Once-Weekly Insulin Injection - The Future of Diabetes Treatment
A huge step forward in making Type 2 diabetes management easier is on the horizon: the promise of a once-weekly insulin injection. It helps improve adherence, convenience, improve clinical inertia with less missed injections & offer better glycaemic control. However, more data are required on glycaemic control, efficacy & safety, dosing algorithms, post-marketing studies.
Clinical Applications of SLGT-2 Inhibitors
Gliflozins is one of the most important pharmacological interventions of 21st century. Kidney outcomes data now extend across a broad eGFR and UACR range in patients with and without diabetes. Gliflozins forms a key component of “kidney GDMT” towards reducing adverse kidney outcomes.Studies have shown that gliflozin also reduces HF, cardiovascular death, non-fatal MI or stroke.
Holistic Approaches for the Management of Diabetes and CKD
Consensus New Joint Statement from the ADA and KDIGO on Management of Diabetes and CKD: It is crucial to screen for CKD in diabetic patients with eGFR and UACR. Holistic approaches for improving outcomes in patients with diabetes and CKD includes lifestyle and first line therapy - SGLT2i, RASi, metformin and statins. CKA and CVD protection with SGLT-2i and nsMRA and CVD protection with GLP-1 RA.
Definition and Interpretation of Remission in T2D
The potential benefits of coding remission in type 2 diabetes includes removal of personal and social stigmatization as diseased or diabetic; providing a target and a reward for the sustained hard work usually necessary to achieve and maintain substantial weight loss. Diagnosing remission of T2D in the absence of ongoing glucose-lowering medication may enhance the acceptance of a diagnsosis.
New Treatments in Heart Failure With Reduced Ejection Fraction
In the treatment of HFrEF, rapid sequencing should be used instead of conventional sequencing, which involves using a combination of beta-blockers + SGLT2 inhibitors, then progressing to angiotensin receptor neprilysin inhibitors, and finally mineralocorticoid receptor antagonists. All of this should be accomplished within four weeks, and then up titration to target dosages.
Fatty Liver - Risk Factor for Diabetic Neuropathy
People with diabetes, steatosis & fibrosis have common risk factors that drive NAFLD & neuropathy by increasing free fatty acids, altered lipid metabolism that drives lipotoxicity, inflammation & NASH. Hyperglycemia plays a role, but other factors like dyslipidemia, high triglycerides, elevated LDL, reduced HDL & increased free fatty acids play a major role in T2D patients.
Impact of Time In Range(TIR) in Diabetes Management
TIR of 70-180 mg/dL is linked with retinopathy, vascular complications, all-cause and cardiovascular mortality in patient with diabetes. TIR is influential on the quality of life: higher TIR is associated with a more positive mood in people with diabetes and lower ratings with negative mood. International consensus recommends time above range (TAR) >180 mg/dL, and TAR >250 mg/dL in patients.
Emerging Therapies SGLT2-Inhibitors for Treatment of NAFLD
Around 70% of T2D patients have nonalcoholic fatty liver disease (NAFLD). Several studies have shown that the emerging therapies like SGLT-2 inhibitors reduce liver fat, inflammatory markers, Hepatic Steatosis, fibrosis & hepatocellular carcinoma. In a recent study, SGLT-2i has been found to reduce the risk of NAFLD by 36% and it has also reduced transaminase elevation in patients with T2D.
Prevention or Delay of T2D and Associated Comorbidities
ADA 2022 guidelines recommend that individuals with pre-diabetes should be monitored annually for the development of diabetes. They also recommend that adults with overweight/obesity at high risk of type 2 diabetes should be subjected to an intensive lifestyle behavior to achieve and maintain 7% loss of body weight and increase moderate-intensity physical activity to at least 150 min a week.
Individualizing Care Goals for Patients at High Risk of T2D
Individuals with the following criteria should be considered for Diabetes Prevention Program: age ≥25 yrs; high-risk individuals [impaired glucose tolerance 140-199 mg/dl, fasting glucose 95-125 mg/dl, BMI ≥24 kg/m2 (Asians ≥22 kg/m2)]; representation of high-risk racial/ethnic groups. In DPP, patients undergoing lifestyle modifications showed 71% reduction in the incidence of diabetes.
Safety Of Chocolate Touch Paclitaxel Coated PTA Balloon Catheter
Chocolate Touch DCB is nitinol constrained balloon designed to reduce vessel trauma and dissections. A study compared the efficacy and safety of the chocolate touch DCB to the commercially approved lutonix DCB. Chocolate touch group showed consistent true DCB success at 2 months. At primary safety endpoint, both groups showed no significance difference and lead to non-inferiority.
Effects Of Empagliflozin in Patients Hospitalized for AHF
In EMPULSE Trial, patients with acute heart failure (AHF) were randomized to empagliflozin (EMPA) 10 mg daily or placebo for 90 days. It was found that EMPA-treated patients had a greater improvement in KCCQ TSS, PLS, QoL, CSS & OSS at Day 90. AHF patients showed improvement in symptoms, physical limitations and quality of life with benefits seen at 15 and maintained through 90 days.
Effect of Renal Denervation on Blood Pressure Reduction
In SPYRAL HTN-ON trial, patients were randomized in 1:1 to undergo renal denervation (RDN) or a sham procedure. It was found that RDN patients showed greater ABSP reduction compared to sham control patients (-18.7±12.4 mmHg vs. -8.6±14.6 mmHg, p=0.004) and office BP systolic reductions showed a similar trend at 3 years (-20.9±15.3 mmHg vs. -12.5±21.6 mmHg, p=0.073).
Mild Perioperative Hypothermia VS Aggressive Warming
A small trial has shown that mild hypothermia (~35.5°C) results in increased morbid myocardial outcomes. Other trials have also reported that moderate perioperative hypothermia (~34.5°C) can increase surgical site infections and transfusion requirements. As per the international guidelines, it is recommended to keep surgical patients normothermic and active intraoperative warming.
Cardiac Rehab & Alternative Therapies for Chest Pain
Studies have shown a significant decrease in angina frequency and increase in exercise capacity in stable angina patients who participated in CR program. Exercise-based CR benefits symptomatic patients with angina when revascularization is not feasible and aggressive medical treatment is followed. Exercise is shown to provide many CV benefits by enhanced oxygen delivery to the myocardium.
Edoxaban VS Dual Antiplatelet Therapy for Valve Thrombosis
A study investigated the effect of Edoxaban compared to DAPT for the prevention of leaflet thrombosis. It was found that the incidence of leaflet thrombosis on CT scans was less frequent with Edoxaban therapy, although did not reach statistical significance. The incidence of new cerebral thromboembolism and neurological or neurocognitive dysfunction were not different between two groups.
New Agents to Lower Triglycerides-rich Lipoproteins
Angiopoietin like protein 3 (ANGPTL3) is a protein expressed in the liver inhibiting LPL and endothelial lipase activity thereby increasing TG, LDL-C and HDL. An ECLIPSE trial studied monoclonal antibody, Evinacumab that targets ANGPTL3. It was found that the Evinacumab decreases LDL-C by 47% and TG by 50%. ANGPTL3 and Apoprotein C III inhibition are promising therapies for hypertriglyceridemia.
Effects of Short-interfering RNA Targeting Lipoprotein(a)
Elevated Lipoprotein(a) is associated with atherosclerotic cardiovascular disease (ASCVD) & aortic stenosis (AS). APOLLO trial found that subcutaneous injection of an siRNA (SLN360) targeting mRNA for LPA gene lowered lipoprotein(a) upto 98%. >70% and >80% reductions in Lp(a) persisted for 150 days after the 300 mg and 600 mg doses. The highest doses reduced LDL-C and Apo-B by 20-30%.
Patiromer For The Management Of Hyperkalemia
DIAMOND trial included patients with HFrEF and hyperkalemia where they were optimized on RAASi therapy including MRA & patiromer. Patiromer showed significantly lesser increase in serum K+ levels than placebo (+0.03 vs +0.13). Patiromer had lesser no. of hyperkalemia events than placebo (61 vs 85). Lesser no. of patients with patiromer had reduction of MRA dose below target (61 vs 83).
Effects of Alirocumab on Coronary Atherosclerosis
A study determined early administration of PCSK9i alirocumab in patients with acute myocardial infarction (AMI). Compared to placebo, Alirocumab resulted in greater decrease in Percent Atheroma Volume (IVUS) (-2.1 vs -0.9, P=0.001). After 52 weeks of treatment, Alirocumab on top of high-intensity statin therapy reducted lipid burden and increased minimal fibrous cap thickness.
