We aimed to understand the relationship between GLP-1 medications, weight change, and thyroid-stimulating hormone (TSH) levels. Lower TSH levels indicate improved thyroid function. We studied 21,538 patients with a history of hypothyroidism who were prescribed semaglutide, dulaglutide, liraglutide, or exenatide and stratified them by their weight change after starting the medication. The amount of weight change was calculated using the patient’s weight when they started the GLP-1 medication and their weight when a follow-up TSH level was taken. We found that patients who were prescribed semaglutide and lost more than five pounds saw the greatest reduction of their TSH levels, as seen in Figure 1. Patients who gained weight while prescribed any of the GLP-1 medications studied had no statistically significant change in their TSH levels. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 277 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 US states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Capuccio S, Scilletta S, La Rocca F, Miano N, Di Marco M, Bosco G, Di Giacomo Barbagallo F, Scicali R, Piro S, Di Pino A. Implications of GLP-1 Receptor Agonist on Thyroid Function: A Literature Review of Its Effects on Thyroid Volume, Risk of Cancer, Functionality and TSH Levels. Biomolecules. 2024; 14(6):687. https://doi.org/10.3390/biom14060687 
2. Agnihothri RV, Courville AB, Linderman JD, et al. Moderate weight loss is sufficient to affect thyroid hormone homeostasis and inhibit its peripheral conversion. Thyroid. 2014;24(1):19-26. doi:10.1089/thy.2013.0055

To assess the potential benefit of a second lead level test, we studied 42,709 children who had their blood lead levels tested at both 12 and 24 months of age. Of the patients who tested positive, only 228 (0.53%) tested positive at both 12 and 24 months of age. We found that 735 kids (1.72%) tested negative at 12 months but had a positive blood lead level at 24 months. This indicates that further testing among those whose initial test was negative is beneficial in identifying future exposure to lead. For those whose initial test was positive, 629 kids (1.47%) went on to test negative at 24 months, indicating improvement to a non-toxic level of lead one year later. Of note, overall positivity rates remain low, as seen in Figure 1. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 277 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Testing for lead poisoning in children. Childhood Lead Poisoning Prevention. U.S. Centers for Disease Control and Prevention. Published May 23, 2024. https://www.cdc.gov/lead-prevention/testing/index.html. Accessed July 25, 2024. 
2. DHS asking parents to test their children for lead poisoning. (2024, August 9). WBAY. https://www.wbay.com/2024/08/09/dhs-asking-parents-test-their-children-lead-poisoning/ 

We found that the rate of ED visits related to caffeine overdose or adverse effects more than doubled for middle school aged children, from 3.1 per 100,000 visits in 2017 to 6.5 per 100,000 visits in 2023. Similarly, the rate nearly doubled for high school aged children, from 7.5 per 100,000 visits to 13.7 per 100,000 visits. Additionally, in all but the youngest population, male patients had much higher rates of caffeine-related ED visits than female patients, sometimes triple the rate. This aligns with prior findings that males have an increased response to caffeine compared to females, which might result in more adverse reactions.⁴ 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 277 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 US states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Mostafavi B. Does your teen consume too much caffeine? Michiganmedicine.org. https://www.michiganmedicine.org/health-lab/does-your-teen-consume-too-much-caffeine?pk_vid=3b258245eb72401b17162667816565e5. Accessed October 9, 2024. 
2. Spilling the beans: How much caffeine is too much? U.S. Food and Drug Administration. August 29, 2024. https://www.fda.gov/consumers/consumer-updates/spilling-beans-how-much-caffeine-too-much. Accessed October 9, 2024. 
3. Murray A, Traylor J. Caffeine Toxicity. [Updated 2023 Jun 26]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK532910/. Accessed November 4, 2024.  
4. Temple JL, Ziegler AM, Graczyk A, Bendlin A, Sion T, Vattana K. Cardiovascular responses to caffeine by gender and pubertal stage. Pediatrics. 2014;134(1):e112-e119. doi:10.1542/peds.2013-3962 

We found that asthma diagnosis rates dropped for patients of all ages in 2020 and 2021, as seen in Figure 1. For individuals 12 and older, the rates have remained lower than the baseline through 2023. However, for children under 12, these rates have trended back toward pre-pandemic levels. 

Next, we examined the rate of face-to-face encounters for asthma to understand care-seeking trends. For pediatric patients under 18, while the percentage of asthma encounters has increased from the pandemic period lows, rates have not returned to pre-pandemic levels. In contrast, those 18 and older maintained a steady rate of seeking care for asthma between 2017 and 2023. 

To assess changes in asthma severity, we investigated the rate of asthma-related ED visits between 2017 and 2023. We observed a decline in the percentage of ED visits that were for asthma for all age groups. This trend aligns with the American Lung Association’s report of a decrease in asthma-related ED visits between 2016 and 2020 and expands on those findings, indicating a continued decline beyond 2020.³ 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 US states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Philip KEJ, Buttery S, Williams P, et al. Impact of COVID-19 on people with asthma: a mixed methods analysis from a UK wide survey. BMJ Open Respir Res. 2022;9(1):e001056. doi:10.1136/bmjresp-2021-001056 
2. American Lung Association. COVID-19 and asthma: What you need to know. Lung.org. https://www.lung.org/blog/covid-19-asthma-faqs.  
3. American Lung Association. COVID-19 and asthma: What you need to know. Lung.org. Accessed September 20, 2024. https://www.lung.org/blog/covid-19-asthma-faqs. Accessed September 20, 2024. 

We studied 2,983 patients prescribed semaglutide or liraglutide and matched them with 2,983 patients without a GLP-1 medication based on age, diabetes diagnosis, the year of their initial lab, the time between initial and follow-up lab readings, their percentage change in their BMI over the study period, and their Social Vulnerability Index score. Patients were required to have at least two CRP or ESR levels at least 30 days apart to be included. 

While follow-up CRP levels decreased for all groups except non-diabetics prescribed liraglutide, none of those changes were significant, as seen in Figure 1. 

Next, we evaluated the change in ESR levels. Patients with and without diabetes did not have a significant change in their ESR levels between their initial and follow-up readings, as seen in Figure 2. 

These findings suggest that these GLP-1 medications do not meaningfully influence inflammation as measured by inflammatory markers after adjusting for weight loss. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Menzel A, Samouda H, Dohet F, Loap S, Ellulu MS, Bohn T. Common and novel markers for measuring inflammation and oxidative stress ex vivo in research and clinical practice—which to use regarding disease outcomes? Antioxidants (Basel). 2021;10(3):414. doi:10.3390/antiox10030414 
2. Mehdi, S. F., Pusapati, S., Anwar, M. S., Lohana, D., Kumar, P., Nandula, S. A., Nawaz, F. K., Tracey, K., Yang, H., LeRoith, D., Brownstein, M. J., & Roth, J. (2023). Glucagon-like peptide-1: a multi-faceted anti-inflammatory agent. Frontiers in Immunology, 14. https://doi.org/10.3389/fimmu.2023.1148209 
3. Forsythe LK, Wallace JM, Livingstone MB. Obesity and inflammation: the effects of weight loss. Nutr Res Rev. 2008;21(2):117-133. doi:10.1017/S0954422408138732 

To better understand whether women prescribed GLP-1 medications have an increased rate of pregnancy, we studied 27,054 women aged 18 to 50 who were prescribed a GLP-1 medication and matched them by age, BMI, conditions affecting fertility, and history of diabetes to 180,866 women who were not prescribed a GLP-1 medication. We found that the rate of pregnancy in the year following GLP-1 treatment, or a matched visit for women not prescribed a GLP-1 medication, was similar for women who were not prescribed a GLP-1 medication and those who were prescribed semaglutide, liraglutide, tirzepatide, exenatide, or dulaglutide, as shown in Figure 1. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 35,500 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Camero, K. (2024, March 21). “Ozempic babies” are surprising women taking weight loss drugs. Doctors think they know why. USA Today. https://www.usatoday.com/story/life/health-wellness/2024/03/21/ozempic-pregnancy-weight-loss-drugs-fertility/73032645007/.  
2. Pawlowski, A. (2023, April 24). Ozempic babies: Weight loss drugs, pregnancy risks, fertility benefits. TODAY. https://www.today.com/health/womens-health/ozempic-pregnancy-fertility-rcna81104.  

To understand the effect on patients with asthma who depend on these long-acting medications, we looked at the rate of emergency department (ED) visits, admissions, and ICU stays for asthma in the periods before and after the change in availability of Flovent. We studied 3,312,869 patients who were prescribed fluticasone propionate within the six months preceding the quarter of interest. We studied only the first and second quarter of each year to control for seasonality. A patient’s fluticasone propionate prescription may have been for Flovent, the authorized generic, another brand, or an independent generic. 

In the first and second quarters of 2024, the rates of all types of visits were higher than the same periods averaged over 2022 and 2023. When looking at inpatient admissions, the rate of visits which were asthma related increased 17.5% for Q1 and 24.1% for Q2 compared to the average of the same quarters in 2022 and 2023.  

Asthma-related ICU admissions also increased in 2024. In the first quarter, the rates were 17.4% higher than the average of the same quarters in 2022 and 2023, while they were 21.3% higher in Q2. 

Lastly, while still increased, the rate of asthma-related ED visits had the lowest increase of the encounter types. In Q1 2024, the rate was 6.5% higher than the average of the same quarter in 2022 and 2023, while in Q2 2024, the rate was 3.6% higher. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Asthma medications: Know your options. Mayo Clinic. Published July 2, 2024.  https://www.mayoclinic.org/diseases-conditions/asthma/in-depth/asthma-medications/art-20045557. Accessed September 4, 2024. 
2. Coltrera F. Still confused after Flovent discontinuation? What to know and do. Harvard Health. Published February 16, 2024. https://www.health.harvard.edu/blog/still-confused-after-flovent-discontinuation-what-to-know-and-do-202402163016. Accessed September 4, 2024.4, 2024. 
3. Treatment with FLOVENT HFA (fluticasone propionate inhalation aerosol). Flovent.com. https://www.flovent.com/. Accessed September 4, 2024. 

We studied 182,477 children born between 2009 and 2016 who had a well-child visit during their eighth year of life, as this is when the U.S. Preventive Services Task Force suggests beginning anxiety screening.³ We adjusted for patient age, sex, race, ethnicity, history of other mental health disorders, mother’s history of anxiety or depression, insurance coverage type, premature birth, Social Vulnerability Index quintile, Rural Urban Commuting Area classification, and BMI. 

Children born first who have siblings had a 48% greater likelihood of being diagnosed with anxiety by their eight-year well-child visit compared to children who were born second or later, as seen in Figure 1. Similarly, only children had a 42% greater likelihood of anxiety than children born second or later. 

The likelihood of depression is higher for both firstborn children with siblings and only children, as seen in Figure 2. Firstborn children were 35% more likely to be diagnosed with depression compared to those who were born second or later, while only children were 38% more likely. 

Original Publication Date: October 15, 2024
Last Updated: October 22, 2024

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Kowalchuk A, Gonzalez SJ, Zoorob RJ. Anxiety disorders in children and adolescents. Am Fam Physician. 2022;106(6):657-664. https://www.aafp.org/pubs/afp/issues/2022/1200/anxiety-disorders-children-adolescents.html. Accessed September 3, 2024. 
2. Moore PS, Mokrova I, Frazier JA, et al. Anxiety and depression correlates at age 10 in children born extremely preterm. J Pediatr Psychol. 2021;46(4):422-432. doi:10.1093/jpepsy/jsaa118 
3. Anxiety in children and adolescents: Screening. U.S. Preventive Services Task Force. Published October 11, 2022. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-anxiety-children-adolescents. Accessed September 30, 2024. 

To understand whether this termination of coverage varied across different age groups, we studied 196 million emergency encounters between January 2017 and June 2024 to assess the proportions of encounters with a coverage type of self-pay by age group. Because 47.1% of Medicaid and Children’s Health Insurance Programs (CHIP) enrollees are under the age of 18,⁵ we were particularly interested in how the rate of self-pay encounters changed for pediatric patients.  

We found that the self-pay rate for all age groups decreased throughout the period of continuous coverage during the COVID-19 pandemic and began to increase again when coverage terminations began in April 2023, as shown in Figure 1. While most age groups returned to their pre-pandemic baselines by June 2024, patients under age 18 exceeded the pre-pandemic average self-pay rate of 3.4%, reaching a rate of 5.4% of emergency encounters in June 2024, an increase of nearly 60%. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,557 hospitals and more than 35,000 clinics from all 50 states and Lebanon. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. Unwinding and returning to regular operations after COVID-19. (n.d.). Medicaid.gov. https://www.medicaid.gov/resources-for-states/coronavirus-disease-2019-covid-19/unwinding-and-returning-regular-operations-after-covid-19/index.html. Accessed September 5, 2024.  
2. Tsai, D. Extension of Temporary Unwinding-Related Flexibilities. Centers for Medicaid & CHIP Services. https://www.medicaid.gov/federal-policy-guidance/downloads/cib050924-e14.pdf. Published May 9, 2024. Accessed September 5, 2024. 
3. Lopes L, Sparks G, Presiado M, et al. KFF Survey of Medicaid Unwinding. KFF. https://www.kff.org/medicaid/poll-finding/kff-survey-of-medicaid-unwinding/. Accessed September 12, 2024.  
4. Galewitz P, Houghton K, Kelman B, Liss S. ‘Worse than People Can Imagine’: Medicaid ‘Unwinding’ Breeds Chaos in States. KFF Health News. https://kffhealthnews.org/news/article/medicaid-unwinding-disenrollment-redetermination-state-delays/. Accessed September 12, 2024.  
5. April 2024 Medicaid & CHIP Enrollment Data Highlights. Medicaid. April 2024 Medicaid & CHIP Enrollment Data Highlights | Medicaid. Accessed September 5, 2024.  

To understand the rate of secondary cancer among patients who received CAR T-cell therapy, we studied 3,296 patients treated with CAR T-cell therapy between January 1, 2017, and August 1, 2023. Secondary cancers included both metastatic cancers and second primary cancers. Overall, we found that 5.2% of treated patients had a new cancer diagnoses three weeks to one year after the start of CAR T-cell therapy, as seen in Figure 1. When we stratified the data by the specific CAR T-cell therapy, we found small variations in the rate of secondary cancer, though no specific treatment was significantly different from the overall rate. 

Skin, respiratory organ, and digestive organ cancers were the most diagnosed types of secondary cancers for patients who had received CAR T-cell therapy, as seen in Figure 2. 

These data come from Cosmos, a dataset created in collaboration with a community of Epic health systems representing more than 274 million patient records from 1,500 hospitals and more than 36,000 clinics from all 50 states, Lebanon, and Saudi Arabia. This study was completed by two teams that worked independently, each composed of a clinician and research scientists. The two teams came to similar conclusions. Graphics by Brian Olson. 

1. CAR T-cell therapy and its side effects. American Cancer Society. Published March 1, 2022. https://www.cancer.org/cancer/managing-cancer/treatment-types/immunotherapy/car-t-cell1.html. Accessed August 28, 2024. 
2. FDA Requires Boxed Warning for T cell Malignancies Following Treatment with BCMA-Directed or CD19-Directed Autologous Chimeric Antigen Receptor (CAR) T cell Immunotherapies. U.S. Food & Drug Administration. Published April 18, 2024. https://www.fda.gov/vaccines-blood-biologics/safety-availability-biologics/fda-requires-boxed-warning-t-cell-malignancies-following-treatment-bcma-directed-or-cd19-directed. Accessed August 28, 2024. 
3. Conger K. Risk of secondary cancers after CAR-T cell therapy low, according to large Stanford Medicine study. Stanford Medicine. Published June 12, 2024. https://med.stanford.edu/news/all-news/2024/06/car-t-secondary-cancer.html. Accessed August 28, 2024. 
4. Raeke M. Secondary cancers following CAR T cell therapy are rare. Penn Medicine. Published January 24, 2024. https://www.pennmedicine.org/news/news-releases/2024/january/secondary-cancers-following-car-t-cell-therapy-are-rare. Accessed August 28, 2024.