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Displaying 11 - 20 of 104 in Policy Library
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Displaying 11 - 20 of 1949 in Annals of Internal Medicine
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How Would You Manage This Patient With Type 2 Diabetes and Chronic Kidney Disease? Grand Rounds Discussion From Beth Israel Deaconess Medical Center
Nearly 15% of U.S. adults have diabetes; type 2 diabetes (T2D) accounts for more than 90% of cases. Approximately one third of all patients with diabetes will develop chronic kidney disease (CKD). All patients with T2D should be screened annually for CKD with both a urine albumin–creatinine ratio and an estimated glomerular filtration rate. Research into strategies to slow the worsening of CKD and reduce renal and cardiovascular morbidity in patients with T2D and CKD has evolved substantially. In 2022, a consensus statement from the American Diabetes Association and the Kidney Disease: Improving Global Outcomes recommended prioritizing the use of sodium–glucose cotransporter-2 inhibitors and metformin and included guidance for add-on therapy with glucagon-like peptide 1 receptors agonists for most patients whose first-line therapy failed. It also recommended nonsteroidal mineralocorticoid receptor antagonists for patients with hypertension that is not adequately controlled with angiotensin-converting enzyme inhibitors or angiotensin-receptor blockers. Here, an endocrinologist and a nephrologist discuss the care of patients with T2D and CKD and how they would apply the consensus statement to the care of an individual patient with T2D who is unaware that he has CKD.
Glucagon-Like Peptide-1 Receptor Agonists and Risk for Suicidal Ideation and Behaviors in U.S. Older Adults With Type 2 Diabetes: A Target Trial Emulation Study: Annals of Internal Medicine: Vol 177, No 8
Background: A major concern has recently emerged about a potential link between glucagon-like peptide-1 receptor agonists (GLP-1 RAs) and increased risk for suicidal ideation and behaviors based on International Classification of Diseases codes. Objective: To investigate the association between GLP-1 RAs, compared with sodium–glucose cotransporter-2 inhibitors (SGLT2is) or dipeptidyl peptidase-4 inhibitors (DPP4is), and risk for suicidal ideation and behaviors in older adults with type 2 diabetes (T2D). Design: Two target trial emulation studies comparing propensity score (PS)–matched cohorts for GLP-1 RAs versus SGLT2is and GLP-1 RAs versus DPP4is. Setting: U.S. national Medicare administrative data from January 2017 to December 2020. Patients: Older adults (≥66 years) with T2D; no record of suicidal ideation or behaviors; and a first prescription for a GLP-1 RA, SGLT2i, or DPP4i. Measurements: The primary end point was a composite of suicidal ideation and behaviors. New GLP-1 RA users were matched 1:1 on PS to new users of an SGLT2i or DPP4i in each pairwise comparison. A Cox proportional hazards regression was used to estimate the hazard ratio (HR) and 95% CIs within matched groups. Results: This study included 21 807 pairs of patients treated with a GLP-1 RA versus an SGLT2i and 21 402 pairs of patients treated with a GLP-1 RA versus a DPP4i. The HR of suicidal ideation and behaviors associated with GLP-1 RAs relative to SGLT2is was 1.07 (95% CI, 0.80 to 1.45; rate difference, 0.16 [CI, −0.53 to 0.86] per 1000 person-years); the HR relative to DPP4is was 0.94 (CI, 0.71 to 1.24; rate difference, −0.18 [CI, −0.92 to 0.57] per 1000 person-years). Limitations: Low event rate; imprecise estimates; unmeasured confounders, such as body mass index; and potential misclassification of outcomes. Conclusion: Among Medicare beneficiaries with T2D, this study found no clear increased risk for suicidal ideation and behaviors with GLP-1 RAs, although estimates were imprecise and a modest adverse risk could not be ruled out. Primary Funding Source: American Foundation for Pharmaceutical Education, Pharmaceutical Research and Manufacturers of America Foundation, National Institute on Aging, and National Institute of Diabetes and Digestive and Kidney Diseases.
Newer Pharmacologic Treatments in Adults With Type 2 Diabetes: A Clinical Guideline From the American College of Physicians
Description: The American College of Physicians (ACP) developed this clinical guideline to update recommendations on newer pharmacologic treatments of type 2 diabetes. This clinical guideline is based on the best available evidence for effectiveness, comparative benefits and harms, consideration of patients’ values and preferences, and costs. Methods: This clinical guideline is based on a systematic review of the effectiveness and harms of newer pharmacologic treatments of type 2 diabetes, including glucagon-like peptide-1 (GLP-1) agonists, a GLP-1 agonist and glucose-dependent insulinotropic polypeptide agonist, sodium–glucose cotransporter-2 (SGLT-2) inhibitors, dipeptidyl peptidase-4 (DPP-4) inhibitors, and long-acting insulins, used either as monotherapy or in combination with other medications. The Clinical Guidelines Committee prioritized the following outcomes, which were evaluated using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach: all-cause mortality, major adverse cardiovascular events, myocardial infarction, stroke, hospitalization for congestive heart failure, progression of chronic kidney disease, serious adverse events, and severe hypoglycemia. Weight loss, as measured by percentage of participants who achieved at least 10% total body weight loss, was a prioritized outcome, but data were insufficient for network meta-analysis and were not rated with GRADE. Audience and Patient Population: The audience for this clinical guideline is physicians and other clinicians. The population is nonpregnant adults with type 2 diabetes. Recommendation 1: ACP recommends adding a sodium–glucose cotransporter-2 (SGLT-2) inhibitor or glucagon-like peptide-1 (GLP-1) agonist to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control (strong recommendation; high-certainty evidence). • Use an SGLT-2 inhibitor to reduce the risk for all-cause mortality, major adverse cardiovascular events, progression of chronic kidney disease, and hospitalization due to congestive heart failure. • Use a GLP-1 agonist to reduce the risk for all-cause mortality, major adverse cardiovascular events, and stroke. Recommendation 2: ACP recommends against adding a dipeptidyl peptidase-4 (DPP-4) inhibitor to metformin and lifestyle modifications in adults with type 2 diabetes and inadequate glycemic control to reduce morbidity and all-cause mortality (strong recommendation; high-certainty evidence).
Association of Semaglutide With Tobacco Use Disorder in Patients With Type 2 Diabetes: Target Trial Emulation Using Real-World Data: Annals of Internal Medicine: Vol 177, No 8
Background: Reports of reduced desire to smoke in patients treated with semaglutide, a glucagon-like peptide receptor agonist (GLP-1RA) medication for type 2 diabetes mellitus (T2DM) and obesity, have raised interest about its potential benefit for tobacco use disorders (TUDs). Objective: To examine the association of semaglutide with TUD-related health care measures in patients with comorbid T2DM and TUD. Design: Emulation target trial based on a nationwide population-based database of patient electronic health records. Setting: United States, 1 December 2017 to 31 March 2023. Participants: Seven target trials were emulated among eligible patients with comorbid T2DM and TUD by comparing the new use of semaglutide versus 7 other antidiabetes medications (insulins, metformin, dipeptidyl-peptidase-4 inhibitors, sodium-glucose cotransporter-2 inhibitors, sulfonylureas, thiazolidinediones, and other GLP-1RAs). Measurements: The TUD-related health care measures (medical encounter for diagnosis of TUD, smoking cessation medication prescriptions, and smoking cessation counseling) that occurred within a 12-month follow-up were examined using Cox proportional hazards and Kaplan–Meier survival analyses. Results: The study compared 222 942 new users of antidiabetes medications including 5967 of semaglutide. Semaglutide was associated with a significantly lower risk for medical encounters for TUD diagnosis compared with other antidiabetes medications, and was strongest compared with insulins (hazard ratio [HR], 0.68 [95% CI, 0.63 to 0.74]) and weakest but statistically significant compared with other GLP-1RAs (HR, 0.88 [CI, 0.81 to 0.96]). Semaglutide was associated with reduced smoking cessation medication prescriptions and counseling. Similar findings were observed in patients with and without a diagnosis of obesity. For most of the group comparisons, the differences occurred within 30 days of prescription initiation. Limitation: Documentation bias, residual confounding, missing data on current smoking behavior, body mass index, and medication adherence. Conclusion: Semaglutide was associated with lower risks for TUD-related health care measures in patients with comorbid T2DM and TUD compared with other antidiabetes medications including other GLP-1Ras, primarily within 30 days of prescription. These findings suggest the need for clinical trials to evaluate semaglutide’s potential for TUD treatment. Primary Funding Source: National Institutes of Health.
Displaying 11 - 20 of 142 in Annals of Internal Medicine: Clinical Cases
Generalized Weakness Due to Hypocalcemia and Hypophosphatemia From Potent Acid Suppression | Annals of Internal Medicine: Clinical Cases
Potent gastric acid suppression can disrupt mineral homeostasis. An older woman receiving alfacalcidol developed weakness accompanied by profound hypophosphatemia with hypocalcemia and secondary hyperparathyroidism after initiation of the potassium-competitive acid blocker vonoprazan. Laboratory findings showed an elevated intact parathyroid hormone level and renal phosphate wasting, whereas her serum magnesium level was 2.7 mg/dL (reference range, 1.7–2.6 mg/dL) and her intact fibroblast growth factor 23 was 41.7 pg/mL (reference range, 19.9–52.9 pg/mL). The patient's weakness and calcium–phosphate abnormalities resolved with mineral repletion and switching from vonoprazan to a proton-pump inhibitor. This case highlights that strong acid suppression may precipitate significant calcium–phosphate derangements despite active vitamin D therapy. Early evaluation of mineral metabolism and reassessment of acid-suppressive therapy are especially important in patients with unexplained weakness.
Hydroxychloroquine Cardiomyopathy—A Case Series and Review of the Literature | Annals of Internal Medicine: Clinical Cases
Cardiomyopathy is a rare but serious adverse effect of long-term hydroxychloroquine therapy, manifesting as conduction abnormalities and heart failure. Its incidence is not well established. We present the largest case series, to our knowledge, of 13 patients with endomyocardial biopsy–proven hydroxychloroquine cardiomyopathy conducted over an 8-year period at one institution. Outcomes after therapy discontinuation varied, ranging from complete resolution to progressive heart failure requiring advanced therapies, including the first reported cases of left ventricle assist device as destination therapy. Early recognition and timely drug cessation may allow for partial or full recovery of cardiac function.
Sequential Drug-Induced DRESS Syndrome With Severe Rhabdomyolysis and Probable Myocarditis: A Case Report | Annals of Internal Medicine: Clinical Cases
DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) is a severe hypersensitivity syndrome with multiorgan involvement. An 81-year-old man with cardiomyopathy and stage IV chronic kidney disease developed DRESS syndrome after sequential exposure to allopurinol and vancomycin. He presented with diffuse rash, eosinophilia, transaminitis, severe rhabdomyolysis (CK 19,228 U/L), and probable myocarditis (troponin 9,712 ng/L). Corticosteroids started late, and a repeat vancomycin dose was temporally associated with rapid multiorgan deterioration and death. This case illustrates a rare presentation of DRESS syndrome with concurrent rhabdomyolysis and myocarditis, emphasizing the lethality of delayed diagnosis and sequential exposure to high-risk agents.
Salmonella Osteomyelitis of the Rib: An Extraintestinal Manifestation | Annals of Internal Medicine: Clinical Cases
Salmonella osteomyelitis is rare, accounting for <0.5% of all bacterial osteomyelitis cases, and rib involvement is exceedingly uncommon. A middle-aged immunocompetent man presented with a 6-month history of right lateral chest pain and a 1-month history of soft tissue swelling. Imaging revealed an abscess and lytic lesion of the right eighth rib. Interventional radiology–guided drainage yielded purulent material growing Salmonella species. The patient improved with intravenous ceftriaxone followed by oral ciprofloxacin. This case highlights that Salmonella can cause osteomyelitis even in immunocompetent hosts without gastrointestinal symptoms or bacteremia.
Retatrutide-Induced Intractable Diarrhea | Annals of Internal Medicine: Clinical Cases
Gastrointestinal symptoms accompanying the use of glucagon-like peptide-1 (GLP-1) receptor agonists and glucose-dependent insulinotropic polypeptide receptor-GLP-1 receptor co-agonists have been extensively catalogued. This case report contains a dramatic presentation of unintended consequences from the use of a novel triple-hormone receptor agonist and points toward the need for increased regulatory measures regarding the marketing of these treatments.
Insulin Autoimmune Syndrome Presenting With Recurrent Hypoglycemia and Extreme Hyperinsulinemia | Annals of Internal Medicine: Clinical Cases
Insulin autoimmune syndrome (IAS) is a rare but important cause of hypoglycemia. Herein, we describe a case of a 67-year-old White man with recurrent episodes of confusion and fatigue relieved by food intake. Biochemical evaluation revealed profound hyperinsulinemia and an elevated C-peptide level, suggesting endogenous insulin production, with no pancreatic lesion on imaging. The presence of insulin autoantibodies confirmed the diagnosis. Fluctuating beta-hydroxybutyrate levels provided an additional physiologic clue, reflecting variable insulin activity resulting from antibody binding and release. This case highlights how characteristic biochemical patterns, including variable ketone levels, can facilitate timely recognition of IAS and help avoid unnecessary diagnostic procedures.
Clinical Characterization of Critically Ill Patients With Neurological Manifestation in Chikungunya Virus | Annals of Internal Medicine: Clinical Cases
This study presents 6 cases of severe meningoencephalitis associated with chikungunya virus infection in older adults with comorbid conditions who were admitted to an intensive care unit in Paraguay. The patients exhibited classic symptoms, such as fever and arthralgia, as well as sensory impairment. They required mechanical ventilation and vasoactive support. Reverse-transcription-polymerase chain reaction confirmed the infection in the cerebrospinal fluid, and the inflammatory and metabolic characteristics were suggestive of severe neurologic involvement. The 50% mortality rate highlights the severity of this complication in older patients. This emphasizes the need for a high index of suspicion for timely diagnosis and management.
Common Variable Immunodeficiency Presenting With Bilateral Optic Nerve Edema: Case Report | Annals of Internal Medicine: Clinical Cases
Common variable immunodeficiency is typically characterized by recurrent infections, autoimmunity, and primary antibody failure, with an increased risk for malignancy. Ophthalmic and neurologic complications are considered rare. We describe a unique case presenting with bilateral optic disc edema, which resolved with IgG replacement therapy.
A Surprising Complication: Arterial Thrombosis in a Patient Receiving RAD-140 (Testolone) | Annals of Internal Medicine: Clinical Cases
RAD-140 is a selective androgen receptor modulator (SARM) that has anabolic effects similar to those of some androgenic steroids and hormones such as testosterone. The androgenic activity of SARMs can increase the risk for thrombosis through various mechanisms. Here, we discuss the case of a 48-year-old man with a history of hypogonadism receiving testosterone replacement therapy taking RAD-140 as a supplement for bodybuilding who presented with arterial thrombosis. The patient was evaluated for hereditary thrombophilic conditions; his test results returned negative. Concurrent use of RAD-140 and testosterone may increase the risk for arterial thrombosis, highlighting the need for clinical awareness of supplement-related adverse effects.