Annals
Established in 1927 by the American College of Physicians

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20 March 2012 Annals of Internal Medicine Tip Sheet

Annals of Internal Medicine is published by the American College of Physicians on the first and third Tuesday of every month. These highlights are not intended to substitute for articles as sources of information. For a copy of an article, call 215-351-2653 or e-mail Angela Collom at acollom@acponline.org

1. Dapagliflozin Effective Add-on for Patients with Inadequately Controlled Blood Glucose

Experts caution that long-term safety data is still lacking

Even on high doses of insulin, some patients with type 2 diabetes still have poorly controlled blood glucose levels. Increasing doses of insulin raises the risks for weight gain, hypoglycemia, fluid retention, and congestive heart failure, so physicians may choose to add additional medications rather than increase the insulin dose. Dapagliflozin, the first in the class of selective renal sodium glucose contransporter (SGLT) inhibitors, offers a novel, insulin-independent mechanism of action for diabetes treatment. Researchers sought to determine the safety and efficacy of adding dapagliflozin therapy in patients whose type 2 diabetes was inadequately controlled while taking high doses of insulin with or without oral diabetes medications. They randomly assigned 808 patients in 126 medical centers to receive either placebo or dapagliflozin once daily for 48 weeks. Halfway through the study, the dapagliflozin patients had better control of blood sugar and had lost weight compared to those on placebo. At the end of the trial, the dapagliflozin patients were on lower doses of insulin, but they also had more episodes of hypoglycemia. The author of an accompanying editorial cautions that the safety and efficacy of dapagliflozin is still under investigation, with safety being the primary issue. Long-term surveillance is necessary to exclude an association between dapagliflozin and cancer. In addition, gastrointestinal side effects and genitourinary symptoms and infections are still a concern.

2. Peer Mentoring Improves Glucose Control in African American Veterans

Diabetes is more common and more severe among African Americans. Patients with diabetes can manage their blood sugar through changes in their diet and exercise habits, but these changes can be difficult to maintain long-term. To determine if behavioral interventions can improve diabetes self-care, researchers randomly assigned 118 African American patients at a Veterans Affairs hospital to one of three groups: usual care; a peer mentoring group; and a financial incentives group. The usual care patients had no interventions. The peer mentoring group received at least one phone call a week from a peer who was trained to use motivational interview techniques and their own personal experiences to help the patient modify behaviors and work towards glucose-control goals. The financial incentives group was offered $100 at six months if they decreased their blood glucose level by one percentage point and $200 at six months if they decreased it by two percentage points. After six months, the patients in the peer mentoring group decreased their blood glucose levels by one percentage point compared to those in the usual care group. Patients in the financial incentives group had a statistically insignificant decrease in blood glucose levels. According to the researchers, talking to peers who have successfully managed their disease shows promise in helping patients improve glucose control.

3. Bleeding Hazard May Trump Potential Benefits of Antiplatelet Therapy for Patients with Chronic Kidney Disease

Approximately 10 to 15 percent of the adult population worldwide has chronic kidney disease, or CKD. People with early-stage CKD have a significantly higher risk for cardiovascular disease, and at end-stage disease, cardiovascular risk increases 30- to 50-fold. Antiplatelet agents are commonly used to prevent cardiovascular events. However, the bleeding risk of antiplatelet agents may be greater among persons with CKD because of impaired hemostasis. Researchers reviewed published randomized trials to summarize the effects of antiplatelet treatment on cardiovascular events, mortality, and bleeding in persons with CKD. The researchers found the evidence on the use of antiplatelets in patients with CKD is low quality. For CKD patients with acute coronary syndromes or those undergoing percutaneous coronary revascularization, antiplatelet agents have little or no effect on myocardial infarction, death, or coronary revascularization, but increase major and minor bleeding. The research also showed that use of antiplatelet agents in persons with CKD who have or are at risk for cardiovascular disease reduces fatal or nonfatal myocardial infarction by approximately 33 percent. However, with a lack of evidence surrounding effects on stroke and mortality, the researchers conclude that the bleeding risks of antiplatelet therapy may outweigh the benefits for patients with CKD.