Monthly Archives: October 2021

Since my last post on booster shots for Covid-19, the CDC issued important updates. Here’s an explanation of the latest recommendations.

What is a Covid vaccine booster?

A Covid vaccine booster is an additional shot beyond the initial regimen. Boosters are not a different formulation of the vaccines. The Moderna booster is half of the original dose. The Pfizer and Johnson & Johnson (J&J) boosters are the same dose. 

Why are boosters being given?

To further enhance immune protection from Covid-19. The additional shot reduces the risk of becoming infected, spreading the virus to others, and developing severe disease. 

Some people with weakened immune systems might not have achieved a sufficient immune response to their first two Covid shots. Common examples of this situation are people on medicines to suppress their immune system to treat autoimmune diseases or to prevent rejection of an organ transplant. 

But even in people with intact immune systems, immune protection from the vaccine gradually wanes over time. Receiving an additional shot restores and enhances protection. For instance, a randomized trial with the Pfizer vaccine showed that people who received a third shot had a relative vaccine efficacy of 95.6% compared to those who only received 2 shots.

Who should receive a booster?

People with weakened immune systems.

This includes people taking medicines that suppress their immune system to treat cancer or autoimmune conditions or to prevent rejection of a transplanted organ. It also includes people with conditions that impair the immune system such as certain cancers or AIDS. If you have a weakened immune system, you should receive a shot of Pfizer or Moderna vaccine at least 28 days after your second shot of Moderna or Pfizer or at least 28 days after your one shot of J&J. 

All people who received the J&J vaccine.

Even if you aren’t immunosuppressed, you should receive an additional Covid shot at least 2 months after your J&J vaccine. You can get the Pfizer, Moderna, or a second J&J shot. There is evidence that getting a Pfizer or Moderna shot will provide more protection than a getting second J&J shot. If you are a woman under 50 years old, I recommend you get a Pfizer or Moderna shot rather than a second J&J. This is because in this population the J&J vaccine has been associated with a very rare, but serious clotting disorder.

All people above age 65 who received either the Moderna or Pfizer vaccine.  

You should receive an additional shot of either Moderna or Pfizer 6 months after your second shot. 

People between 18 to 65 years old with chronic health conditions who received either the Moderna or Pfizer vaccine.

If you have chronic health conditions such as diabetes, coronary artery disease, or asthma, you should receive an additional shot of either Moderna or Pfizer 6 months after your second shot.

People between 18-65 years old who live or work in a setting that puts them at a higher risk of getting Covid and received either the Moderna or Pfizer vaccine.

This includes people who live in long-term care settings, along with teachers, grocery store workers, and health care workers. If you fall into this category, you can receive an additional shot of either Moderna or Pfizer 6 months after your second shot. 

If I received Moderna or Pfizer for my first two shots, for my third should I stick with the same vaccine or switch to another one?

It is acceptable to receive the same vaccine or switch. So if you received Pfizer for your first two shots, you can get a third Pfizer shot or switch to Moderna. Likewise, if you received Moderna for your first two shots, you can get a third Moderna shot or switch to Pfizer. The safety and efficacy of sticking with the same shot versus switching appear to be similar. 

Where should we get our Covid booster shot?

It is widely available at many pharmacies. It works best to make an appointment with the pharmacy online. When you sign up for the booster, you can indicate you are in one of the categories that makes you eligible. Some doctor’s offices and public health departments are also offering boosters.

Can I get my flu shot and Covid booster at the same time?

Yes. The CDC states it is safe to do so.

This week was supposed to be part 2 of Protecting Your Mind as You Age. But in the meantime, the US Preventative Task Force released guidance on Aspirin. Our office has received many calls asking for guidance. Thus, it will be this week’s topic.

Background

First, let me put Aspirin in context. Aspirin decreases your body’s ability to form blood clots by making cells called platelets less sticky. When you have a heart attack, a clot forms in an artery that supplies blood to the heart, thereby blocking the heart’s ability to get blood. The same thing happens in most strokes. So by lowering your tendency to form clots, Aspirin can lower the risk of heart attacks and strokes. 

Aspirin also decreases inflammation. Inflammation is an important part of our immune system’s response to sickness or injury. But prolonged inflammation can cause harm. Aspirin’s anti-inflammatory effect is thought to be the mechanism by which it may lower risk of developing colon cancer according to a number of studies.

But like most meds, Aspirin has downsides. Hindering your ability to form clots increases the risk of bleeding in your brain and digestive tract. As we age, the risk from bleeding increases. For instance, an older person who falls and hits their head might be more prone to bleed in their brain if they’re on Aspirin.

So Should I Take Aspirin?

It depends on your unique health situation, including your medical conditions and the other meds you take. So you should communicate with your doctor if you’re not sure what to do. In the interim, stay on Aspirin if your doctor instructed you to do so. Here are the principles your doctor will use to decide if Aspirin will help you.

Aspirin lowers risk of heart attacks and strokes in people with coronary artery disease and cerebrovascular disease.

If you’ve had a heart attack or been found to have significant narrowing in your coronary (heart) arteries, Aspirin has proven benefit. Likewise, if you’ve had a stroke, Aspirin has evidence of lowering the risk of having another one. So for many people with coronary artery disease and cerebrovascular disease, Aspirin continues to be beneficial. But even here the details matter. For instance, some with people with coronary artery disease or cerebrovascular take other meds that decrease clotting such as Plavix, Eliquis, Warfarin, or Xarelto. Adding Aspirin to these meds might do more harm than good. This kind of scenario is why there is no substitute for communicating with your doctor about your particular situation.

Aspirin doesn’t have strong evidence for preventing heart attacks and strokes in people without coronary artery disease or cerebrovascular disease.

If you don’t have significant narrowing in your coronary arteries or have never had a heart attack, there isn’t strong evidence Aspirin will lower your risk of having heart disease. Likewise, if you’ve never had a stroke or mini-stroke, Aspirin doesn’t have strong evidence for decreasing your risk of having a stroke. In these scenarios, you’re unlikely to benefit from Aspirin, but it will increase your risk of bleeding. The bad outweighs the good.

What the U.S. Preventative Task Force (USPTF) Recommended

USPTF is an organization that reviews evidence and provides guidance on how to prevent health problems.  After reviewing the latest studies on Aspirin, USPTF issued updated recommendations for people without a history of coronary artery disease or cerebrovascular disease. If you have a history of narrowing in your coronary arteries, having a heart attack, or having had a stroke or mini-stroke, these recommendations, don’t apply to you.

In people 60 years and older, do not start Aspirin to prevent cardiovascular disease. 

This is because Aspirin doesn’t have strong evidence to prevent heart disease. It does, however, increase the risk of bleeding–a risk that worsens with age.

In people 40-59 years old, discuss whether or not to start Aspirin with your doctor.

A risk calculator can estimate your risk of developing cardiovascular disease over the next 10 years. It takes into account risk factors such as diabetes, smoking history, cholesterol level, and family history of heart disease. If your estimated risk is over 10%, you and your doctor can discuss if the benefits of taking Aspirin outweigh the increased risk of bleeding.

Bottom Line

If your physician has instructed you to be on Aspirin, stay on it until you’ve communicated with him or her. If you’ve had a heart attack or narrowing in your coronary arteries that required a stent or bypass surgery, you’ll most likely need to stay on Aspirin. The same is true if you’ve had a stroke or mini-stroke. If you don’t have a history of coronary artery disease or cerebrovascular disease and are taking Aspirin, talk with your physician about whether it’s worth continuing to do so. There is no urgency in having this conversation. The risk from taking a low dose Aspirin (such as 81 mg) daily over a short period of time is low. 

When working with patients to control cardiovascular disease risk factors such as hypertension and high cholesterol, I find most people are more concerned with preventing a stroke than a heart attack. This is understandable. Our brain is responsible for so much of what makes life meaningful—talking, thinking, remembering, walking, feeling. Indeed, the brain is essential to who we are. It is the one organ we can’t transplant and still be the same person. People are justifiably concerned with protecting this most crucial organ.

Of course, strokes are not the only malady that can afflict our brains. Perhaps the most feared brain diseases are the dementias, the most common of which is Alzheimer’s. Although genes play a role in developing dementia, research tells us that there are a number of steps individuals can take to lower their risk of developing it. Prevention is especially important because unfortunately we currently do not have effective treatments for dementias such as Alzheimer’s.

Exercise

Exercise is the intervention with the most evidence for enhancing and protecting your brain. It does so through multiple mechanisms. Exercise lowers elevations in blood sugar and blood pressure levels that have been shown to be harmful to the brain. It also decreases inflammation and helps improve sleep. It increases our body’s production of endorphins which are chemicals that relief pain and lift our mood. Finally, exercise stimulates the release of growth factors that promote function of brain cells. 

Aim for at least 30 minutes every day of some form of exercise. This can include aerobic activities such walking, jogging, biking, or tennis. It also includes resistance training to keep our muscles strong. This can involve going to the gym for weight training or using our own body weight with push-ups, planks, squats, lunges, or yoga. There is some evidence that racquet sports like tennis, pickleball, or racquetball offer the most benefit since they involve connecting with other people as we move.

Sleep

During sleep our brain washes away metabolic debris, including the proteins that contribute to amyloid plaques found in Alzheimer’s Disease. Sleep also decreases inflammation which has been associated with neurodegenerative diseases like Alzheimer’s. Thus it is not surprising that lack of sleep has been associated with an increased risk of dementia.

One common form of sleep disruption is obstructive sleep apnea (OSA). In OSA, tissues in the back of throat collapse, thereby blocking the airway. The person stops breathing, preventing them from getting deep, restorative sleep. OSA is manifested by the bed partner reporting the individual is snoring or even gasps for breath. The person may not feel refreshed in the morning and feel the need to sleep later in the day, especially while engaging in non-stimulating activities such as watching TV or sitting at a stop light. If you’re concerned you might have OSA, schedule an appointment with a sleep physician to schedule a sleep study. 

Here are some keys to getting a good night of sleep:

1. Go to bed and get up at a consistent time. 
2. Expose yourself to sunlight for at least 5 minutes in the morning as soon as you get up.
3. Exercise.
4. Don’t drink caffeine after noon. It stays in your system and impairs deep, restorative sleep.
5. Don’t eat for four hours before bed.
6. Limit alcohol at night since it can hurt quality of sleep.
7. Keep the bedroom cool, quiet, and dark.
8. Keep your cell phone out of the bedroom
9. Set aside 30-60 minutes before bed for a relaxing bedtime ritual such as a bath, meditation, praying, reading, or calming music.
10. Don’t do anything in bed except sleep or sex. You want your mind to associate bed with sleep.
11. If you get up to go to the bathroom, don’t look at the time. This will cause anxiety and make it harder to get back to sleep. 
12. If you can’t get to sleep, go to a dimly lit room and read a boring book until you feel sleepy. Then go back to bed.

Next week I’ll discuss more evidence-based strategies for protecting your brain and lowering your risk of dementia as you age.

Over the past few weeks in my clinical practice I’ve had many conversations with patients about Covid boosters. Here’s some basic information to help make sense of it all.

What is Covid vaccine booster?

A Covid vaccine booster is simply an additional shot of the same vaccine. For example, if your first covid two shots were Pfizer, a booster is getting a third Pfizer shot. At this point, boosters are not a different strength or formulation of the vaccines.

Why are boosters being given?

For two reasons. 

First, some people with weakened immune systems might not have achieved a sufficient immune response to their first two Covid shots. Common examples of this situation are people on medicines to suppress their immune system to treat autoimmune diseases or to prevent rejection of an organ transplant. For such individuals, receiving a third shot will improve their immune system’s capacity to respond to Covid if they encounter it. 

The second reason for boosters is to restore immune protection from Covid that may wane over time. Thus far the biggest concern about waning protection is with the Pfizer vaccine. CDC data from September showed that beyond 120 days after the second dose of Pfizer, effectiveness of protection from hospitalization fell from 91 percent down to 77 percent. A study from Israel showed that among people 60 years or older who had been vaccinated 5 months earlier, those who had received a third shot of Pfizer were 19.5 times less likely to have severe Covid than those who had only received two shots.  

Protection from the Moderna vaccine seems to be waning less than Pfizer. The same CDC data that showed decreasing protection from Pfizer over time showed no such diminishment with Moderna. It found that Moderna vaccine continues be 92 percent effective against hospitalization even four months after the second shot.

Who should receive a booster?

There are two categories of people for whom the Centers for Disease Control (CDC) recommends a booster.

The first category are people with moderately or severely weakened immune systems. This includes people taking medicines that suppress their immune system to treat cancer or autoimmune conditions or to prevent rejection of a transplanted organ. It also includes people with conditions that impair the immune system such as certain cancers, immunodeficiencies, or advanced HIV. 

If you have a weakened immune system, you should receive a third shot of your Pfizer or Moderna vaccine at least 28 days after your second shot. The CDC did not make a recommendation about whether immunosuppressed people who received Johnson and Johnson should get an additional shot. But based on the recommendation of trustworthy experts, I recommend that immunosuppressed people who got the J&J get a booster with Pfizer, Moderna, or J&J.

The second category are certain individuals who received their second Pfizer shot over 6 months ago.

-If you are 65 years or older and received your second Pfizer shot over 6 months ago, you should get a Pfizer booster.

-If you are 18 years and older and have a health condition such as diabetes or heart disease, you are eligible to receive a third dose of Pfizer vaccine 6 months after your second one.

-If you are 18 years and older and live or work in a setting that puts you at risk of getting Covid, you are eligible to receive a third dose of Pfizer vaccine 6 months after your second one.  This category includes people who live in long-term care settings, along with teachers, grocery store workers, and health care workers. 

Should I get a booster if I received the Moderna vaccine? 

Only if your immune system is suppressed by a medicine or a health condition according to current CDC recommendations. But stay tuned because the FDA will be meeting on October 14 to discuss Moderna boosters and on October 15 to discuss J&J boosters.

Where should we get our Covid booster shot?

The simplest way is by making an appointment online with a pharmacy in your area. When you sign up for the booster, you can indicate you are in one of the categories that makes you eligible.

Can I get my flu shot and Covid booster at the same time?

Yes. The CDC states it is safe to do so.