SPRINTing towards lower BP goals : A re-analysis of the ACCORD-BP trial

February 2, 2018

The new 2017 ACC/AHA guidelines recommend a BP goal of <130/80 mmHg for everyone – including patients with diabetes. The 2018 ADA guidelines also recommend a goal of <130/80 mmHg, but only in patients at high risk of cardiovascular disease and only when it can be achieved without undue treatment burden. This change in recommendations is largely driven by results of the Systolic Blood Pressure Intervention Trial (SPRINT), which demonstrated a 25% reduction in the primary composite outcome of CV events with intensive BP control (SBP target <120 mmHg). However, extrapolating these findings to patients with T2DM has been challenging as patients with diabetes were excluded from SPRINT. A recent re-analysis of the ACCORD-BP study shed some new light.

Guest Authors: Kevin Cowart, Pharm.D. and Karen Sando, Pharm.D.

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Top Ten Things Every Clinician Should Know About the 2017 Hypertension Guidelines

December 15, 2017

We interview Eric MacLaughlin, Joseph Saseen, and Kristin Rieser about the ACC/AHA Guidelines for the Prevention, Detection, Evaluation, and Treatment of High Blood Pressure in Adults released in November 2017.  Dr. MacLaughin, a member of the Guideline Writing Committee, gives a insiders view of the guidelines development process and explains the rationale for lower blood pressure goals.  Drs. Saseen and Rieser talk about some of the practical considerations that we all must consider as we move forward to making these recommendations a reality.

Guests:  Kristin Rieser, Pharm.D., Joseph Saseen, Pharm.D, and Eric MacLaughlin, Pharm.D.

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Painting a New CANVAS for SGLT-2 Inhibitors?

October 13, 2017

While good glycemic control has been shown to prevent microvascular complications (e.g. retinopathy, nephropathy, neuropathy), only a few anti-diabetic agents have been shown to reduce macrovascular complications (e.g. cardiovascular events. Empagliflozin, a sodium glucose transporter-2 (SGLT2) inhibitor, not only reduced the risk of CV events but also all-cause mortality in the EMPA-REG OUTCOME study.  Based on this data, the SGLT2 inhibitors were given favorable second-line treatment status in the most recent AACE/ACE clinical practice guidelines. But do all SGLT2 inhibitors confer the same benefits… and risks? The Canagliflozin and Cardiovascular and Renal Events in Type 2 Diabetes (CANVAS) trial assessed the cardiovascular and renal benefits from long-term canagliflozin use.  The results are both reassuring and unexpected.

Guest Author:  Sean Lasota, Pharm.D.

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Testing the Limits on Blood Glucose Monitoring: Can We Safely Cut Back?

September 8, 2017

Is self-monitoring of blood glucose (SMBG) cost-effective?  SMBG is often recommended to help guide treatment decisions.  Consumer-oriented advertising often promotes frequent SMBG as means to achieve better glycemic control but current clinical practice guidelines do not provide specific recommendations regarding the frequency of blood glucose monitoring. The lack of conclusive evidence supporting the clinical benefits of routine SMBG combined with the rising costs of healthcare has led some payers to place limits on SMBG testing supplies.  Is this wise policy?  Or does it lead to poor health outcomes?

Guest Authors:  KyAnn Wisse, PharmD, BCACP and Dawn Fuke, Pharm.D, BCPS

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Peeling Back the Layers on Coated Aspirin

April 14, 2017

More than 15 million Americans have coronary heart disease and most should be taking aspirin daily.  Given aspirin’s ubiquity in cardiovascular medicine and patients’ pill boxes, it is shocking that there are still so many unanswered questions about aspirin use. Which dose and dosage forms should be prescribed?  How common is aspirin resistance?  What is the relationship between platelet inhibition and clinical outcomes?

Guest Author:  Daniela Valencia, Pharm.D.

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Think Before You Make a RAS Decision: Evaluating the Use of RAS Blockers in Patients with Diabetes

February 24, 2017

Hypertension affects more than 70% of patients with type 2 diabetes mellitus and further increases the risk of cardiovascular disease in this high-risk population. While renin angiotensin system (RAS) blockers are clearly indicated in patients with heart failure, chronic kidney disease with proteinuria, and coronary artery disease (CAD), experts have come to different conclusions regarding their role as initial antihypertensive therapy for patients with diabetes.

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Is there a Role for Fixed-Ratio Injectable Combinations in Type 2 Diabetes?

January 13, 2017

Pharmacotherapy for diabetes management has expanded in recent years with several new drug classes. Current guidelines recommend several options for patients who have not reached their goal A1c on metformin monotherapy including glucagon-like peptide-1 receptor agonists (GLP-1 RAs) or basal insulin. However, if basal insulin is chosen as the first add-on treatment with metformin, the post-prandial blood glucose (PPG) often will remain elevated.  A combination product that includes both a basal insulin plus a GLP-1 RA has the potential to addresses both fasting blood glucose and PPG … and perhaps has some other advantages over using either product alone.

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Sweetening the Deal: Effects of SGLT-2 Inhibitors on Kidney Disease Progression

November 11, 2016

Approximately one in three patients with diabetes in the United States have chronic kidney disease (CKD).  The Empagliflozin, Cardiovascular Outcomes, and Mortality in Type 2 Diabetes (EMPA-REG OUTCOME) trial, published in 2015, demonstrated a reduction in cardiovascular and all-cause mortality in patients treated with empagliflozin. More recent data from the EMPA-REG OUTCOME trial suggests that empagliflozin may also confer significant renal protection. 

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Eleven Things Every Clinician Should Know About the “Egregious Eleven”

September 29, 2016

A recent paper published in Diabetes Care proposing a new classification system for diabetes challenges our existing paradigm and has significant implications for our treatment approach for diabetes.

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Liraglutide: the new LEADER for second line therapy in diabetes management?

September 2, 2016

According to the current (2016) ADA guidelines, no agent is “the preferred” second line therapy after metformin monotherapy — instead the benefits, risks, cost, and convenience of each option should be considered and treatment should be individualized.  The liraglutide and cardiovascular outcomes in type 2 diabetes (LEADER) trial, which assessed the long-term cardiovascular effects of liraglutide, a GLP-1 receptor agonist, comes at an interesting time shortly after the publication of the empagliflozin, cardiovascular outcomes, and mortality in type 2 diabetes (EMPA-REG OUTCOME) trial.  Both studies found a cardiovascular benefit. How, then, will the results of these trials affect the algorithm for type 2 diabetes management and more importantly, clinical practice?

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