!
Medication Prophylaxis

• Any time you are starting urate lowering therapy, you need prophylaxis at the same time!!

• Colchicine is preferred agent for ppx: 0.6mg daily, okay in CKD (CrCl<30, 0.3mg/daily or 0.6mg qod)

• If cannot do colchicine (diarrhea is common), NSAID, e.g. Naproxen 200 or 250mg BID (limited by CKD)

• Last option is prednisone  for those who cannot tolerate colchicine or NSAID: pred 2.5-7.5mg (usually start with 5mg), if worried about diabetes, try to get away with lower dose (e.g. 2.5mg daily)

• Titrate up q2-4 weeks (with uric acid via lab to direct)

Duration of prophylaxis: continue for 3-6 months AFTER target uric acid (longer for tophaceous gout)
Lots of crystal still in joint, take a long time to dissolve, people tend to have flares until treated for a long time

Medication monitoring
Allopurinol is safe (stop if rash), CBC/CMP after initiation, liver issues are not much of an issue, can monitor periodically q6-12 months (CBC, CMP), more frequently if renal impairment. Similar for colchicine.
Diet: low purine diet, low alcohol, reduce high fructose corn syrup, no concrete evidence on cherry juice, avoid red meats/organ meats/scallops, mussels, meaty fish
HCTZ increases uric acid>> change and may help uric acid improve
Losartan is gout-friendly-- evidence it decreases uric acid

Myth busters:

• No need to stop urate lowering therapy while having a gout flare

• No need to stop urate lowering therapy in AKI (can lead to bad flare)

• Okay to start urate lowering therapy DURING a gout flare (despite what UptoDate says)

• Colchicine is safe and NOT highly toxic and can be safely taken as long as adjusted for renal impairment, drug interactions

Refer to rheum:
polyarticular gout
tophaceous gout
unable to be treated with allopurinol/feboxostat

Ethical Deviations and Inequities in the Delivery of Health Care (Matthews, 2/11/26)

A recording of this presentation is available HERE.

***

Special thanks to Dr. Adora Matthews, Sutter's CME of Inclusion and Belonging. She gave an important presentation on Inequity in the Delivery of Health Care-- as a celebration/reminder of Black History Month and a reminder of our commitment to delivering equitable and excellent care to every patient we serve. 

Dr. Matthews reminded us of four important historical occurrences that still contribute to fractured trust in the medical system for black Americans:

1) Dr J. Marion Sims, often referred to as "the father of modern gynecology", a white man, who operated on black slaves without anesthesia, perfected his hysterectomies and vesico-vaginal fistula repair on black slaves without consent, and contributed to a long-held notion in medicine that "black people don't feel pain the same as white people". After  all surgical assistants resigned due to discomfort with his work, he ultimately forced three black slave women (named Anarcha, Betsy, and Lucy) to assist him in these experimental surgeries.

A statue to honor these three women, the "Mothers of Gynecology" stands today in Montgomery, Alabama. 

2) The Tuskegee Syphilis experiment, which took place from 1932-1972, in which 400 black male sharecroppers were knowingly observed to study the natural history of syphilis, even after cure/treatment for syphilis was widely available (in the form of penicillin!). Spouses were infected, babies were born with congenital syphilis, extreme pathology was documented. This is widely considered the greatest failure of medical ethics in our country. This experiment didn't end until it was leaked to the press in 1972. A formal apology rendered by President Bill Clinton in 1997, calling the experiment "shameful and racist". 

3) Henrietta Lacks was a black woman who was treated in 1951 for cervical cancer at John's Hopkins University. After she died that same year, her cell line (HeLa) was used (without consent) for countless projects, including vaccine development, medical research, most recently for the COVID vaccine development. 110,000 publications are attributed to her cell lines, which are still in use today. The Lacks family was unaware of this use of her cells until 1973, when they were approached by a scientist who wanted to study them. 

These historical truths (and many others) contribute now to systemic inequity and mistrust. We must be aware of these histories, warned Dr. Adora Matthews, when we are caring for black American patients. We must be aware of them when we see current inequities. And while being aware isn't enough, it's a start.

Four current inequities for Black patients:

1) Healthcare access: black and brown patients have higher rates of being uninsured, are less likely to have preventive care, and less likely to have a regular PCP.

2) Chronic disease management: black American women have some of the highest rates (40%) of metabolic syndrome, which doubles CV risk, increases all cause mortality, and is associated with DM, CKD and stroke.

3) Maternal and fetal health outcomes: black women have highest rates of maternal mortality and fetal mortality, even when controlling for SES (see graphs below)

4) Pain management: Biased beliefs about black patients and pain tolerance dating back centuries with no evidence-- still exist today. There is literature from emergency rooms, hospitals and clinics that black patients are less likely to receive pain medication for the same painful condition.

Dr. Matthews reminded us that knowing the history (and the current inequities) is where we begin-- from here we begin to look at systems and address systemic racism in the daily work we do. We turn our grief, sadness, anger and despair into hope for our patients. We confront our own biases by attending lectures like these and participating in unconscious/implicit bias assessment ( Harvard's can be found HERE). 

Practicing Changing OB Updates in 2024-25 (Watson, 4/23/2025)

 A recording of this presentation is available HERE.

***

Thanks to Dr. Hannah Watson, our interim Maternity Care Director at the Santa Rosa Family Medicine Residency, for an excellent talk on 2024-2025 OB Updates. She covered five studies recently published, which suggested some practice changes in the care of OB/Gyn patients. I love looking at recent literature to either reinforce our current practice or to update in real time what we do clinically. 

She also toured us through some beautiful wildflowers!

Here are my take home pearls:

1) VTE prophylaxis in patients after c-section (while hospitalized) may not change outcomes. 

In this retrospective cohort study of patients who received VTE ppx vs. those who didn't, 0.31% vs 0.08% (not statistically significant) developed VTE; 6.7% vs. 1.7% were readmitted, 3% vs 1% wound complications.

Bruno AM, Sandoval GJ, et al Postpartum pharmacologic thromboprophylaxis and complications in a US cohort. Am J Obstet Gynecol. 2024 Jul;231(1):128.e1-128.e11. doi: 10.1016/j.ajog.2023.11.013. Epub 2024 Feb 12. PMID: 38346912; PMCID: PMC11194157.

2) While antepartum betamethasone (for fetal lung maturity) has excellent evidence prior to 34 weeks EGS, in patients who deliver at 34-36 weeks, the positive impact of maternal steroids varies based on gestational age AND mode of delivery (LTCS vs. vaginal). 

In this secondary analysis of the 2017 Antenatal Later Preterm Steroids (ALPS) Trial, 7ounger gestational age and surgical delivery confer greater benefit of steroids. Of note, GDM patients were excluded from the ALPS trial.

Clapp MA, Li S, Cohen JL, Gyamfi-Bannerman C,  et al Betamethasone Exposure and Neonatal Respiratory Morbidity Among Late Preterm Births by Planned Mode of Delivery and Gestational Age. Obstet Gynecol. 2024 Dec 1;144(6):747-754. doi 10.1097/AOG.0000000000005756. Epub 2024 Oct 10. PMID: 39388700.

3) Pregnant patient with GDM may benefit with improved glucose control from split dosing their long acting (i.e. glargine) insulin when using over 20-30 units per day. Also injecting prandial insulin 20-30 minutes BEFORE eating improves glycemic control. 

Valent AM, Barbour LA. Insulin Management for Gestational and Type 2 Diabetes in Pregnancy. Obstet Gynecol. 2024 Nov 1;144(5):633-647. doi: 10.1097/AOG.0000000000005640. Epub 2024 Jun 13. PMID: 38870526.

4) Concurrent partner treatment (oral metronidazole and topical clindamycin) for patients with bacterial vaginosis (BV) reduces risk of recurrence of BV by 50% at 12 weeks. 

Recurrence rates of BV were still high: 63% at 12 weeks in the control group (no partner treatment) and 35% in the partner treatment group.

https://www.nejm.org/doi/full/10.1056/NEJMoa2405404

5) The Jada (aspiration system) demonstrates equivalent outcomes to the Bakri (balloon system) for post partum hemorrhage management.

Of note, Dr. Watson says that both she and patients generally prefer the Jada system, which generally stays in for one hour; whereas the Bakri requires traction for up to 12 hours. Evidence shows either system is better the sooner it is placed.

Shields, Laurence E. MD; Klein, Catherine MSN, RN et al Effectiveness of the Intrauterine Balloon Tamponade Compared With an Intrauterine, Vacuum-Induced, Hemorrhage-Control Device for Postpartum Hemorrhage. Obstetrics & Gynecology 145(1):p 65-71, January 2025. | DOI: 10.1097/AOG.0000000000005770

Advancements in GLP-1 Receptor Agonists: Where we are and where we're going (Felton, 2/19/25)

 A recording of the presentation is available HERE.

***

Many thanks to Dr. Erin Felton for an excellent presentation on a hot topic: GLP-1 Receptor Agonists, the class of medications that is literally taking our nation by storm. As Dr. Felton said during her presentation, direct to patient advertising and word of mouth has led to droves of patients coming to their providers asking for these medications, most commonly, for weight loss. 

A recording is available above.

comorbidities associated w/obesity

Here are my notes:

• obesity is a chronic, relapsing , treatable multifactorial disease
• it is associated with comorbidities (e.g. HF, DM2, uterine cancer) and complications
• BMI, as we know, is not a perfect measure, but it's what we currently have
• According to 2023 CDC data: 1/5 US adults are obese
• By 2030, there are estimates that 1/3 US adults will have a BMI>30
• There are racial and socioeconomic disparities associated with obesity
• these are particularly evident in communities of color (black and Latinx)
• 

We must be aware of our own "fat bias" in medicine

• always ask patients for permission before discussing their weight
• give patients a right to decline weighing in
• focus on chronic disease aspect of obesity (rather than weight)
• consider how to create a supportive environment for obese patients

There are several FDA approved medications for obesity, the GLP-1 Receptor Agonists are the new kids on the block, but see the image below for all meds that are currently approved for long-term usage, short-term usage, and off label usage:

GLP-1 is an endogenous incretin hormone that is produced by the L cells in the distal ileum and colon in response to food intake. GLP-1 receptor agonists mimic this mechanism. In addition, GLP-1 receptors are expressed in multiple organs: GI tract, pancreas, hypothalamus, brainstem, heart, kidney, muscle, fat cells. It is thought that effects on the brain influence appetite and satiety. Receptors in the GI tract decrease gastric emptying and slow gastric motility.

Current GLP-1 Receptor Agonists:

Murphy EJ,”What’s new in Endocrinology”, Medical Management of HIV Conference, 2024

The newer kid on the block are multi-targeted incretin therapies, including GIP, which is secreted more proximally in the small intestine; it stimulates downstream GLP-1, enhances insulin, promotes satiety and seems to be associated with less nausea.

The newest agent, tirzepatide, is a combo of GIP/GLP-1. There are currently two versions of tirzepatide on the market: Mounjaro (indication: DM) and Zepbound (indication: weight loss). Zepbound is currently covered by Partnership medi-cal.

Current combos/multi-targeted incretin therapies:

Specific prescribing info for semaglutide and tirzepatide:

There are no direct head to head trials comparing semaglutide to tirzepatide.

Indirect comparisons suggest more weight loss with tirzepatide, as well as potentially lower side effect profile.

Side Effects

We should definitely be talking to our patients about side effects when we are prescribing these medications.

The most common side effects of GLP-1 medications are GI symptoms (nausea, vomiting, constipation, etc). GI symptoms are extremely common (25-40%) but do decrease over time. In many trials, a large percentage of people self-discontinued the medications due to side effects. 

Going slow can mitigate the GI side effects, as they do abate over time. Reducing meal size and adopting a low fat (and low glycemic index) diet can also reduce side effects. Patients should have some nutritional counseling (even if it's just from the PCP). Increasing fiber may also help. 

Dizziness and dehydration have  also been reported. This could be due to morning hypoglycemia. Small frequent meals and maintaining good hydration are recommended.

As mentioned above, the newer combination medications MAY be better tolerated.

Contraindications:

Contraindications to these medications include: medullary thyroid cancer/MEN2, pregnancy, hx pancreatitis or gallstone disease (relative/not absolute). Of note, there was some post-marketing signal in 2023 suggesting a correlation with suicidality, further assessment in 2024 did not confirm this signal, but consider ongoing assessment in patients with a hx of depression or SI. 

Starting/stopping

There is good evidence that discontinuing GLP-1 meds lead to gaining back a large percentage of weight that was lost (though overall, pts do maintain a small percentage of weight lost). A retrospective cohort study of 125K patients, just released in 2025 found that 53% of patients and 72% of patients had discontinued these medications at 1 and 2 years, respectively. Somewhere between 1/3 and 1/2 of these patients  resumed these medications within 1 year of stopping.

Wilding et al, Step 1 Extension, Diabetes Obes Metab 2022

About insurance:

• Medicare specifically does NOT cover weight-loss drugs. However, as of 3/24, Medicare will cover semaglutide for obese patients for CVD prevention IF they have documented CVD (e.g. prior MI, PVD, etc)
• Only about 20% of Medicaid programs cover weight loss drugs (Medi-Cal does! See the image below showing the current PHP covered medications)
• Only about 25% of employer-based insurance cover weight loss drugs
• Locally, Kaiser does NOT cover weight-loss drugs unless you have another specific indication (e.g. DM2, HFrEF, CVD)
• There has been varying pharmacy supply

Patient Counseling pearls

• There is significant weight regain after discontinuation of GLP1s, though studies so far have still showed a net loss. 
• Most patients who newly initiate treatment with GLP RA discontinue within 2 years. 
• High burden of GI side effects, gets better with time.
• Need for long term therapy due to weight regain?
• Other factors for adherence: high cost, availability of medication
• All studies done at target dose of 2.4mg

Finally, there are more and more studies being published showing benefit in outcomes other than weight loss. These include CVD, OSA, MASN/MAFLD, dementia, Parkinson's, disease, as well as substance use disorder. Stay tuned. 

Osteopathic Manipulation in the Hospital (Earl, 12/4/2024)

A recording of this presentation is available HERE.  

Many thanks to Dr. Connie Earl for a FANTASTIC Grand Rounds presentation this week on Osteopathic Manipulation in the Hospital. Dr. Earl, who previously ran the Forestville Wellness Center through West County Health Centers, is currently doing a year of extra "residency" training on Osteopathic and Neuromuscular Medicine (ONMN) at Maine Medical Center. She shared with us her passion for Osteopathic Manipulation (OMM/OMT) and a TON of what she described as "really weird studies that demonstrate ways in which OMN may be used in the hospital setting".

As an allopathic-trained physician, I admit I am often envious of the anatomy knowledge and tremendous skills of my osteopathic colleagues-- and I can tell you from personal experience that Dr. Earl has amazing clinical skills (and hands!)

For those of us less familiar with OMT, she started with the four principles of osteopathy: 

1. The body is a unit; the person is a unit of body, mind and spirit.

2. The body is capable of self-regulation, self-healing and health maintenance.

3. Structure and function are reciprocally interrelated.

4. Rational treatment is based upon an understanding of the basic principles of body unity, self-regulation and the interrelationship of structure and function.

Aren't these principles cool?  

Dr. Earl also contrasted OMT with allopathic medicine, which often focuses on treating/curing/preventing the disease; whereas osteopathy focuses on what we can do to protect the host. 

Well-structured randomized control trials of OMT are extremely challenging to create because of a wide variety of methodological variants. For example, OMT is a response to a personal and individual host. If you protocolize an OMT intervention (in order to standardize it), you are already compromising the validity of the treatment. OMT techniques vary widely, sham OMT is challenging to replicate, and many studies include trainees of varied levels of experience. 

Where she is currently training at Maine Medical Center, a 700 bed Level 1 Trauma Center, the OMN service typically treats 60-70 patients. These include patient post-CABG, poly-trauma patients, patients after GI surgeries, NICU babies, term babies and mothers, and more. 

Founding father of OMT, AT Still, is famous for his evocative quotes. One that captures another important tenet of OMT is a focus on the lymphatics system: "We strike at the source of life and death when we go to the lymphatics."

Dr. Earl shared some really amazing and interesting observational data of OMT during the 1918 Flu Pandemic, in which there was a remarkable 6% death rate for all-comers. Observational studies found that patients treated with OMT (there was no influenza treatment at the time) had closer to a 0.25% death rate. Dr. Earl stressed that these were not RCTs, and yet. . .OMT has been associated with improved respiratory function, supporting increased circulation and increased lymphatic flow. All of which certainly could have biologic plausibility in terms of helping with viral respiratory illness. 

Canine and rat studies both demonstrate improvement in lymphatic pumps with OMT. Human studies, whose lymphatic pumps are a little more challenging to study, demonstrate increased tidal volumes. 

Here are some examples of patients cared for by OMN providers at Maine Medical Center:

• post-CABG patients: improved peripheral circulation, improved cardiac indices, decreased time to dc (1/2 day), decreased time to first BM, increased functional independence
• post-sternotomy patients:: decreased pain, LOS, increased mean inspiratory volume
• GI surgeries, especially ileus: decreased LOS, decreased time to flatus, less pain, decreased time to first stool, decrease use of opioids
• IBS/constipation: decreased pain, bloating, constipation and increased quality of life
• Inpatient pediatric patients
• breast/chest feeding: latch issues, increased exclusive breastfeeding, better milk transfer, decreased pain
• birth trauma: hypoglossal nerve trauma/compression, hyoid connections and torticollis
• premature neonates/NICU for feeding tolerance
• 

  

Let me know if you want references to any of the OMT studies. I have them!

Integrative Approach to Anxiety and Depression (Brown, 10/30/2024)

A recording of this presentation is available HERE.

Many thanks to Dr. Andrew Brown, who gave an excellent Grand Rounds presentation this week on Integrative Approach to Anxiety and Depression. Anyone in primary care knows that we do a lot of management of psychiatric disorders in the primary care setting, often with very little specialty support. Many patients are interested in pursuing not just standard medical therapy (SSRI + cognitive behavioral therapy), but also integrative modalities.

Dr. Brown laid out the evidence for a wide range of non-pharmaceutical and non-psychotherapy treatments for anxiety and depression. The bottom line is that there are many, many, many integrative options with a range of small to moderate to strong evidence for the management of anxiety/depression. Put your seatbelts on. And don't use too many at once!

Integrative modalities, for the purpose of this talk include 

• lifestyle/behavioral 
• nutrition 
• supplements and 
• physical practices

Lifestyle/behavioral

Exercise works! The USPSTF recommends 2.5 hours/week of aerobic exercise for overall improved health. And good news, exercise can improved depression!  Some exercise modalities may be better than others, including: include walking/jogging/yoga/strength training. The more "intense" the better. However, in a 2023 review article, ANY regular exercise, regardless of type, setting, or supervision decreased depression scores by 5-7 points. 

There is not much evidence for exercise in anxiety, with a different review paper finding a benefit of exercise for anxiety in 7 of 25 studies and no benefit in the remaining 18.

It should come as no surprise that substance use and substance use disorders are frequent comorbidities with anxiety and depression. Note in the chart below:

• 16% of people with anxiety disorder also have SUD
• 16% of people with an adjustment disorder also have SUD
• 16% of people with depression also have SUD

Nicotine and tobacco, alcohol, and yes, even marijuana>>worsen anxiety

Sleep and anxiety/depression, as we know, have a bidirectional relationship. Treating the underlying cause of sleep helps (e.g. sleep disordered breathing). If you target insomnia, you improve mental health.

Social support helps too. Social support and connectedness -- perhaps even via online platforms-- helps depression and anxiety, even in people with a diagnosed social anxiety disorder!

Time spent in the natural world, including activities like "forest bathing", nature-based treatment, gardening, wilderness time, outdoor adventuring all have a positive effect on mood and anxiety. Many of the studies looking at time in nature are Korean studies, and plenty show positive effect, which is durable (at least up to 12 weeks after the outdoor time). One study even found that LOOKING at images of nature had a positive impact on mood. 

Nutrition 

Eating a healthy diet improves depression and anxiety! And there are plenty of different healthy diets that have been shown to improve mood in a 2021 Systematic Review: a diet high in fruits/veggies, a diet with less calories, a diet high in omega-3 fatty acids, probiotics, a diet rich in dietary minerals, and a ketogenic diet. Even eating breakfast works!

What doesn't work? An unhealthy diet: insufficient protein, high fat, lots of carbs/sugars, and a diet low in tryptophan (which is found in protein-rich foods, not just turkey).

Supplements

Many many botanicals are used to treat symptoms of depression anxiety. Four that Dr. Brown highlighted with moderate/strong evidence for positive effect are:

• Kava Kava (Piper methysticum): 50-70mg TID, mixed evidence, some concern for hepatoxicity
• St. John's Wort (Hypericum perforatum): strong evidence in depression, 500-1800mg/day. A 2017 Meta-analysis found it to be equivalent to SSRIs (of note, not safe to take at same time as SSRIs)
• Saffron (Crocus sativus): 30-200mg/day, strong evidence for depression and anxiety, $$ cost can be an issue, also concerns regarding first trimester SAB in early pregnancy
• Lavender (Lavandula angustifolia): "a few drops", moderate evidence, compared to lorazepam in a trial of preoperative patients was found to be "equivalent". SE: gynecomastia
• 
  
  

Probiotics: studies show a small but consistent positive effect in depression/anxiety (not enough to be used as monotherapy, but consider for adjunct)

Vitamin Supplements

Dr. Brown highlighted five vitamins with some efficacy in depression/anxiety:

• Vitamin D: stronger evidence in depression (than anxiety)
• B Complex, found in dark/green/leafy veggies, may be good adjunct
• Zinc: dose response benefit in depression and anxiety
• Magnesium: strong evidence as either monotherapy OR adjunct, depression more than anxiety, change of 4 points on GAD7 or PHQ9, so may be good choice for mild-mod depression/anxiety

Physical Practices

Dr. Brown finished up his presentation talking about a range of physical practices that, again, have some evidence for treatment of depression and/or anxiety, specifically:

• Acupuncture: 2024 Meta-analysis found that acupuncture was BETTER than SSRIs for depression, particularly if electro-acupuncture techniques are used. Most studies indicate that a combination of SSRI and acupuncture decreases rates of remission. There is less evidence for acupuncture in anxiety.
• Acupressure: no evidence for durable benefit, but may be good for episodic symptoms (and can be self-done)
• Progressive Muscle Relaxation: strong evidence in pre-procedural anxiety and symptoms report for patients. There are a wide range of muscle relaxation techniques, many can be taught in just a few minutes in the office setting
• Breathwork: Once again, there are many different breath practices. Two easy ones to teach in the office are: Box, 4-7-8 (see images below). Both have been shown to help with symptom management

Finally, do Apps work? Apps tend to be cheap and easy for patients to get, particularly in a low resource. According to Dr. Brown. There have been 50+ studies, including an RCT, looking at apps for physical practice changers, and they have shown a significant but small/moderate effect on depression/anxiety. So consider apps an option too!

References:

• de Noronha, S.I.S.R., de Moraes, L.A.G., Hassell, J.E. et al. High-fat diet, microbiome-gut-brain axis signaling, and anxiety-like behavior in male rats. Biol Res 57, 23 (2024). https://doi.org/10.1186/s40659-024-00505-1

• Fatemi, F., Siassi, F., Qorbani, M. et al. Higher dietary fat quality is associated with lower anxiety score in women: a cross-sectional study. Ann Gen Psychiatry 19, 14 (2020). https://doi.org/10.1186/s12991-020-00264-9

• Mohit Kumar, Babita Bhatt, Chitralekha Gusain, Nayan Mahajan, Mahendra Bishnoi, Sex-specific effects of ketogenic diet on anxiety-like behavior and neuroimmune response in C57Bl/6J mice, The Journal of Nutritional Biochemistry, Volume 127 (2024). https://doi.org/10.1016/j.jnutbio.2024.109591.

• Haduch, A.; Bromek, E.; Kuban, W.; Daniel, W.A. The Engagement of Cytochrome P450 Enzymes in Tryptophan Metabolism. Metabolites 2023, 13, 629. https://doi.org/10.3390/metabo13050629

• Gregory L. Stonerock, Rahul P. Gupta, James A. Blumenthal, Is exercise a viable therapy for anxiety? Systematic review of recent literature and critical analysis, Progress in Cardiovascular Diseases, Volume 83, 2024, Pages 97-115, https://doi.org/10.1016/j.pcad.2023.05.006.

• Noetel M, Sanders T, Gallardo-Gómez D, Taylor P, del Pozo Cruz B, van den Hoek D et al. Effect of exercise for depression: systematic review and network meta-analysis of randomised controlled trials BMJ 2024; 384 :e075847 https://doi:10.1136/bmj-2023-075847

• Kedzior, K.K., Laeber, L.T. A positive association between anxiety disorders and cannabis use or cannabis use disorders in the general population- a meta-analysis of 31 studies. BMC Psychiatry 14, 136 (2014). https://doi.org/10.1186/1471-244X-14-136

• Berglund, M. and Ojehagen, A. (1998), The Influence of Alcohol Drinking and Alcohol Use Disorders on Psychiatric Disorders and Suicidal Behavior. Alcoholism: Clinical and Experimental Research, 22: 333s-345s. https://doi.org/10.1111/j.1530-0277.1998.tb04388.x

• Lev-Ran S, Roerecke M, Le Foll B, George TP, McKenzie K, Rehm J. The association between cannabis use and depression: a systematic review and meta-analysis of longitudinal studies. Psychological Medicine. 2014;44(4):797-810. doi:10.1017/S0033291713001438

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