#223 Hot COVID Cakes: COVID19 Disparities, Steroids, Hormones for Depression, Probiotics

July 2, 2020 | By Deb Gorth

Half COVID, Half Hotcakes, 100% Fresh w/guest Utibe Essien MD, MPH

This episode is Half COVID Cakes, Half Hotcakes, and 100% fresh.  Our guest Dr. Utibe Essien MD, MPH @UREssien and Curbsider/epidemiologist, Dr. Rahul Ganatra MD, MPH @rbganatra discuss some Hot COVID Cakes including: racial differences in COVID-19 outcomes, why dogs and dexamethasone may hold the key to defeating COVID-19, how hormonal adjunctive therapies might be key for depression, and when to poo-poo probiotics versus when a side of Lactobacillus may be beneficial. 

Listeners can claim Free CE credit through VCU Health at curbsiders.vcuhealth.org (CME goes live at 0900 ET on the episode’s release date).

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Credits

Written and Produced by: Rahul Ganatra MD, MPH, Emi Okamoto MD; Sarah P. Roberts MPH; and Matthew Watto MD

Show Notes and CME questions by: Deborah J. Gorth ScM

Cover Art: Deborah J. Gorth ScM

Hosts: Matthew Watto MD; Rahul Ganatra MD, MPH, Emi Okamoto MD, and Sarah P. Roberts MPH

Editor: Matthew Watto MD (written materials); Clair Morgan of nodderly.com

Guest: Utibe Essien MD, MPH

Sponsor

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.

Time Stamps

• 00:00 Intro, disclaimer, guest bio
• 02:20 Silver Linings / Picks of the Week: Chicken Run (2000) and Chicken Run 2 on Hulu; Philly Inquirer story on COVID sniffing dogs; Buy some nectarines…or peaches! And check out their Wikipedia page!
• 07:33 Hospitalizations and Mortality Among Black and White patients with COVID-19
• 26:10 Dexamethasone for COVID-19
• 28:55 Hormonal therapy for depression
• 38:16 Probiotics
• 45:00 Outro

Hot COVID Cakes – Pearls

1. Weathering is a hypothesis that cumulative chronic exposure to socioeconomic disadvantage leads to accelerated health deterioration in Black Americans.  
2. Black Americans are disproportionately represented among patients hospitalized with COVID-19.
3. Daily low dose dexamethasone may significantly reduce mortality from COVID-19 in seriously ill patients.
4. Some dogs are particularly good dogs and may help us detect COVID-19. 
5. The WHO predicts that by 2030 depression will be one of the leading three causes of disease burden.
6. T3 (triiodothyronine) in addition to a TCA can accelerate the therapeutic response in major depression
7. Testosterone supplementation could help depressive symptoms in individuals with concomitant clinical signs of testosterone deficiency.
8. The American Gastroenterological Association does not recommend the use of probiotics in patients with active Clostridioides difficile infection, Crohn’s disease, ulcerative colitis, or irritable bowel syndrome. 
9. Probiotics may have a role in the prevention of Clostridioides difficile infection secondary to antibiotic use. 

Hot COVID Cakes #5

Racial Disparities in COVID-19

Dr. Price-Haywood and colleagues used a retrospective, observational, cohort analysis to study the racial differences in COVID-19 (Price-Haywood et al 2020).  Their study population was drawn from individuals within an integrated-delivery health system in Louisiana who tested positive for SARS-CoV-2 on PCR. The primary outcomes for this study were both hospitalization and in-hospital death. 

While the population served by this health system is 31% Black and 65% white non-Hispanic, 76.9% of the patients hospitalized with COVID-19 were Black. Using a multivariable analysis, this study found that Black race, increasing age, a higher Charlson Comorbidity Index Score (a marker to capture common medical comorbidities), public insurance, residence in a low-income area, and obesity were all associated with increased odds of hospitalization. Despite the increased rate of hospitalization, Black race was not independently associated with higher mortality. 

The healthsystem studied includes residents of the Ninth Ward, an area devastated by Hurricane Katrina. Black patients in this study had a higher prevalence of obesity, diabetes, hypertension, and chronic kidney disease than white patients. Although not discussed by the study’s authors, weathering is a hypothesis that cumulative exposure to socioeconomic disadvantage and discrimination can lead to accelearted deterioration in physical health (Forde et al 2019). This phenomena may account for the baseline health disparities observed in this study. 

For more on the critical appraisal of this important study, see this twitter thread by @rbganatra.

Teaser of the RECOVERY Trial of Dexamethasone for COVID-19

The RECOVERY Trial is a large randomized control trial from England showing that a daily low dose of dexamethasone (6mg) leads to a significant reduction in all cause mortality in severely ill patients; one-third mortality reduction in patients on mechanical ventilation, one-fifth reduction in patients receiving oxygen, and no benefit in patients who did not require respiratory support (Preprint on Medrxiv). 

Adjunctive Hormone Therapies for Depression

The World Health Organization predicts that by 2030 depression will be one of the three leading causes of burden of disease (WHO 2006). Depression is particularly difficult to treat; only two thirds of patients achieved remission after four sequential treatments in the STAR*D Trial. A recent review of numerous small studies suggests that adjunctive hormonal therapies show promise as novel effective treatments for depression (Dwyer et al 2020).

Studies suggest that targeting the hypothalamic-pituitary-thyroid axis with triiodothyronine (T3 ) in addition to a tricyclic antidepressant (TCA) may accelerate response (Aronson et al 1996).  However, evidence for T3 supplementation on top of a selective serotonin reuptake inhibitor (SSRI) is not as compelling. Adjunctive therapies targeting the hypothalamic-pituitary-gonadal axis also hold promise. Systemic hormone replacements therapy (HRT) may enhance the effect of SSRIs in individuals with perimenopausal symptoms and depression (Schneider et al 1997). Additionally, the FDA recently approved brexanalone, a 60-hour infusion available through specialized centers, for the treatment of postpartum depression (Dacarett-Galeano and Diao 2019). Remarkably, this infusion was shown to begin being effective after only one treatment. While there is no evidence to screen for testosterone deficiency, testosterone supplementation may help depressive symptoms in individuals with concomitant clinical signs of testosterone deficiency (Elliott et al 2017, Dwyer et al 2020). With the exception of brexanalone, the use of hormone therapies is not FDA approved for treatment of depression. However, with more research, adjunctive hormones may offer an additional tool for managing this debilitating disease.  

The Utility of Probiotics

The American Gastroenterological Association (AGA) recently released new guidelines for the role of probiotics in the management disease. Outside of clinical trials, the AGA did not recommend the use of probiotics in patients with active Clostridioides difficile infection, Crohn’s disease, ulcerative colitis, or irritable bowel syndrome. Based on low quality evidence, the AGA provides a conditional recommendation for the use of probiotics for the prevention of Clostridioides difficile infection secondary to antibiotic use (Su et al 2020).

Links*

1. Chicken Run (2000) and Chicken Run 2 on Hulu. 
2. Philly Inquirer story on COVID sniffing dogs
3. Buy some nectarines…peaches! And check out their Wikipedia page!
4.  

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will learn about the role of race in COVID-19 outcomes, possible hormonal adjunctive therapies for depression, and when to recommend probiotics. 

Learning objectives

After listening to this episode listeners will…  

1. Learn the effect of race on COVID-19 outcomes.
2. Know the indications for adjunctive hormonal treatment for depression.
3. Discuss the role of probiotics for the treatment of common gastrointestinal illness.

Disclosures

Drs. Essien and Ceasar report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

Essien UR, Ganatra RB, Okamoto E, Roberts SP, Gorth DJ, Watto MF. “#223 Hot COVID Cakes: COVID19 Disparities, Steroids, Hormones for Depression, Probiotics”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list. Original air date July 2, 2020.