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

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?

The EAGLE has Landed! Reassuring the Safety and Efficacy of Drugs for Smoking Cessation in Mental Illness

Persons diagnosed with a psychiatric disorder consume nearly half of all cigarettes smoked in the United States!  Seven first-line therapies have shown to increase long-term abstinence rates, with bupropion sustained release (SR) doubling and varenicline tripling the odds of quitting. However, the FDA issued black box warnings in 2009 regarding increased neuropsychiatric events and suicidality with bupropion and varenicline use.  Thus many clinicians have been reluctant to prescribe these agents in persons with mental illness.  The EAGLES study compared the efficacy of non-nicotine therapies to nicotine replacement therapy in smokers with mental illness

Preventing Weight Gain - Recommending Behavior Change in Young Adults

We're all aware that there is an obesity epidemic and its linked to dozens of health problems.  But nothing we've done so far — public awareness campaigns, changes in school lunch programs, and approving new drugs for weight loss — has halted this epidemic.  The prevalence of obesity continues to climb in young adults  and most of us keep packing on the pounds as we get older!  Thus preventing weight gain in young adults is critically important to long-term outcomes. The recent results of  the Study of Novel Approaches to Weight Gain Prevention (SNAP) provides evidence to guide recommendations for behavioral change. 

What’s the story, H. pylori? New regimens in the toolbox?

The list of regimens for Helicobacter pylori eradication is longer than ever.  In recent years, American and European guidelines have recommended clarithromycin-based triple therapy or bismuth-containing quadruple therapy for primary treatment of H. pylori infection. However, increasing resistance to these regimens has forced us to consider alternative treatments, including but not limited to: the addition of probiotics, use of sequential regimens, and the inclusion of levofloxacin in the antibiotic cocktail. With all these choices, the clinician is left wondering what the best option is.

PATHWAY-2: Does the road lead to spironolactone for resistant hypertension?

Resistant hypertension (RH) is frequently encountered in primary care practice and often presents a significant clinical challenge because limited evidence-based guidance exists. RH is a major cause of cardiovascular disease and death, and has been associated with a 50% increased risk of myocardial infarction, stroke, congestive heart failure, and chronic kidney disease when compared to patients without RH. The American Heart Association defines RH as uncontrolled BP despite maximal treatment with a three-drug regimen, ideally including a diuretic. The exact prevalence of RH is unknown, but large randomized controlled trials suggest it affects one in five patients with elevated BP.  Previous research findings suggest chlorthalidone, spironolactone, and eplerenone are all effective add-on therapies when BP remains uncontrolled with typical first line agents.  The Pathway-2 study provides the first direct comparative evaluation of three different four-drug antihypertensive regimens.

Does Coenzyme Q10 Have the ENERGY to Change Heart Failure Therapy?

Could a nutritional supplement be the “magic bullet” in heart failure therapy?  Coenzyme Q10 (CoQ10), or ubiquinone, is an electron carrier in mitochondria and plays a key role in ATP synthesis. It is also thought to have antioxidant effects and may stabilize LDL molecules. All of which would, theoretically, help the failing heart.

Beyond Slip, Slop, Slap, and Wrap: Vitamin B3 for Skin Cancer Prevention

“Slip! Slop! Slap! And Wrap!®”, the slogan created by the American Cancer Society is a catchphrase intended to attract the public’s attention, raise awareness of the dangers of ultraviolet (UV) radiation, and promote prevention against skin cancer. Despite public awareness campaigns, the incident of non-melanoma skin cancer (NMSC), including both basal cell carcinoma (BCC) and squamous cell carcinoma (SCC), continues to climb — quite rapidly. They are the most common cancers in the United States. Given the significant and growing morbidity, mortality, and economic burden ofNMSC, finding effective preventative measures are of great interest.

Lixisenatide and Cardiovascular Outcomes: The Burden of Proof

After cardiovascular (CV) safety concerns emerged with rosiglitazone use, the Food and Drug Administration (FDA) now requires outcome studies to be performed for all new diabetes medications.   The first CV safety study (ELIXA) for a drug in the glucagon-like peptide 1-receptor agonist (GLP-1 RA) class – lixisenatide - was published in December 2015.  Lixisenatide is a once-daily injectable GLP-1 RA approved for use in Europe and awaits FDA approval in the United States.

Drug Treatment for Agitation in Alzheimer’s Disease: A Conundrum

Managing behavioral health in persons withdementia is an enormous and growing problem. Most patients with Alzheimer's disease (AD) have challengingneuropsychiatric symptoms such as agitation. These symptoms are distressing andoften overwhelming for caregivers often resulting in institutionalization andincreased healthcare utilization. Several medications are used off-labelto treat these symptoms including antidepressants, antipsychotics,anticonvulsants, anxiolytics and cholinesterase inhibitors.   But manyregulatory bodies, professional associations, and patient advocacy groups havepromoted initiatives to decrease the inappropriate use of medications andencourage the use of alternatives, particularly behavioral interventions. The combination of dextromethorphan hydrobromideand quinidine sulfate (Nuedexta) has been recently studied for the off-labeltreatment of agitation in Alzheimer’s disease.  A patient-centered, systematic, andevidence-based approach should be considered when addressing the behavioral and psychological symptoms of dementia.

Crossing the Periprocedural Bridge in Patients with Atrial Fibrillation

For over two decades LMWHs have been routinely used to provide therapeutic coverage in patients who must temporarily stop warfarin. Current guidelines suggest using injectable anticoagulants during warfarin interruption (aka bridging) in patients with atrial fibrillation based on patients’ risk of arterial thrombosis. Using the CHADS₂ score to assess risk, the guidelines recommend (grade 2C) bridge therapy if the CHADS₂ score is 5 or higher and not bridging if the CHADS₂ score is 2 or lower. But what about patients with a CHADS₂ score of 3 or 4?