Old concept: Love is blind. Marriage is an eye-opener.
New concept: Love is not blind - it simply enables one to see things others fail to see.
Johann Sebastian Bach
I am happy to contribute to the editorial by Lisa Eramo published in Medical Economics, January 2018. The article is important as it raises physician awareness of Merit-based Incentive Payment System (MIPS) under which hypertension management falls. MIPS, part of 2015 MACRA, will go into effect in 2019.
This meta-analysis of four major clinical trials (ELIXA, LEADER, SUSTAIN 6, EXSCEL) reveals safety of GLP-1 agonists, bur more importantly their cardiovascular benefits on mortality, myocardial infarction and stroke in adults with type 2 diabetes.
The next natural step would be the quest for oral version of GLP-1 agonist given its positive profile on appetite, glucagon, insulin, glucose metabolism, proteinuria and cardiovascular system.
Now we have long-term data from the original HiLo trial. Patients with no distant metastasis, well-differentiated thyroid carcinoma do as well with low-dose radioactive iodine (30 mCi) treatment compared to those receiving the high dose RAI (100 mCi).
Unless distant metastasis is documented, patients with well-differentiated papillary or follicular cancer should receive 30 mCi I-131 when indicated. A group of 450 patients was followed for about 7 years.
This major observational study shows that the tight control of risk factors is associated with much lower rates of cardiovascular events and total mortality in patient with type 1 diabetes. Such factors are hyperglycemia, systolic blood pressure, protein in the urine, and the “bad” cholesterol (A1c, sBP, McAlb, LDLc).
This association has already been seen in adults with type 2 diabetes. For a practitioner, this study calls for a tight control of the above risk factors in patients with type 1 diabetes as in those with type 2. A group of 30,000 DM1 individuals were followed for about 10 years
This simple study shows that frozen red raspberries in quantities of 125-250 mg (1-2 cups), when taken with a typical high-carb breakfast, improve insulin resistance in adults with prediabetes. Although these results would need to be validated, having red raspberries for breakfast sounds just right.
This 5-year observational study shows that thyroid hormone supplementation increases major adverse cardiovascular events (MACE), cardiovascular death, and all-cause mortality in patients with heart failure. Indirectly, this is in accordance with the well-documented benefits of beta-adrenergic receptor blockade in persons with cardiac failure.
Clinically, in patients with concomitants hypothyroidism and heart failure, thyroid hormone supplementation should be started at a low dose, increased slowly, and aiming a higher TSH target than in general population.
A nice academic demonstration of the Woltman’s sign in a patient with profound hypothyroidism, who’s TSH was 200 mIU/L. Delayed relaxation of the ankle reflex normalized as TSH improved with proper thyroid hormone supplementation. The Woltman’s sign could be useful if thyroid laboratory testing is not available and the patient’s baseline ankle reflex is known.
This short phase 2 clinical trial shows that the oral insulin 338 improves fasting plasma glucose similar to the long-acting insulin glargine. Hypoglycemia rates are also similar. However, further studies of the oral insulin 338 are halted due to its need for high doses and cost. A group of 50 patients were followed for 8 weeks. The quest for the first oral insulin, nonetheless, continues.
Clinical experience has consistently shown that addition of a GLP-1 agonist to a SGLT2 inhibitor improves hyperglycemia in patients with uncontrolled diabetes. Current study SUSTAIN 9 proves just that for semaglutide, a once weekly injectable GLP-1 agonist.
Addition of semaglutide reduced A1c by 1.4% and bodyweight by 8.4 lbs. Results were statistically significant. As expected, the GI side effects were more pronounced with semaglutide. About 72% of patients were also taking metformin and 13% sulfonylurea.
A group of 300 participants were followed for 30 weeks.
The current study is of a major clinical significance as it shows that EPA lowers ischemic cardiovascular events by 25% in high rick CVD patients who are already receiving statin therapy. The EPA treated patients, however, experienced more hospitalizations for atrial fibrillation and a higher propensity for serious bleeding than placebo. Findings are remarkable as they come from a major randomized clinical trial (IMPROVE IT). About 8,000 patients were followed for 5 years.
This outcome data is in accordance with established observation and notion that hypertriglyceridemia is an independent risk factor for cardiovascular disease, mainly via increased inflammation and concentration of the non-HDL cholesterol. Prior clinical studies have also shown that EPA lowers non-HDL cholesterol more than DHA.
Omega-3s, EPA and DHA, are two key ingredients of fish oil. A stable and pure form of EPA has been FDA approved for very high serum triglyceride >500 mg/dL since 2012. It is marketed under the brand-name vascepa. Lovaza, a mixture of EPA and DHA, has also been approved by FDA since 2004 for severe hypertriglyceridemia.
I anticipate that in the future NLA, ACC/AHA, AACE and ADA guidelines will reflect and incorporate the current findings of IMPROVE IT.
From about the year 1720, when he was thirty-five, until his death in 1750, Bach's harmony consists in this melodic interweaving of independent melodies, so perfect in their union that each part seems to constitute the true melody. Herein Bach excels all the composers in the world.
At least, I have found no one to equal him in music known to me. Even in his four-part writing we can, not infrequently, leave out the upper and lower parts and still find the middle parts melodious and agreeable.