Episode 68 - Prevention - Aspirin, STIs, and Diabetes - a podcast by Rio Bravo Family Medicine Residency Program

Episode 68: Prevention - Aspirin, STIs, and Diabetes. 

Updates on aspirin use for preeclampsia prevention, updated STIs screening guidelines, and new age to start screening for diabetes.  

Introduction:  COVID-19 Booster Shots.  

Every week there is a lot of information to cover about COVID-19. I’m sure you are aware of some of this information, but here you have it again for historical purposes. 

Pfizer and BioNtech announced on September 20, 2021, that their COVID-19 vaccine is protective in pediatric patients between 5 and 11 years of age. 

Let’s remember that this vaccine is being used for patients older than 12, but so far none of the vaccines have been authorized for younger patients. A submission to FDA has been sent, but no approval has been given yet.

Recently, we mentioned to you that a booster shot for the mRNA COVID-19 vaccines were likely to be authorized by the FDA around September 20. Indeed, an authorization for a booster was given on September 22, 2021. This authorization was given to the Pfizer/BioNtech vaccine only, and it can be given at least 6 months after the completion of the primary series.

The patients who are authorized to receive the booster shot are: Patients who are 65 years of age and older; patients between 18 and 64 years of age at high risk of severe COVID-19; and individuals 18 through 64 years of age with frequent occupational exposure to COVID-19.

The Moderna vaccine has not been authorized for a booster shot.

Let’s remember that both Pfizer and Moderna have been authorized for a third dose in patients who are immunocompromised. The third dose can be given 4 weeks after completing he initial 2 doses of these vaccines. Patient who may receive a third dose are those who are receiving active cancer treatment, recipients of an organ transplant, or have a moderate or severe immunodeficiency. 

Stay tuned for more updates in the future.

This is Rio Bravo qWeek, your weekly dose of knowledge brought to you by the Rio Bravo Family Medicine Residency Program from Bakersfield, California. Our program is affiliated with UCLA, and it’s sponsored by Clinica Sierra Vista, Let Us Be Your Healthcare Home. 

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Prevention - Aspirin, STIs and Diabetes
By Hector Arreaza, MD, and Valerie Civelli, MD

The USPSTF has been very active lately. They have released several recommendations in the last few months. 

Aspirin and preeclampsia: On September 28, 2021, the USPSTF released their recommendation about the use of aspirin to prevent preeclampsia in pregnant persons at high risk. This recommendation is consistent with the previous recommendation given in 2014. New evidence has reinforced that aspirin is effective at reducing risk of perinatal mortality when used properly.

The recommendation states: “The USPSTF recommends the use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.” This is a grade B recommendation. A grade B recommendation means the net benefit of this preventive intervention is moderate to substantial.

Who is at risk for preeclampsia? You can classify the risk as High, Moderate, and Low.

High: Preeclampsia during previous pregnancies (especially if you had an adverse outcome), multifetal gestation, chronic hypertension, type 1 or 2 diabetes before pregnancy, kidney disease, autoimmune disease, or a combination of multiple moderate-risk factors. Recommend aspirin if a woman has 1 or more of those high-risk factors. 

Moderate: Nulliparity, obesity, history of preeclampsia in mother or sister, black persons, low income, age 35 years or older, personal history factors (e.g. low birth weight or small for gestational age, previous adverse pregnancy outcome, >10-year pregnancy interval, and in vitro conception. Recommend aspirin if patient has 2 or more of these moderate risk factors. You may recommend aspirin even to women with 1 of these risk factors. 

Low: Do not recommend aspirin to pregnant women who have low risk for preeclampsia. A patient is considered low risk if she had a previous uncomplicated term delivery and has none of the risk factors mentioned above.

As a side note, given the current movement for diversity, equality and inclusion, the article also states that “black persons have higher rates of preeclampsia and are at increased risk for serious complications due to various societal and health inequities,” not due to biological propensities.

When do you stop aspirin in pregnancy?

The decision to continue aspirin in the presence of obstetric bleeding (or bleeding risk) should be considered on a case-by-case basis. You can decide to stop at 36 weeks or continue until delivery based on your clinical judgement or local protocol.

Bottom-line: Recommend low-dose aspirin to pregnant women who are at increased risk for preeclampsia after 12 weeks of gestation.

Chlamydia and gonorrhea screening: On September 14, 2021, the USPSTF recommended screening women younger than 24 years old who are sexually active for BOTH chlamydia and gonorrhea infection. Also, screen all women 25 years and older who are at increased risk.

 

Increased risk means: a previous or coexisting STI, history of incarceration, and any kind of sexual intercourse out of a mutually monogamous relationship (new partner, more than one partner, partner who has sex with other partners, partner with an STI, history of exchanging sex for money or drugs). 

 

The screening for GC/Chlamydia in women is a grade B recommendation.

 

In this recommendation, the term “women” refers to persons born with female genitalia and does not apply to persons who identify as women but have male genitalia. 

 

This recommendation also includes pregnant persons and adolescents.

 

The evidence is insufficient (Grade I) to assess the balance and benefits and harms of screening for chlamydia and gonorrhea in asymptomatic men. Remember, a grade I recommendation is not a recommendation for or against a preventive intervention. To make it easy to remember “I stands for I don’t know, more research is needed”.

 

Recommendations about the age to start screening or the frequency of screening is not given explicitly, but the population with the highest incidence is women between 15-24 years old. Use your clinical judgement to determine when to start and how often.

 

Prediabetes and diabetes screening: On August 24, 2021, the USPSTF updated their recommendation for prediabetes and diabetes screening.

 

The recommendations states: “The USPSTF recommends screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity (BMI above 25). Clinicians should offer or refer patients with prediabetes to effective preventive interventions. This is a Grade B recommendation.

 

The age to start screening is now 35 years old (instead of the previous recommended age of 40). This is an update from the recommendation given in 2015.

 

We should consider screening at a younger age in:

Persons from groups with high incidence and prevalence. These groups are American Indian/Alaska Native, Asian American, Black, Hispanic/Latino, or Native Hawaiian/Pacific Islander persons. 

Persons with family history of diabetes, history of gestational diabetes, or a history of polycystic ovarian syndrome.

Screen Asian Americans with a BMI of 23 or greater after age 35.

How to screen for prediabetes and diabetes? You have three options: 

Fasting glucose (normal below 100, prediabetes below 125, diabetes above 126)

Hemoglobin A1C (normal Below 5.6, prediabetes below 6.4%, diabetes above 6.5%). Do not use point of care A1C for screening, use a venous sample instead.

Oral glucose tolerance test in the morning (fasting); measure glucose 2 hours after ingesting 75 g of oral glucose (normal below 140, prediabetes below 200, diabetes above 200). The diagnosis of prediabetes or type 2 diabetes should be confirmed with repeat testing before starting intervention.

Random glucose above 200 is highly suggestive of diabetes. 

     The diagnosis of diabetes should be confirmed before starting interventions.

Summary: Aspirin for preeclampsia prevention, screen for gonorrhea and chlamydia all women younger than 24, and screen for diabetes everyone older than 35 with overweight or obesity.

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HIV Series Part II: HIV Transmissibility
By Robert Dunn, MS3, Ross University School of Medicine.

People infected with HIV are often thought to be contagious even by touch; though the reality is transmission is primarily transmitted via sexual contact, bodily fluids, from mother to baby during pregnancy, shared needles, or accidental needle sticks in the medical workplace. And when it comes to sex, it is common that a person is afraid to engage in any sexual contact with a HIV positive person, even though the patient may have their infection controlled with medicine.

Per the CDC, the most common ways of contracting HIV are through sex without protection, shared needles, and perinatal transmission from mother to child.

Sexual transmission:

With anal sex, the receptive partner, or bottom, is at higher risk of contracting HIV because the rectal mucosa is thin, more prone to micro-abrasions and create an opportunity to contract HIV. The insertive partner, or top is also at risk of infection via the opening of the urethra, the foreskin of an uncircumcised penis, or any cuts, scratches or open sores on the penis. 

With vaginal sex, the woman can be infected via the mucus membranes that line the vagina and cervix. And the man can become infected from the vaginal fluid or blood that may carry HIV. 

Needlesticks:

Sharing needles is high risk for contracting HIV. If one person has HIV and uses a needle, the blood of that person is carried on the needle and can inject the virus directly into anyone else who uses that needle. This can occur if people are sharing injected drugs, medications, or even in a needle stick accident that may occur when treating patients in the hospital with HIV. 

Vertical transmission:

Perinatal transmission occurs when the mother infected with HIV passes the infection to her newborn. It is now recommended to test every pregnant woman for HIV and treat as needed. This can occur while the fetus is in the womb or upon delivery. It is recommended that the mother be placed on HIV medication immediately to reduce the risk of infecting the baby. 

These are ways how HIV is NOT transmitted: kissing on the cheeks, hugging, holding hands, sharing silverware, talking to someone, mosquitos, or sharing toilet.

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Now we conclude our episode number 68 “Prevention – Aspirin, STIs, and Diabetes.” Dr Arreaza and Dr Civelli explained the most recent updates by the USPSTF regarding use of aspirin to prevent preeclampsia, screening for gonorrhea and chlamydia in women, and screening for diabetes in patients older than 35. Robert continued with his HIV series and explained how HIV is mostly transmitted, a good reminder for all of us that the most common way of transmission continues to be sexual transmission. Even without trying, every night you go to bed being a little wiser.

Thanks for listening to Rio Bravo qWeek. If you have any feedback about this podcast, contact us by email RBresidency@clinicasierravista.org, or visit our website riobravofmrp.org/qweek. This podcast was created with educational purposes only. Visit your primary care physician for additional medical advice. This week we thank Hector Arreaza, Hasaney Sin, Valerie Civelli and Robert Dunn. Audio edition: Suraj Amrutia. See you next week! 

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References:

Erman, Michael, Pfizer/BioNTech say data show COVID-19 vaccine safe and protective in kids, Reuters, reuters.com, September 20, 2021. https://www.reuters.com/business/healthcare-pharmaceuticals/pfizerbiontech-say-data-show-covid-19-vaccine-safe-protective-kids-2021-09-20/, accessed on September 29, 2021.

 

Aspirin Use to Prevent Preeclampsia and Related Morbidity and Mortality: Preventive Medication, United States Preventive Services Taskforce, September 28, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/low-dose-aspirin-use-for-the-prevention-of-morbidity-and-mortality-from-preeclampsia-preventive-medication.

 

Chlamydia and Gonorrhea: Screening, United States Preventive Services Taskforce, September 14, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/chlamydia-and-gonorrhea-screening.

 

Prediabetes and Type 2 Diabetes: Screening, United States Preventive Services Taskforce, August 24, 2021, https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-for-prediabetes-and-type-2-diabetes

 

Ways HIV can be Transmitted. CDC, April 21, 2021. https://www.cdc.gov/hiv/basics/hiv-transmission/ways-people-get-hiv.html. Accessed on September 21, 2021.

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