Latest / Morning Medical with Dr. Chow / Couples' Sleep Health, Diuretics for Heart Failure, and Ozempic Needle Disposal Concerns

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Couples' Sleep Health, Diuretics for Heart Failure, and Ozempic Needle Disposal Concerns · Morning Medical with Dr. Chow

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Good morning, everyone, and welcome to another episode of Morning Medical with Dr.
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Chow.
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I am your host, Dr.
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Chi-Ming Chow.
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In today's episode, we will explore some intriguing topics that are making headlines in
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the medical world.
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We will be discussing the potential benefits of couples sleeping separately, the use of
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diuretics for ambulatory heart failure patients with volume overload, the proper disposal of
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Ozempic and Wegovy needles, and the ongoing efforts to reduce the prices of these
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medications.
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So, let us dive right in.
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Our first topic today is about the benefits of couples sleeping separately.
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This might sound unusual to some, but specialists are now saying that there are
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significant advantages to this practice.
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More than one-third of Americans have reported that they occasionally or consistently sleep in
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another room to accommodate their bed partner, according to a study by the American Academy of
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Sleep Medicine last year.
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Interestingly, it is millennials who are most likely to sleep separately, rather than older
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people.
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Take the case of Michael Solender and his wife, who have been together for 42 years.
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They initially slept in the same bed for the first decade of their marriage but started
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sleeping in separate rooms after Michael developed chronic and heavy snoring, which
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eventually led to a diagnosis of sleep apnea.
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Despite the use of a continuous positive airway pressure machine to eliminate his snoring, they
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continued to sleep apart due to other issues.
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Michael tends to be warm at night, while his wife is usually cold.
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For them, maintaining separate rooms for sleep has resulted in a healthier and better
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relationship.
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Michael emphasizes that there is no shame or stigma attached to their decision.
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Snoring, temperature variations, cover stealing, and tossing and turning are common
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reasons why partners may choose to sleep separately.
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Other factors include illness, different work shifts, and partners who go to bed and wake up
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at different times.
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Dr.
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Seema Khosla, a pulmonologist and spokesperson for the American Academy of Sleep Medicine,
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highlighted the importance of achieving adequate sleep, which is usually seven to eight
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hours for adults.
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She noted that people who consistently experience poor sleep are more likely to have
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conflicts with their partners.
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Dr.
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Khosla, who is also the medical director of the North Dakota Center for Sleep, mentioned that
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it is really a question of people prioritizing their sleep.
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Sleeping separately is probably more common than many of us think.
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The same goes for sleep apnea, which is a leading cause of heavy snoring.
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Michael Solender shared his experience of realizing the impact sleep deprivation had on
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both himself and his wife.
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He would often wake her up and himself up during the night.
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He started falling asleep at red lights, while watching television, or even while sitting up
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and reading a book.
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It was then that he knew he had an issue and sought the help of a sleep specialist.
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Key to making separate sleep spaces work is open communication.
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Michael Solender and his wife discussed the matter beforehand, ensuring that it was not
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about avoiding intimacy but rather about recognizing the need for quality sleep.
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Dr.
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Khosla has observed some reluctance among her patients when she suggests sleeping apart.
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Usually, it is due to someone's spouse snoring or an alarm that wakes them up early in the
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morning.
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However, with open conversation, many couples find that sleeping separately can indeed work
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for them.
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Tracey Daniels and her husband have also been sleeping apart for about four years.
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Initially, there was no big talk; she simply headed to the guest room due to her husband's
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snoring and her being a light sleeper.
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After being diagnosed with breast cancer and undergoing surgery, she initiated a
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conversation about their sleeping arrangements.
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Now, they have a routine where he tucks her in and gives her a kiss before bed, and they
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rotate their three dogs at night.
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Dr.
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Phyllis Zee, chief of sleep medicine at Northwestern University Feinberg School of
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Medicine, pointed out that sleep separation is common in her practice.
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She believes it would be beneficial for couples to discuss sleep compatibility before getting
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married.
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Sleep tends to become less robust as people reach middle age, making them more prone to
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conditions like insomnia or sleep apnea.
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While there is no shame in sleeping apart, Dr.
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Zee noted that technology has made sharing a bed easier in some ways.
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White noise machines, cooling pillows and bedding, mattresses with dual temperature
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controls, and dual control electric blankets can all help mitigate sleep issues.
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Dr.
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Zee also mentioned that some couples have given up sharing blankets, opting to use their own to
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make sleep easier.
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There is a whole market of products designed to address these issues.
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Sleep separation is more accepted now as people have become more aware of the importance of
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quality sleep to overall health.
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However, there are also benefits to sleeping together.
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Dr.
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Zee advises seeking professional help before making a decision, as some sleep issues may be
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treatable.
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Our next topic today focuses on the use of diuretics for ambulatory heart failure patients
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with volume overload.
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This discussion is based on a recent study that compared three different diuretic regimens to
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determine the most effective approach for patients experiencing persistent congestion
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despite high doses of oral loop diuretics.
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The study, known as the DEA-HF trial, was a small randomized crossover study that aimed to
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narrow down the best way to intensify diuretic therapy in an outpatient setting.
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The investigators compared the potency of three diuretic regimens in patients who were
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refractory to congestion.
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The regimens included high-dose intravenous furosemide plus oral metolazone, furosemide
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alone, and furosemide plus acetazolamide.
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The results were quite revealing.
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The combination of high-dose intravenous furosemide plus oral metolazone led to
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significantly more total sodium excretion at six hours, amounting to 4,691 milligrams,
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compared to 3,835 milligrams for furosemide alone and 3,584 milligrams for furosemide plus
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acetazolamide.
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These findings were statistically significant, with a P value of 0.015 and 0.001,
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respectively.
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In terms of total urinary volume excreted, the best results were also seen with the
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combination of furosemide plus metolazone, which resulted in 1.84 liters of urine.
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This was followed by 1.71 liters for furosemide alone and 1.58 liters for furosemide plus
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acetazolamide, with a P value of 0.039.
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These results support the findings of older trials such as the CLOROTIC and 3T trials.
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However, it is important to note that the combination of furosemide plus metolazone was
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associated with a significantly higher rate of worsening renal function, occurring in 39
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percent of patients, compared to 16 percent for furosemide alone and just 2.6 percent for
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furosemide plus acetazolamide.
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Despite this, the study authors noted that this did not translate into more hospital admissions
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due to acute kidney injury.
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On the other hand, furosemide plus acetazolamide did not result in better
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natriuresis, urine volume, or weight reduction compared to high-dose intravenous furosemide
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alone.
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This was in contrast to the ADVOR trial, which found that lower-dose furosemide plus
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acetazolamide did provide a benefit.
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The investigators theorized that the diminishing returns in the present trial may be
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due to the higher dose of furosemide tested or the greater use of background SGLT2 inhibitors.
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From a physiological perspective, both SGLT2 inhibitors and acetazolamide block sodium
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reabsorption in the proximal tubule of the nephron.
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On a background of high SGLT2 inhibitor use, adding intravenous acetazolamide to a loop
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diuretic may not be as effective in augmenting diuresis.
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This was highlighted by Dr.
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Paula Rambarat and Dr.
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G.
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Michael Felker in an accompanying editorial comment.
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Adding to the complexity of diuretic choices is the availability of a relatively new
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subcutaneous formulation of furosemide that can be self-administered by patients at home.
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Future studies are needed to compare outcomes with subcutaneous furosemide versus combination
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therapy with intravenous furosemide in ambulatory, congestion-refractory heart failure
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patients.
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Additionally, it remains unknown whether combination therapy with metolazone in addition
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to subcutaneous furosemide improves outcomes.
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Dr.
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Rambarat and Dr.
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Felker emphasized the need for future prospective studies that are adequately powered
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to assess important clinical endpoints such as symptom burden and heart failure
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hospitalizations.
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They concluded that only through such rigorous research can the role of outpatient parenteral
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diuretic therapy in managing congestion-refractory heart failure patients be
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firmly established.
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The DEA-HF trial was a prospective study conducted in 2023 at a single day-care heart
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failure unit located in a hospital.
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Eligible patients included those with chronic heart failure with New York Heart Association
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class II to IV symptoms and at least one sign of congestion while on at least two heart
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failure drugs.
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They also needed to have estimated glomerular filtration rates greater than 20 milliliters
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per minute per 1.73 square meters and no history of renal replacement therapy or
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ultrafiltration within 30 days before randomization.
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In the crossover study, 42 patients were subjected to a random sequence of weekly
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treatments with intravenous furosemide 250 milligrams, intravenous furosemide 250
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milligrams plus oral metolazone 5 milligrams, or intravenous furosemide 250 milligrams plus
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intravenous acetazolamide 500 milligrams.
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Treatments were administered once a week, and the overall study participation lasted for
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three consecutive weeks.
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The study had a high completion rate, with 88 percent of participants completing the entire
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sequence of treatments and follow-up.
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The mean age of participants was 72 years, and 40 percent were women.
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Half of the participants had left ventricular ejection fraction 50 percent or higher, and
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three-quarters were in New York Heart Association class III.
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All participants were on high-dose oral loop diuretics at baseline, and most were on
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guideline-directed medical therapy, including SGLT2 inhibitors.
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The incidence of electrolyte abnormalities and symptomatic hypotension was similar across all
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treatment groups.
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The study authors acknowledged the possibility of carryover effects between treatments,
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although they found no statistical evidence of this.
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However, they cautioned that as a single-center study, the results may be limited in their
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generalizability to other settings.
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They also noted that conducting the study as a multicenter trial would be impractical.
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In summary, the DEA-HF trial provides valuable insights into the effectiveness of different
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diuretic regimens for ambulatory heart failure patients with volume overload.
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While high-dose intravenous furosemide plus oral metolazone showed the most promise in
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terms of sodium excretion and urinary volume, it also came with a higher risk of worsening
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renal function.
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Future studies are essential to further explore these findings and determine the best
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strategies for managing congestion-refractory heart failure patients in an outpatient
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setting.
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Our next topic today focuses on the proper disposal of needles used for administering
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Ozempic and Wegovy.
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These medications, which have spiked in popularity, are used for managing type 2
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diabetes and weight loss.
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According to a Gallup poll, 6% of United States adults have tried these injectable weight-loss
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drugs, and 3% are currently using them.
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Both drugs are injected weekly using prefilled pens, and it is crucial for people to know how
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to properly dispose of the needles after administration.
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Health officials emphasize that the needles cannot simply be tossed into the trash, recycle
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bin, or flushed down the toilet.
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The general rule of thumb, according to the United States Food and Drug Administration, is
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to dispose of needles in a 'heavy-duty plastic household container.' Ideally, this should be a
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puncture-resistant sharps container, similar to the ones you would find at a doctor's office.
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However, if a sharps container is not available, people may be able to use household
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items, depending on local regulations.
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For example, a sturdy container such as a coffee can or laundry detergent bottle can be
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used for needle disposal, provided it has a tight-fitting lid to keep the needles safely
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inside.
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In certain states, you can put your sturdy container into the trash, while in others, the
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needles must be brought to a facility for proper disposal.
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Regulations can vary, so it is essential to familiarize yourself with local guidelines to
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ensure that you are taking the proper precautions.
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Joseph Wendelken, the public information officer for the Rhode Island Department of
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Health, noted that in Rhode Island, you would ideally put needles in a sharps container and
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then place them in a dark trash bag.
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The Food and Drug Administration also recommends checking with your local trash
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removal services or health department to verify official recommendations for needle disposal.
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Novo Nordisk, the manufacturer of both Ozempic and Wegovy, offers a Drug Disposal Program
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where consumers can order a sharps disposal container or a medicine return container
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through the company's website.
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This program provides an additional resource for those looking to dispose of their needles
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safely and in compliance with regulations.
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Ozempic was approved in 2017 to help patients manage type 2 diabetes.
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Along with proper diet and exercise, it can help regulate blood sugar levels and
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potentially contribute to weight loss, although the drug has not officially been approved for
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that purpose.
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Wegovy, on the other hand, was approved by the Food and Drug Administration in June 2021
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specifically for weight loss and weight management, intended for obesity patients aged
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12 and older.
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Given the widespread media attention and the increasing number of people using these
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medications, it is more important than ever to follow proper procedures for needle disposal.
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If you are unsure of the guidelines in your area, health officials advise checking with
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your local health department to ensure safety and compliance.
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Our final topic today revolves around the ongoing efforts to reduce the prices of the
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popular medications Ozempic and Wegovy.
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United States Senator Bernie Sanders has expressed optimism that Novo Nordisk, the
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manufacturer of these drugs, can be pressured to lower their prices in the United States.
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This optimism stems from Sanders' belief in the power of public shaming to bring about change,
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much like it did last year with the high cost of insulin.
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According to Sanders, Novo Nordisk's Chief Executive Officer Lars Jorgensen is set to
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testify before the Senate Committee on Health, Education, Labor, and Pensions, which Sanders
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chairs, in a hearing scheduled for September.
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The focus of this hearing will be on the United States prices for Ozempic and Wegovy.
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Sanders told Reuters in a phone interview, 'I think we got a real shot, and I was pleased to
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see President Biden supporting that effort.'
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Sanders successfully utilized a similar strategy last year when he targeted Novo
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Nordisk, Eli Lilly, and Sanofi over the exorbitant prices of insulin.
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Following months of pressure and a scheduled Senate hearing, all three companies announced
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they would cut their insulin prices.
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Sanders believes that highlighting the 'greed of the pharmaceutical industry' and
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specifically targeting Novo Nordisk for 'ripping off the American people' can achieve
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similar results for Ozempic and Wegovy.
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A spokesperson for Novo Nordisk mentioned that while the net prices of both drugs have dropped
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by 40 percent since their launch, these savings are not being passed on to consumers.
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The company attributed this to pharmacy benefit managers, who act as intermediaries between
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drug companies and consumers.
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Sanders, however, has stated that this price drop is not sufficient.
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Pharmacy benefit managers, or PBMs, play a significant role in determining which drugs are
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covered by insurance and at what price.
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Sanders plans to introduce legislation that would expand the maximum number of drugs
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eligible for Medicare price negotiations from 20 to 50 per year.
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Additionally, he aims to extend the annual $2,000 cap on out-of-pocket costs to Americans
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outside of Medicare.
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Sanders hopes to garner bipartisan support for these measures, which were also advocated by
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President Biden in his State of the Union address earlier this year.
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Sanders emphasized that while PBMs do play a negative role, pharmaceutical companies cannot
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use them as an excuse for high drug prices.
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He pointed out that drug companies are still 'ripping off the American people,' regardless
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of the involvement of PBMs.
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Sanders noted that Novo Nordisk has not engaged constructively with the Senate committee.
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The company has offered briefings for the committee staff and sent a 22-page letter
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responding to questions, but Sanders stated that these efforts have not been sufficient.
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Sanders' ultimate goal is to see the price of Ozempic in the United States reduced to around
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$155, which is the drug's price in Canada.
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Currently, a month's supply of Ozempic lists at approximately $935.77 in the United States,
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while Wegovy lists for $1,349.02 per month.
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Most consumers do pay less due to insurance, but the high list prices still impact overall
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healthcare costs.
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In conclusion, Sanders remains focused on Novo Nordisk due to its production of what could
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become the most profitable drug in history.
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However, he has also indicated that he will address the high prices of Eli Lilly's rival
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drugs, Mounjaro and Zepbound, which list for about $1,100 per month.
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Sanders described their prices as 'outrageous' and noted that the total market for weight loss
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drugs could exceed $100 billion by the end of the decade.
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Before we wrap up today's episode, I want to remind everyone of the importance of staying
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informed about healthcare policies and their impact on our lives.
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The efforts to reduce drug prices are crucial for making healthcare more accessible and
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affordable for all.
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Thank you for joining me today on Morning Medical with Dr.
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Chow.
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Stay healthy and informed, and I look forward to having you with us again tomorrow.