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Sunday, May 8, 2016

2016 American Diabetes Association (ADA) Guideline for Primary Care of Diabetes

The American Diabetes Association (ADA) published the 2016 Standards of Medical Care in Diabetes (Standards) to provide clinicians, patients, researchers, payers, and other interested parties with the components of diabetes care, general treatment goals, and tools to evaluate the quality of care. The ADA Professional Practice Committee revised recommendations based on new evidence to include 8 key areas important to primary care providers, including:
Diagnosis – 
1. remains an A1c >6.5%, 
2. fasting plasma glucose >126; or 
3. an oral glucose tolerance 2 hr. result >200 mg/dL, or
4.  a random glucose >200mg/dL and classic symptoms of hyperglycemia.
English: Overview of the most significant poss...
English: Overview of the most significant possible symptoms of diabetes. See Wikipedia:Diabetes#Signs_and_symptoms for references. Model: Mikael Häggström. To discuss image, please see Template talk:Häggström diagrams (Photo credit: Wikipedia)
Glycemic targets - The HbA1c goal for most non-pregnant adults is less than 7%; more stringent HbA1c goals (such as <6.5%) may be recommended for patients without co-morbidities and who have a short duration of diabetes, and less stringent  A1c goals are appropriate for older patients with significant comorbid illness.
Hypoglycemia – severe or frequent hypoglycemia is an indication to modify treatment regimens.
Medical management – intervention should always include lifestyle modification with diet and exercise. If lifestyle modification is not sufficient to reach target A1c goals, then metformin should be added at or soon after diagnosis. If A1c is over target for longer than 3 months, then a second agent should be added. The second agent could be from the class of: sulfonylureas, thiazolidinediones, dipeptidyl peptidase-4 inhibitors, sodium–glucose cotransporter 2 (SGLT2) inhibitors, glucagon-like peptide-1 (GLP-1) agonists, or basal insulin.
Cardiovascular risk factor management - blood pressure treatment goal is <140/90 mm Hg, and an ACE or an ARB should be used as part of BP management. Statins are recommended for most persons with diabetes age 40 or older.
These recommendations highlight individualized care to manage the disease, prevent, or delay complications, and improve outcomes.
Citation: Chamberlain JJ, Rhinehart AS, Shaefer CF, Neuman A. Diagnosis and management of diabetes: Synopsis of the 2016 American Diabetes Association standards of medical care in diabetes. Ann Inter Med. 2016;164:542-552. doi:10.7326/M15-3016.

Saturday, April 23, 2016

MammaPrint Assay Reduces use of Chemotherapy in Breast Cancer Patients

In the American Association for Cancer Research (AACR) meeting 2016, Martine Piccart, MD, PhD, of the Jules Bordet Institute in Brussels, Belgium said that use of the gene assay was associated with a 46% reduction in prescriptions for chemotherapy among the 3,348 high-risk patients and 14% reduction for all 6,648 patients in the study. The meeting coverage was published in the Medpage Today on 22.04.2016.
English: Validation chart for Agendia's MammaP...
English: Validation chart for Agendia's MammaPrint Assay, part of the Symphony Breast Cancer Suite (Photo credit: Wikipedia)
Patients at high clinical/pathologic risk but low risk by the 70-gene MammaPrint assay had a 5-year distant metastasis-free survival (DMFS) of 94.4% without chemotherapy versus 95.9% with chemotherapy, a difference that did not reach statistical significance (HR 0.78, 95% CI 0.50-1.21).
In patients with a low clinical risk but high genetic risk, the 5-year DMFS was 95% to 96% with or without chemotherapy.
As compared to standard clincopathological classification, MammaPrint re-stratified 20% of Clinical High Risk patients to Low risk.  97% of this Low Risk patient group which primarily chose to forgo chemotherapy, were disease free at 5 years.
The first ever prospective clinical study for a breast cancer recurrence assay, RASTER (MicroarRAy PrognoSTics in Breast CancER) was published in 2013.
"The MammaPrint FFPE (Formalin Fixed Paraffin Embedded) tissue test has been approved by the FDA."
It confirmed the utility of the MammaPrint (Agendia) 70-gene signature to identify those breast cancer patients that may safely forgo chemotherapy.


Tuesday, April 12, 2016

DPP-4 Inhibitora like Saxagliptin and Alogliptin may increase the Risk of Heart Failure

Diabetes drugs containing saxagliptin (Onglyza) and alogliptin (Nesina) may increase the risk of heart failure, the US FDA announced on 5th April, 2016.
A U.S. Food and Drug Administration (FDA) safety review has found that type 2 diabetes medicines containing saxagliptin and alogliptin may increase the risk of heart failure, particularly in patients who already have heart or kidney disease.
Heart failure can result in the heart not being able to pump enough blood to meet the body’s needs. As a result, a new warning is being added to the drug labels about this safety issue.
Saxagliptin and Alogliptin are part of the class of dipeptidyl peptidase-4 (DPP-4) inhibitor drugs, which are used with diet and exercise to lower blood sugar in adults with type 2 diabetes.
Patients taking these medicines should contact their health care professionals right away, if they develop signs and symptoms of heart failure such as:
  • Unusual shortness of breath during daily activities
  • Trouble breathing when lying down
  • Tiredness, weakness, or fatigue
  • Weight gain with swelling in the ankles, feet, legs, or abdomen
Patients should not stop taking their medicine without first talking to their health care professionals.
Health care professionals should consider discontinuing the medicine in patients who develop heart failure and monitor their diabetes control. If a patient’s blood sugar level is not well-controlled with their current treatment, other diabetes medicines may be required.
The original article can be accessed here.

Sunday, April 10, 2016

LAMA and LABA combination Treatment for COPD is more Effective than Monotherapy

Treatment of chronic obstructive pulmonary disease (COPD) has always been a challenge to the physician.
According to a publication, [Published online ahead of print March 3, 2016]. Chest. doi:10.1016/j.chest.2016.02.646, “A systematic review with meta-analysis of dual bronchodilation with LAMA/LABA for the treatment of stable chronic obstructive pulmonary disease” by Calzetta L, Rogliani P, Matera MG, Cazzola M., dual bronchodilation with Long-acting Muscarinic Antagonists/Long-acting Beta Agonists (LAMA/LABA) for the treatment of stable chronic obstructive pulmonary disease (COPD) is more effective than a LAMA or a LABA alone
Dual bronchodilation with Long-acting Muscarinic Antagonists/Long-acting Beta Agonists (LAMA/LABA) for the treatment of stable chronic obstructive pulmonary disease (COPD) is more effective than a LAMA or a LABA alone, regardless of the drugs used.
Enlarged view of lung tissue showing the diffe...
Enlarged view of lung tissue showing the difference between healthy lung and COPD (Photo credit: Wikipedia)
This according to a review and meta-analysis of 23,168 COPD patients (combinations n=10,328; monocomponents n=12,840) who participated in trials that lasted at least 3 months. Researchers found:
• All LAMA/LABA combinations were always more effective than the LAMA or LABA alone in terms of improvement in trough FEV1.
• There was a gradient of effectiveness among the currently available LAMA/LABA fixed-dose combinations, although there was not a significant difference among them.
• LAMA/LABA combinations also improved both quality of life scores, and did not increase the cardiovascular risk when compared with monocomponents.
There are currently 3 FDA approved LABA/LAMA combination inhalers:
• Umeclidinium bromide and vilanterol (Anoro-GSK).
Glycopyrronium bromide and indacaterol (Ultibro-Novartis).
Tiotropium and olodaterol (Stiolto Respimat-Boehringer Ingelheim Pharmaceuticals).


Sunday, September 20, 2015

Better Prevention be the goal than the Treatment of Drug Resistant Gonorrhoea

It has been published in The Guardian that a multi-drug resistant Gonorrhoea strain has been detected in 15 cases by Public Health England since March; the British Association for Sexual Health and HIV reported. It has triggered an unprecedented national public health alert in England.
Gonorrhoea is caused by a bacterium called Neisseria gonorrhoeae. It has become resistant to penicillin, tetracycline, quinolones and many more groups of drugs, finally is being treated with Ceftrixone in combination with azithromycin.
Neisseria Gonorrhoeae

Now, it has been reported that several cases are not responding to azithromycin and some cases have become resistant to ceftrixone too.
News of the British cases comes less than a day after the European Centre for Disease Prevention and Control (ECDC) reported gonorrhoea rates in Europe had gone up by 79% since 2008, particularly among men. The UK reported 61% of all cases in Europe. It has risen by 19 per cent in 2014 amongst heterosexuals and a whopping 32 per cent in gay men.
There were almost 35,000 cases of gonorrhoea reported in England last year. It is the second most common bacterial sexually transmitted infection in the UK after Chlamydia, with the bacteria transmitted through discharge from the penis and vagina.
It’s a clever little bug that doesn’t always show symptoms and patients carry the infection without even realizing it, called carriers.
The main causes of resistance to the antibiotics are inadequate/inappropriate treatment and emergence of mutated strains of bacteria.
Hence, it is better to emphasize on prevention than to go for treatment of Drug Resistant Gonorrhoea.
Gonorrhea: Protect Yourself- According to the recommendations of CDC:

It is critical that individuals protect themselves against infection.
Prevention strategies include:
(1)                         Abstinence or mutual monogamy— The surest way  to avoid transmission of gonorrhea is to abstain from sexual intercourse, or to be in a long-term, mutually monogamous relationship with a partner who has been  tested and is known to be uninfected.
(2)                         Condoms— When used consistently and correctly, condoms can reduce the risk of transmission of gonorrhea.
(3)                         Regular screening— Screening for those at greatest risk is critical. CDC recommends that sexually active gay and bisexual men and high-risk sexually active women be tested for gonorrhea at least once a year.
(4)                         Prompt and effective treatment— Anyone who becomes infected should get treated with a ceftriaxone injection and either azithromycin or doxycycline right away to cure the infection and prevent transmission to others. Patients receiving a treatment other than dual therapy that includes ceftriaxone should be tested one week after completing treatment to confirm that the infection has been cured.
Prevention is better than cure, “A stitch in time prevents none.”


Sunday, September 13, 2015

DPP-4 Inhibitors Used to Treat Type 2 Diabetes Mellitus may cause Joint Pain

FDA Issues Warning for DPP-4 Inhibitors; published in ClevelanD Clinic on 08.09.2015, drugs like sitagliptin, saxagliptin, linagliptin, and alogliptin, used to treat Type 2 Diabetes Mellitus, may cause joint pain that can be severe and disabling. Nevertheless, FDA has not advised to stop the medications.
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