Apr 26, 2019

Sugar high

The story

Type 2 diabetes (T2D) plus chronic kidney disease (CKD) equals half your waiting room and too many of your after-work conversations. SGLT2 inhibitors are here to help.

The wait

Residency seems to trickle by, but it's a blur compared to the 18 years that have passed since renin angiotensin blockade was shown to be effective in T2D patients with nephropathy. So while ACE inhibitors and ARBs remain a treatment mainstay, there's room for another bullet point in your assessment and plan. Sodium–glucose cotransporter 2 (SGLT2) inhibitors work directly in the kidney and have shown a trend towards renal benefit in prior studies. A mega-trial for renal outcomes was only a matter of time.

The study

CREDENCE compared SGLT2 inhibitor canagliflozan to placebo in 4,400 patients with T2D and evidence of CKD. All patients were on ACE inihibitors or ARBs. After median follow-up of 2.6 years, the trial was stopped early when investigators found a 30% decrease in the primary composite outcome of end-stage kidney disease, doubling of serum creatinine, or death from renal or CV causes. Observed CV benefits were on par with prior SGLT2 inhibitor trials. And though canagliflozan was associated with fracture and amputation in 2017's CANVAS trial, no such trend was evident here.

The takeaway

With an estimated number needed to treat of 22 for the primary outcome and 40 for CV death, myocardial infarction, or stroke, canagliflozan impressed. Make sure to consider an SGLT2 inhibitor for all of your eligible clinic patients.

Say it on rounds

When your patient is crashing and your senior resident went home

Most stressors are temporary, but some have staying power. A Swedish population based cohort study found that patients with stress related disorders – in this case PTSD, acute stress reaction, and adjustment disorder – were more likely to experience incident cardiovascular disease than unaffected siblings and matched controls. Effects were most pronounced in the first year after diagnosis, when patients were 65% more likely than siblings to develop CV disease. 

When the code pager goes off mid-nap

Change of pace. Sedation with propofol is thought to decrease vascular tone, while α-2 agonists like dexmedetomidine (dex) may increase it. An open label, prospective study of 38 patients with septic shock switched patients from sedation with propofol to sedation with dex for 4 hours and then back to propofol. Pressor requirements dropped by more than half when patients were switched to dex. The findings will need to be confirmed in larger studies.
Crit Care Med

When your attending's looking right at your phone

Observation changes behavior, and a study of adherence to hepatitis C virus (HCV) treatment in persons who inject drugs (PWID) found a benefit for directly observed therapy (DOT) in the Bronx. Of 150 patients with genotype 1 HCV infection in opioid agonist therapy programs, those assigned to DOT had higher adherence (86% vs. 75%) to therapy compared to self-administered individual treatment. HCV remains vastly undertreated, and PWID are often denied treatment due to concerns over adherence and drug resistance.

Brush up

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) primarily affects patients with underlying liver disease. So while hepatitis and alcohol abuse drive many of today's cases, non-alcoholic fatty liver disease (NAFLD) is expected to be a big contributor in the future. Disease incidence is 2 - 4% yearly in patients with cirrhosis, and HCC currently ranks as the second most lethal malignancy (in terms of 5-year overall survival) behind pancreatic cancer. Surgical resection, liver transplant, and transarterial chemoembolization (TACE) are treatment options for early or intermediate stage disease, while sorafenib is frontline therapy for advanced disease.

Get meta

With surveillance of high-risk patients in HCC. A 2014 analysis of 15,000 patients with cirrhosis across 47 studies found that HCC surveillance was associated with higher rates of early detection, curative treatment, and overall survival. Abdominal ultrasound every 6 months with or without serum alpha-fetoprotein is recommended for patients with cirrhosis, regardless of cause. Patients with chronic HBV or HCV with advanced fibrosis can also be considered for screening.

What your tech friends are talking about

New technology converts brain electrical activity into speech in a process that could one day be transformative for patients with motor neuron disorders like ALS. Here's an example of the tech in action.

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