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June 17, 2016

Heart disease and diabetes

The story

The slew of new diabetes drugs looks a lot like alphabet soup. And while most are great at reducing hemoglobin A1c, the race is on to see which can protect the heart.

New kids on the block

Three new oral hypoglycemic drug classes have hit the market in the past decade. Glucagon-like peptide 1 agonists (GLP-1) stimulate insulin secretion, dipeptidyl peptidase-4 (DPP-4) inhibitors block GLP-1 breakdown, and sodium-glucose cotransporter (SGLT) inhibitors block glucose resorption in the kidney. Initial trials evaluating the cardiovascular benefits of the new agents were weakly positive or unconvincing. Remember: heart disease is the most common cause of death in diabetes.

New results

High-risk cardiac patients on liraglutide (Victoza), a GLP-1 agonist, were 13% less likely to experience death from cardiac causes, nonfatal MI or stroke than those on placebo in a 9,000 person RCT. The investigators estimated a 3-year number needed to treat of 66 to prevent one event.
NEJM

Sounds familiar

We learned in November that patients with established cardiovascular disease on the SGLT inhibitor empagliflozin (Jardiance) were 14% less likely to experience death, MI or stroke than those on placebo in the 7,000 patient EMPA-REG OUTCOME trial. New long-term data from the trial shows that empagliflozan decreased episodes of new or worsening renal disease by almost 40% vs. placebo.
NEJM

The takeaway

Early evidence shows benefits beyond glucose control for liraglutide and empagliflozin. Watch out, though, since variable Medicare and Medicaid coverage may makes these drugs difficult to obtain for your clinic patients.

Say it on rounds

When you confuse Zika with an olympic sport

Much attention has focused on Rio, but just about all of South and Central America are in the midst of Zika outbreak. An epidemiological study from the Colombian government found no cases of microcephaly in the infants of over 1500 patients with Zika symptoms or laboratory-confirmed infection during the third trimester of pregnancy. The country's four confirmed cases of Zika-related microcephaly occurred in asymptomatic pregnancies.
NEJM

When your co-resident orders STAT Colace for the entire floor

Could be mania, or could be standard practice. A small, single-blinded Norwegian RCT found that blue-light blocking glasses decreased mania scores on a clinician-assessed scale in hospitalized patients with bipolar disorder. The investigators say that blocking blue light may inhibit circadian activation in the brain.
Bipolar Disord

Get meta

With whole grains and disease risk. Investigators looked at 45 mostly cohort studies and found that 90 g / day, or about 3 servings of whole grains, reduced risk of cardiovascular disease, total cancer, and all cause mortality by 15 - 20% relative to those with low whole grain consumption. 
BMJ

Brush up

Osteoporosis

Protect your elderly patients from hip fracture. Start screening women for osteoporosis with a bone mineral density (BMD) scan at age 65. Treatment is recommended for those with a T score of -2.5 or less, history of spine or hip fracture, or a high FRAX score. Bisphosphonates are often used as first-line therapy for those without contraindications, but watch for osteonecrosis of the jaw or atypical femur fractures. Several new treatment agents are in use or in development.

What's the evidence

For tried-and-true bisphosphonates? The Fracture Intervention Trial of 1998 showed that 4 years of bisphosphonate therapy increased BMD in women with osteoporosis and decreased clinical fractures. Long-term trial follow-up in 2006 showed that low and moderate risk women could stop bisphosphonate therapy after 5 years without significantly increasing fracture risk. 

What your health policy friends are talking about

In the aftermath of tragedy in Orlando, debate has stirred about whether or not it's time to scratch an FDA ban that prohibits sexually active gay men from donating blood.

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