Articles

Thyroid cancer: low-dose radioactive iodine works in the long term too

Thyroid cancer: low-dose radioactive iodine works in the long term too

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.

GT

Risk factors control is also important in type 1 diabetes

Risk factors control is also important in type 1 diabetes


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

GT

Red raspberries for breakfast

Red raspberries for breakfast

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.

GT

Incidence of Cushing's disease is on the rise

Incidence of Cushing's disease is on the rise

The study finds that the incidence of pituitary Cushing is still rare but increased over the past 30 years. Its current incidence is estimated to be 2.0 cases/million/year. However it is unknown if this increase is real or due to improved physician awareness and biochemical testing.

GT

Thyroid supplementation in heart failure

Thyroid supplementation in heart failure

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.

GT

The lost Woltman’s Sign of Hypothyroidism

The lost Woltman’s Sign of Hypothyroidism

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.

GT

Oral insulin 338 is effective but expensive

Oral insulin 338 is effective but expensive

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.

GT

Addition of Ozempic to a SGLT2 inhibitor improves hyperglycemia and bodyweight

Addition of Ozempic to a SGLT2 inhibitor improves hyperglycemia and bodyweight

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.

GT

Vascepa (fish oil) reduces ischemic cardiovascular events in high risk patients

Vascepa (fish oil) reduces ischemic cardiovascular events in high risk patients

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.

GT

Lipoprotein(a), Familial Hypercholesterolemia and CVD

Lipoprotein(a), Familial Hypercholesterolemia and CVD

Familial hypercholesterolemia (FH) has a high prevalence of cardiovascular morbidity and mortality, due to the lifelong cumulative exposure of high serum cholesterol levels.

The study finds that only a minority of patients are capable of achieving LDLc targets set by the European guidelines. About 25% of FH patients reach LDLc ≤100 mg/dL and only 8% of very high-risk CVD patients reach LDLc ≤70 mg/dL.

Importantly, those with high Lp(a) experienced twice as much CHD events than those with low Lp(a) levels. Specific drug development toward Lp(a) would be a breakthrough in helping patients with familial hypercholesterolemia.

A group of 714 FH adults were followed for about 11 years.

GT

Jardiance lowers blood pressure significantly in African American adults

Jardiance lowers blood pressure significantly in African American adults

Jardiance shows positive outcomes in African American adults. It reduces the A1c by 0.8%, body weight by 2.7 pounds and more interestingly the systolic blood pressure by 8 mmHg, similar to a standard blood pressure medication.

A group of 150 African American participants were randomized to receive Jardiance 25 mg daily or placebo for 6-months.

The SGLT2 inhibitor would be a great choice for patients with concomitant hyperglycemia and systolic hypertension.

GT

Newer diabetes medications also help prevent heart and kidney disease

Newer diabetes medications also help prevent heart and kidney disease

About 80,000 diabetes patients were analyzed from 8 clinical trials.

Authors found that GLP1 agonists and SGLT2 inhibitors prevented cardiovascular events (MACE) equally by 14% in those with established CVD. However, both classes of medications did not appear to be effective in reducing MACE in adults with diabetes but without established CVD.

SGLT2 inhibitors showed superior results compared to GLP1 agonists in regard to preventing hospitalizations for heart failure or severe kidney disease progression, such as end-stage-renal disease or death.

If cost, side effects, drug interactions and contraindications allow, diabetes patients would greatly benefit from these therapies on three fronts; glucose control, heart and kidney disease prevention.

GT

Pituitary enlargement due to hypothyroidism

Pituitary enlargement due to hypothyroidism

Another nice report of total pituitary enlargement due to the long-standing untreated primary hypothyroidism. Low levels of FT3 and FT4 lead to excessive TRH and TSH production, in turn causing pituitary expansion.

This case is unique as it is found in a child suffering from growth retardation. Proper treatment with thyroid hormone supplementation reversed the illness.

GT

2018 Cholesterol Guidelines: Diabetes Mellitus

2018 Cholesterol Guidelines: Diabetes Mellitus

For diabetes patients, practical recommendations would be:

  • Start moderate-intensity statin therapy if:

    • Young — age 20-39 with microvascular complications or long-standing DM.

    • Older— age 40-75 without major risk factors.

  • Start high-intensity statin ± ezetimibe if the following factors are present with the goal of reducing LDLc ≥50%:

    • Multiple risk factors

    • ASCVD 10YR ≥20%

  • For adults >75, clinician-patient discussion is needed if statin were to be started or continued.

GT

2018 Cholesterol Guidelines: Severe Hypercholesterolemia

2018 Cholesterol Guidelines: Severe Hypercholesterolemia

An approximate solidifying recommendation is:

  • For patients with severe hypercholesterolemia defined by baseline LDLc ≥190 mg/dL; target LDLc is <100 mg/dL. To achieve this target, patients could receive the following medications in the following order: max statin ± ezetimibe ± BAS ± PCSK9 inhibitor.

    • If baseline TGs >300 mg/dL, do not use BAS

    • If baseline LDLc is very high, >220 (+30) mg/dL, then target LDLc could be <130 (+30) mg/dL

GT

Second line diabetes medication on the risk of CVD

Second line diabetes medication on the risk of CVD

Among patients with type 2 diabetes initiating second-line diabetes therapy, the short-term cardiovascular outcomes of GLP-1 receptor agonists, SGLT-2 inhibitors, and DPP-4 inhibitors were similar.

Higher cardiovascular risk was associated with use of sulfonylureas or basal insulin compared with newer drug classes.

Clinicians may consider prescribing GLP-1 receptor agonists, SGLT-2 inhibitors, or DPP-4 inhibitors more routinely after metformin rather than sulfonylureas or basal insulin.

JAMA

From diabetes to hyponatremia to osteoporosis

From diabetes to hyponatremia to osteoporosis

Patients with diabetes mellitus are at increased risk for bone fragility fracture secondary to multiple mechanisms.

Hyperglycemia can induce true dilutional hyponatremia. Hyponatremia is associated with gait instability, osteoporosis, and increased falls and bone fractures, and studies suggest that compromised bone quality with hyponatremia may be independent of plasma osmolality.

Analyses of this research support the hypothesis that hyponatremia is an additional risk factor for osteoporosis and fragility fracture among patients with diabetes mellitus.

JES

Familial Hypercholesterolemia and CVD risk factors

Familial Hypercholesterolemia and CVD risk factors

Genetic inability to clear LDL-particles leads to familial hypercholesterolemia. Persistent high serum LDLc and total-cholesterol are major cumulative risk factors for premature cardiovascular disease.

The article identifies other independent risk factors contributing to CVD in these patients. Such factors are male sex, smoking, hypertension, diabetes, elevated Lp(a), and family history of CVD.

Obviously, the modifiable contributors; hypertension, smoking and diabetes need to be managed aggressively.

GT

Systolic Blood Pressure and Dementia Risk

Systolic Blood Pressure and Dementia Risk

About 9,000 adults were randomized to receive tight or less-tight systolic blood pressure control. They were followed for about 5 years for cognition and dementia outcomes.

Although the primary outcome was almost significant, the secondary outcomes were truly significant for improvement of mild cognitive impairment or probable dementia with intensive systolic blood pressure <120 mmHg over those who achieved sBP <140 mmHg.

While further trials are needed to clarify the above findings, there appears to be no harm of lowering the sBP down to <120 mmHg in this study.

GT

Statins improve diabetic retinopathy?

Statins improve diabetic retinopathy?

This major observational study suggests that statins reduce the risk of diabetic neuropathy, diabetic foot ulcers, and more importantly the risk of diabetic retinopathy. Risk reduction ranges from 10% to 45%. This could be due to statin-induced decreased microvascular inflammation. About 38,000 patients were followed for 7.5 years.

GT