Use of Glucose Lowering Agents in Advanced CKD
GLP1 agents with CKD benefits are Dulaglutide, Semaglutide weekly, and Liraglutide daily. As per the AWARD study, Dulaglutide showed a 40% eGFR decline and ESKD. Insulin therapy is not exhibited to prevent the CKD development. Starting with lower doses (0.25 units daily dose), basal insulin + non-insulin agents, mixed insulin (70/30% or 75/25%) or BASAL - BOLUS should be the last option.
Glycemic Monitoring in Advanced Chronic Kidney Disease (CKD)
Insulin resistance and impared glucose metabolism increase risk of hyperglycemia in early CKD and hypoglycemia in advanced CKD/dialysis. An HbA1c target is recommended ranging from less than 6.5% to 8.0% in patients with diabetes & CKD not treated with dialysis. Linagliptin (no renal adjustment) or Sitagliptin is recommended for mild hyperglycemia.
CVD and T2D: Assessing Risks And Prioritizing Therapies
Current guidelines recommend SGLT2i such as dapagliflozin and empagliflozin and GLP1-Ra as first-line treatment in patients with T2DM and cardiovascular disease. Saxagliptin is not recommended in patients with T2DM and high risk of HF (class of recommendation III, level of evidence B) in international guidelines, whereas DPP4i as a pharmacological class can be used for glycaemic control.
Energy Metabolism in a Weight Reduced State
With moderate dietary restriction, physical activity can enhance short-term weight loss by 20-25%. If there is a severe dietary restriction, physical activity will have minimum effect on weight loss. People should get adequate amounts of sleep, decrease sedentary behavior and increase light, moderate and vigorous intensity physical activity including household, andoccupational activity.
Use of Sulfonylurea Based on Diet Recall
Sulfonylurea is the most potent diabetes agents and to avoid hypoglycaemia, sulfonylurea has to be selected based on diet composition and pattern of the patent. A study conducted by Panchal D revealed that the use of sulfonylurea drugs as per the diet pattern, particularly meal pattern and percent of carbohydrate achieve glycaemic control with minimum risk of hypoglycaemia in T2D patients.
Management of Primary Hyperparathyroidism
• Alendronate and Denosumab can be used to increase bone density • Cinacalcet can be used to reduce the serum calcium concentration into the normal range if there are no contraindications• Calcium intake/supplementation should follow the guidelines: 800 mg/day for women 70 years old.
Surgical Management of Primary Hyperparathyroidism (PHPT)
Surgery is recommended if Serum calcium is >1 mg/dL (0.25 mmol/L); Skeletal involvement: A fracture by VFA or vertebral X-ray or BMD by T-score < -2.5; Renal involvement: eGFR or creatinine clearance (>250 mg/day in women; >300 mg/day in men) or Nephrocalcinosis or nephrolithiasis by X-ray, or ultrasound, or Hypercalciuria (>250 mg/day in women; >300 mg/day in men).
Diagnosis of Hyperparathyroidism
PHPT can be evaluated with:Biochemical: Measure adjusted total serum calcium, phosphorus, intact PTH, 25OHD, creatinine.Skeletal: Three-site DXA; imaging for vertebral fractures; Trabecular Bone Score if available.Renal: eGFR, or creatinine clearance, 24-hour urinary calcium and biochemical risk factors for stones; imaging for nephrolithiasis/nephrocalcinosis.
Treatments for Non-alcoholic Fatty Liver Disease
Nonalcoholic steatohepatitis (NASH) treatment is recommended in intermediate and high risk patients. Current treatments for patients with NAFLD (not FDA approved but can be used for obese or diabetic patients) were lifestyle interventions, bariatric surgery, GLP-1RA and Pioglitazone. Studies have shown that Pioglitazone increases adiponectin, reduces fat, and lowers liver fibrosis risk in NASH.
Caution Before Universally Recommending SGLT2i or GLP-1RAs in Inpatient Cardiac Care Setting
SGLT2i and GLP-1RA have clear outcomes benefits in high CV risk patients with diabetes, but the drugs are currently underutilized. However, the side effect profile of these medications must be carefully considered before initiation of these drugs in the hospital. Initiation of drug at the conclusion of hospital stay or at discharge may be safest and most effective approach at this time.
Risk of Acute Kidney Injury in Real-World Use of Dapagliflozin
A study compared the occurrence of acute kidney injury in new users of Dapagliflozin & of comparator GLDs. Comparators incorporated GLDs besides SGLT2 inhibitors or monotherapy of insulin, metformin, or sulfonylureas. Study exhibited that a reduced risk of AKI was correlated with Dapagliflozin than other GLDs and adjusted with findings from Dapagliflozin clinical trials.
SGLT2is and GLP-1RAs—What Are the Benefits?
SGLT2 inhibitors & GLP1RAs should be considered in T2D patients with ASCVD or at high risk regardless of A1c. Empagliflozin, Semaglutide, Liraglutide, Canagliflozin reduced the rate of CV death, non-fatal MI or stroke . Dapagliflozin, Lixisenatide, was not associated with a significant difference in CV events. Substantial evidence exists supporting their safety & efficacy.
Rivaroxaban Plus Aspirin: Mortality in Chronic CAD or PAD
Patients with stable CAD or PAD plus baseline high-risk features experienced greater mortality benefit with rivaroxaban plus aspirin therapy.The authors concluded that combination of rivaroxaban plus aspirin compared to aspirin alone reduced overall and cardiovascular mortality for patients with chronic CAD or PAD. They also concluded that mortality benefits are greater for patients .
Apixaban for Treatment of Embolic Stroke of Undetermined Source (ATTICUS) Randomized Trial
Despite the significant frequency of covert atrial fibrillation, secondary prophylaxis with aspirin is the current standard therapy for ESUS (AF). The efficacy of apixaban in 353 ESUS patients (68.5 yrs old, 51% male) was evaluated. 130 and 120 subjects from apixaban & ASA arms, respectively, complete study. By far, apixaban has been found to be better.
Quadruple UltrA-low-dose Treatment for Hypertension - QUARTET
The author presented that starting with standard dose monotherapy is more successful than starting with quarter standard doses of four types of blood pressure reducing drugs. By 12 weeks, 15% of intervention and 40% of control had uptitrated. Despite increased up titration in the usual care group, quadpill had better BP management. Their BP was lower day and night.
TOMAHAWK: Immediate Angiography After Out-of-Hospital Cardiac Arrest
The 30-day risk of all-cause death was not reduced by rapid unselected coronary angiography in patients with resucitated OHCA of suspected cardiac origin, shockable or non-shockable arrest rhythm, and no ST-elevation. Trial COACT of solely OHCA patients with shockable arrest rhythms reported no difference in clinical outcome between immediate and delayed coronary angiography at 90 days and 1 year.
Association of Coronary Artery Calcium Score Groups With Adverse Plaque
In a multicenter clinical trial, the author demonstrated the initial viability of electrical pulmonary vein isolation (PVI), procedural execution, and acute safety. The InspIRE clinical trial was designed to assess the safety and efficacy of a fully integrated biphasic PFA system. However, 1 in 6 patients with stable chest pain has CAD.
DBP and cardiovascular events in atrial fibrillation individuals with SBP < 130 mm Hg
Secondary analysis of the SPRINT and ACCORD-BP trials showed DBP < 60 mm Hg was related with a 74% increase in CV outcome, whereas DBP between 70 and 80 mm Hg was associated with the nominally lowest risk. Because ventricular perfusion occurs largely during diastole, reduced DBP may cause hypoperfusion & myocardial injury. So lowering DBP too much may negate the benefits of lowering SBP.
Individualizing the target Diastolic BP in patients being treated for HTN and Diabetes
Heart disease is more common in diabetics with HTN. DBP commonly rises to about 70 mm Hg during treatment. This post-hoc analysis of ACCORD -BP revealed that intensive SBP lowering (120 mmHg) did not diminish the risk of the primary clinical objective. For patients with CVD and DM, the ideal DBP treatment target is slightly lower than the current guideline range of 70-80 mm Hg.
Diastolic Blood Pressure: Should we care
BP is closely linked to vascular and total mortality, with no evidence of a threshold below 115/75 mmHg. The author concluded that excessive diastolic hypotension combined with antihypertensive medication enhanced CAD risk. According to author, reperfusion removes risk at low diastolic BP. CAD blockage raises diastolic BP whereas revascularization lowers it.
