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Ok this clip about navigating the American Healthcare System from the recent South Park ozempic special (which was brilliant) needs to be the opening of every healthcare conference panel
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Bijan Salehizadeh
819 posts
Bijan Salehizadeh
@bijans
Healthcare investor. Howard Stern. Arcade Fire. Bowie. U2. California dreamin'
DC Katılım Temmuz 2007
3.8K Takip Edilen13.3K Takipçiler
Bijan Salehizadeh retweetledi
Trial lawyers are lobbying against self-driving cars because they're too safe. They need people to be killed and injured so that they have material for lawsuits.
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Bijan Salehizadeh retweetledi
@slotkinjr @wapo just stunning how mindless DC City Council is on this issue. It's as if ANYTHING except protecting citizens from bodily harm is more important.
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The Edge en Tomorrowland con Martin Garrix con una nueva canción de U2??
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Bijan Salehizadeh retweetledi
$HIMS
🚨 AMERICAN PHARMACISTS ASSOCIATION URGES FDA *NOT* TO ADD THE 7 NOMINATED PEPTIDES TO THE 503A BULKS LIST -- CITING SAFETY CONCERNS
APhA concedes black + gray-market demand is massive... 🤔
Unclear what their proposed mechanism is for reducing peptide demand if they are not added to the 503A Bulks List
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@foundmyfitness Sure but let’s not conflate on label use in men below 300 or 400 total T vs. Supra physiological levels or off label use. Entirely different issues and the men in actual need have now suffered from lack of access for 3 decades now precisely because of this confusion.
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"Off-label" use of testosterone therapy was associated with a 51% greater relative risk of major cardiovascular events.
Among 227, 108 men using it, those without documented low testosterone also had higher mortality and more heart attacks, strokes, and heart failure over 10 years.
Observational, not causal.
And it does not contradict randomized evidence such as TRAVERSE (which I've spoken about before) in properly diagnosed hypogonadism, where testosterone therapy showed no increase in cardiovascular events vs. placebo.
But it does caution against liberal use of TRT.
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Yes actually the AUA and the leaders in our field are focusing on that and have literally been on public panels in Washington advocating for it.
I have done research in the space and believe it or not, most men still get their TRT from primary care and urologists. Telemed and DTC is on the rise.
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This is absolutely not based on literature or guidelines. There is no data for optimal when men are normal, asymptomatic and healthy and your cutoff of 500 as low is against all literature. Please stop pushing incorrect information. You are recommending putting people on things for the rest of their life when they dont need it. There are real implications for this. Youre not trained in andrology, endocrinology or urology. You should not be advising this stuff
Jesse Morse, M.D.@DrJesseMorse
Men, if your total testosterone is under 500 ng/dL then you are symptomatic, you just might not know it. The standard normal range is between 250-1,000 ng/dL. It used to be up to 1,200 ng/dL in the 1990s and has decreased significantly since. The reasoning behind this is likely multi-factorial and a topic for a separate discussion. The most common symptoms I observe in men with a total testosterone is under 500 ng/dL are: Fatigue Brain Fog Difficulty shedding abdominal fat Low libido Sexual dysfunction (ED) Low motivation Low confidence Inability to put on muscle Difficulty growing facial/body hair The ‘optimal’ range for fertility is from 600-900 ng/dL. When someone consider testosterone hormone replacement therapy (TRT), in my opinion, the goal should be to get them in the optimal range of 600-900 ng/dL. Bring them back to where they should be. They don’t need to be in the 1,200 to 1,500 ng/dL range, just getting these men back to the optimal range will make a WORLD of difference. One of the ways I describe this to my patients is that if you’re car is running on ‘E’ (empty, low gas), your gas level is still technically in the ‘normal’ range. Would you be good with starting a race every day on E? Probably not. Just because your total testosterone is in the ‘normal’ 350 or 450 ng/dL doesn’t mean they are in the ‘optimal.’ Normal isn’t good enough. You deserve to be optimal. I see patients all the time, men under the age of 40, with total testosterone under 400 ng/dL. They’re suffering and they don’t deserve to be. Optimize your health. Don’t guess. Measure your hormone levels. Check the article I wrote recently below breaking everything down ⬇️
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@ArnieKapur99 @AJTraxler will post publicly! So far pdut at 0.03% and 0.3% have not inhibited systemic dht.
but 1% is a big jump so we’ll see
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First application of 1% Precision Dutasteride to a damp scalp.
I’ll apply it throughout the weekend, then repeat my serum DHT test on Monday.
Will I meaningfully suppress my serum DHT?
Time will tell
Anagen💈@anagenxyz
Can we block DHT in the scalp without blocking it throughout the body? That is the entire goal of Precision Dutasteride. Dutasteride inhibits both enzymes that produce DHT. In our initial testing, Precision Dutasteride 0.03% did not measurably lower serum DHT. Our clinical study is now testing three concentrations: > 0.03% > 0.3% > 1% But we want an early look at the highest dose. Today is Day 1 of Precision Dutasteride 1%: > @VerbinnenAndrew will apply it to a wet scalp for 3 days > @zach_schrier will apply it to a dry scalp for 3 days On Day 4, we draw their blood. Will we detect any dutasteride?
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How can TRT be descheduled? Is AUA focused on that? It’s an access issue first and foremost and many docs afraid to write so the compounders and async tele providers plus underground lab move in. If I had to guess vast majority of men on TRT not using traditional in person doctors / urologists.
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Just stating this random number of 500 and making the recommendations you are asking doesn’t really benefit anyone. It definitely doesn’t promote good patients care and it will continue to promote the overprescribing of testosterone in men who don’t need it. But are we also under-prescribing testosterone? Absolutely. Both are true and I see it in my practice every day.
The real way to make change is through education and policy change. The @AmerUrological is actively working with the FDA to update labels, change perceptions on TRT. They are working on updates to their TRT guidelines as we speak which includes a vigorous review of literature by leaders in the field.
By educating more men, and more practitioners on the indications, safety and benefits of identifying and treating low testosterone we all win. More men will ask about getting checked, more practitioners will be comfortable checking levels and either treating it themselves or referring to someone who does. The solution is not just picking 500 and saying let’s use that.
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CMS to doctors:
We have to cut same day EM charges by 50% if a procedure is performed and we must cut the overall fees to save money.
To hospitals: You can keep the facility fees, we don't mind overpaying you, we can always blamed the doctors!
@HEALTHCOSTtruth @HeathVeuleman @crappiedoc @pgipe @noahkaufmanmd
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Bijan Salehizadeh retweetledi
Could Sunday’s FIFA World Cup final be moved or delayed? Every indication FIFA officials are now scrambling amidst shifting smoke/air quality models for Sunday 5pm. One official says it’s become “a big f*cking nightmare.”
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Agree w/ this entirely.
TRT is medically beneficial for many men and frankly should be part of an annual screening for all men 30+. Many clinicians (and media) continue to completely confuse medical TRT with supra-physiological bodybuilding dosing of T.
Primary care docs are particularly bad at managing this since those who trained in 90s/early 00s were taught exogenous T is "dangerous" and to be avoided.
Just one example: 2021 T4DM trial (n=1,007 men with TT ≤404 ng/dL, belly fat, and prediabetes/T2DM). Those randomized to TRT saw a 40% relative risk reduction in type 2 diabetes at 2 years, and greater fat loss (-4.6 kg vs -1.9 kg), muscle gain, and waist size reduction vs. placebo.
Rory Not Sorry@rorynotsorry
I try and stay out of political discourse, but the weaponization of testosterone replacement therapy on both sides of the aisle disgusts me. Low testosterone is a very real issue that affects men’s quality of life.
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@christymaginn yeah patch is problematic for cost/supply reasons. Progesterone pills and estrogen topical very very cheap local pharmacy.
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@bijans Not sure on HRT for women pennies a day. But do agree. HRT is problematic as patch is expensive to produce and the full generic market went to the patch for women. Brand pulled out right before it got easier to access putting it in shortage and lots of recalls among the pellets.
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I listened in today on a policy call about the new proposal. A former senior government official said that CMS 100 percent knows about split scheduling risk if this rule is enacted and believes that most patients won’t put up with it and most doctors’ ethical guidance won’t allow them to ignore a procedure that needs to happen that same day.
That is absolutely wild as a justification. Basically a huge FU - good luck not getting sued by your patients if you put off that biopsy or procedure to many specialities.
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CMS 2027 proposal to cut E/M payment by 50% when billed same-day as a procedure will badly hurt patient access.
Practices will of course split visits - E/M one day, procedure the next - leading to many more appointments, longer wait times, patients missing second visits, more fragmented care.
This really burdens elderly/chronic patients who due to health and transport reasons need same-day evaluation + treatment.
Urge CMS to reconsider.
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Excellent and timely podcast episode by @RenaMalikMD about this topic.
I’m very much a believer in descheduling TRT and educating PCPs about it.
Even on this great episode, there is vehement disagreement about access. We need to separate androgen abuse from legit TRT replacement for men in need.
Can’t understand why this is so hard even for smart MDs to get.
pca.st/episode/439302…
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@christymaginn Yeah plus things regulators or practices patterns make difficult (HRT for women which should cost pennies a day generic but is compounded at huge markup)
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@bijans Everything else they compound isn't. It's just GLP-1s, ketamine, minoxidil, testosterone and estradiol that is the bulk of $$ makers for compounding pharmacies. It does seem like we have taken what payers don't want to mess with but people want and moved it to compounding.
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@mkarolian @StuartBlitz @slotkinjr Fair and fertility really needs to be thought through and HCG can help.
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@StuartBlitz @bijans @slotkinjr I am personally very split on the issue. Taking TRT shuts down the HPG axis and often doesn't rebound when you come off TRT.
I also think Ro, Hims, etc are predatory, to the point where there are certainly hundreds of thousands of men who are now hooked on it for life.
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Sure. So is everything else they compound.
And the reason it is compounded is because it is scheduled because the presumption is abuse and so writing it to a local CVS is difficult and risky.
I’m not sure how that is relevant to the clinical need and hundreds of papers supporting the need?
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