Commentary

Dec 6, 2013

We’ve all encountered patients who’ve had difficulty taking their medications as prescribed.  Many of our patients don’t achieve the recommended treatment goals or derive much benefit their medications.  There are many reasons why patients don’t take their medications in an ideal manner — including cost barriers, unpleasant side effects, treatment complexity, and forgetfulness.  

Pharmacists are often the health care professionals charged with improving medication...

Comments: 1      Views: 7,462


Nov 24, 2013

The pessimist complains about the wind; the optimist expects it to change; the realist adjusts the sails.”  - William Arthur Ward.
 

After a decade of waiting, new treatment guidelines on the management of cholesterol in adults were published on November 12, 2013.1,2,3 These guidelines depart quite significantly from previous recommendations and have already generated some controversy. Here are the top ten things every clinician should know and do....

Comments: 5      Views: 28,131


Sep 29, 2013

A 65 year old patient presents to your clinic with an A1C of 7.2%, a blood pressure of 146/80 mmHg and a LDL cholesterol of 103 mg/dL. Should you order a BNP level to determine the patient’s risk of developing heart failure?

Brain-type natriuretic peptide (BNP) is a biomarker which has an established role in the diagnosis of heart failure (HF).1 It is released by the cardiomyocytes in response to volume overload and myocardial stretch. The ACCF/AHA guidelines state that BNP...

Comments: 1      Views: 8,700


Sep 14, 2013

The recently published Look AHEAD trial found intensive lifestyle interventions had no benefit on cardiovascular (CV) morbidity and mortality in patients with diabetes mellitus (DM).  Could the results possibly be valid?  Should we stop emphasizing diet and exercise? In patients with DM, CV disease is the leading cause of morbidity and mortality.  Preventing CV disease has been traditionally accomplished by addressing modifiable risk factors and encouraging weight loss through lifestyle...

Comments: 1      Views: 7,248


Jun 21, 2013

When estimating a patient's renal function to determine an appropriate medication dose, many clinicians turn to the Cockcroft-Gault (CG) equation. But is this equation the best method to quickly assess and characterize renal function?   Several studies have compared various methods to predict renal function.1,2,3  The most accurate way to measure creatinine clearance (CrCl) requires a 24-hour urine collection; however this method is not routinely used in clinical practice because...

Comments: 0      Views: 10,624


Jun 14, 2013

Millions of Americans take a multivitamin daily. Millions do not. Should healthcare providers recommend a daily multivitamin to patients who do not already take one? Or discourage those who do? A recent survey of nearly 12,000 adults found that the most commonly used supplements were multivitamin-minerals and the most common reason for using dietary supplements was “to improve overall health.” Other reasons included “to maintain health,” “to supplement the diet,” and “to prevent health...

Comments: 0      Views: 5,176


May 23, 2013

The World Health Organization (WHO) estimates that only 53% of pregnant women worldwide received any antiretrovirals during pregnancy to prevent mother-to-child HIV transmission in 2009.  In the absence of any intervention, the risk of transmission is high (upto 45%).1  Therefore it is crucial that infants born to previously untreated mothers receive postexposure prophylaxis.  The current recommendation is to give zidovudine to HIV-infected pregnant women antepartum, during labor...

Comments: 0      Views: 4,588


Mar 12, 2013

Patients with a history of a single unprovoked venous thromboembolism (VTE) have a 10-30% risk of a recurrence within 5 years following cessation of anticoagulation.1 The decision to extended anticoagulation beyond 6-12 months in patients with a previous VTE must weigh the benefit of reducing recurrent VTEs versus the burdens of anticoagulation therapy (e.g. bleeding, drug costs, need for monitoring). The burdens of therapy aren’t trivial.  While 3.6% of recurrent VTEs are fatal,...

Comments: 0      Views: 8,156


Dec 20, 2012

Compelling indications in JNC7 that warrant β-blocker therapy include heart failure with reduced ejection fraction (HFrEF)2,3, acute myocardial infarction (AMI)4, high coronary disease risk, and diabetes. While there is long-standing evidence supporting the use of β-blockers in the treatment of hypertension5,6, the 2007 American Heart Association (AHA) Scientific Statement on Hypertension Management considers β-blockers 3rd or 4th line...

Comments: 1      Views: 10,371


Sep 30, 2012

Does insulin worsen cardiovascular outcomes and cause cancer? Should insulin be reserved as the last resort? In 2008, ACCORD raised questions about the cardiovascular safety of insulin, at least in patients with type 2 diabetes.1  And an analysis in Diabeteologica suggested insulin glargine increased the risk of cancer.2 So while intensive blood glucose control slows the progression of microvascular complications and most clinicians agree that there is a link between...

Comments: 0      Views: 4,521


Sep 30, 2012

The biggest superstar in the dietary supplement industry is fish oil.  It is available over-the-counter and you can even buy orange juice fortified with it. Unfortunately, most of these products contain very low amounts of omega-3 fatty acids (O3FA). The most concentrated source of omega-3 fatty acids is found in the prescription product, Lovaza®, which enjoys $1 billion in sales...

Comments: 2      Views: 11,500


Aug 14, 2012

The Patient Protection and Affordable Care Act (PPACA but often called the ACA) was signed into law by President Barack Obama on March 23, 2010 after it passed both the House and Senate following 2 years of debate in Congress. On June 28, 2012, the US Supreme Court upheld the constitutionality of many of the most controversial provisions of the law – including the so-called “individual mandate” to purchase health insurance. The goal of the ACA is to improve access to care while lowering the...

Comments: 4      Views: 13,462


Jun 16, 2012

Blood pressure is known to follow a circadian rhythm in which the blood pressure falls by approximately 10% overnight. In many patients with hypertension (HTN) this drop in nocturnal blood pressure is blunted.  These patients are affectionately called “non-dippers.”  The non-dipping blood pressure pattern has been associated with a higher risk of cardiovascular events.  Several studies have evaluated the utility of changing blood pressure medication dosing times to bedtime.  ...

Comments: 1      Views: 8,936


Mar 29, 2012

Dronedarone (Multaq®), a guideline recommended drug therapy option for paroxysmal and persistent atrial fibrillation (AF), has failed to deliver on the initial hopes and hype as the safer alternative to amiodarone.  Recent studies have shown that dronedarone is associated with severe liver injury, pulmonary fibrosis, pneumonitis, as well as an increased risk of stroke and death.1-6 With the addition of a boxed warning prohibiting its use in patients with permanent AF, dronedarone...

Comments: 1      Views: 7,050


Mar 14, 2012

The American College of Chest Physicians Antithrombotic Guidelines, 9th edition are now available.  Here's a short summary about what every clinician should know.

2.   The Patient’s Opinion Matters.  Patient values and preferences regarding antithrombotic treatment vary.  Although the AT9 authors believe a reasonable trade-off between stroke and major bleeding events would be in the range of 2 or 3 to 1, they emphasize the need for shared decision making.2  This is...

Comments: 2      Views: 9,455


Feb 29, 2012

“See you in four weeks!” This has been a common ending to most anticoagulation clinic appointments over the years.  But perhaps it’s time for this routine to change?  A welcomed 12-week holiday may be coming for many patients based on evidence from a recent study as well as a new recommendation in the recently released 9th edition of the American College of Chest Physicians (ACCP)...

Comments: 1      Views: 6,302


Feb 3, 2012

Yet another clinical trial attempting to prove that adding a second lipid lowering agent to a statin-based regimen has failed. The Atherothrombosis Intervention in Metabolic Syndrome with Low HDL/High Triglycerides: Impact on Global Health Outcomes (AIM-HIGH) trial prospectively compared cardiovascular (CV) event rates in statin treated patients with established atherosclerotic vascular disease who were randomized to...

Comments: 1      Views: 6,485


Jan 31, 2012

For diabetes patients uncontrolled on basal insulin therapy, is adding exenatide a good choice? Current treatment algorithms advocate for the addition of prandial insulin in patients who have not reached their glycemic targets with basal insulin.1 Exenatide is not FDA-approved for use in combination with basal insulin because current studies evaluating the combination of exenatide and...

Comments: 0      Views: 8,092


Jan 3, 2012

Should elderly patients with heart failure receive beta-blockers?  SENIORS — a parallel group, randomized, double-blind, multi-center trial comparing nebivolol to placebo — attempted to answer this question.1  Concern about the tolerability of beta-blockers in elderly patients persists despite some evidence that they are likely safe in older adults with heart failure (HF).2,3,4  The current American Heart Association (AHA) guidelines recommend that all clinically stable patients with HF and...

Comments: 0      Views: 5,765


Dec 16, 2011

Clinicians trying to make decisions based on the current best evidence are faced with an overwhelming obstacle, Too Much Information (TMI)! With over 25,000 new randomized controlled trials published each year how can a provider critically appraise these studies, determine their internal and external validity, put these results into context with what is already known, and then make an informed decision? Some of these data are biased and have uncertain value in...

Comments: 3      Views: 10,737


Oct 20, 2011

Do you tell your patients to take levothyroxine in the morning 30 to 60 minutes before food and at least 4 hours apart from other medications?  It is well known that many medications and foods influence the absorption and distribution of thyroxine (T4).  Morning administration of levothyroxine, before meals and other medications, is recommended by expert consensus and the package...

Comments: 2      Views: 9,637


Sep 29, 2011

The evidence regarding the benefits of statin therapy in patients with chronic kidney disease has been far from clear. There is no doubt that treatment of low density lipoprotein cholesterol (LDL-C) with statins reduces coronary events in many patient populations (average 20% reduction per 1 mmol/L LDL-C reduction or 38mg/dL).1 But previous trials in the end stage CKD population, two...

Comments: 1      Views: 7,421


Sep 8, 2011

The wait for alternatives to warfarin for stroke prevention in atrial fibrillation has been a long one. Patients and clinicians have long noted the limitations of warfarin, with dietary restrictions, drug-interactions and frequent monitoring.  Last year, dabigatran became available as an alternative based on the results of the RE-LY trial.1 Recently, the results of the ROCKET-AF trial...

Comments: 1      Views: 6,356


May 10, 2011

For patients with atrial fibrillation, what’s the best scoring system to estimate stroke risk? Clinicians have long relied on the CHADS2 [congestive heart failure, hypertension, age ≥ 75 years, diabetes, and previous stroke or TIA] scoring system to make antithrombotic treatment decisions. The CHADS2 scoring system is validated and has good predictive value.1 Current treatment...

Comments: 2      Views: 10,284


May 3, 2011

Are you treating to an evidence-based blood pressure goal in patients with diabetes? Consensus guidelines suggest that we should aim for a blood pressure of < 130/80 mmHg.1,2 However, the support for this recommendation is derived from epidemiological data and subgroup analyses rather than well-designed, randomized controlled trials specifically designed to determine the optimal BP...

Comments: 2      Views: 8,895


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