174. Gestational Diabetes Screening, DOAC for Valvular Afib, COVID19, Semaglutide

DOAC are just as safe if not safer for warfarin for valvular afib (NOT valve replacement but moderate to severe mitral stenosis). Please, just give normal lovenox for covid patients. Stop DM drugs in the elderly cause no-glycemia is more dangerous than hyperglycemia. semaglutide works as along as you keep taking it. gestational diabetes screening should be a two stop process.


Effectiveness and Safety of Direct Oral Anticoagulants Versus Warfarin in Patients With Valvular Atrial Fibrillation: A Population-Based Cohort Study: Annals of Internal Medicine: Vol 0, No 0 (acpjournals.org)



researchers did a New-user retrospective propensity score–matched cohort study matching roughly 28,000 new users of DOACs with new users of warfarin. During a median follow-up of roughly 130 days,

primary effectiveness outcome was a composite of ischemic stroke or systemic embolism. The primary safety outcome was a composite of intracranial or gastrointestinal bleeding.



the rate of stroke or systemic embolism was significantly lower among DOAC users than warfarin users (3.9 vs. 6.0 events per 100 person-years). NNT of 50

The rate of major bleeding events was also lower among DOAC users (7.1 vs. 10.6 events per 100 person-years). And a NNH 28 to prescribe warfarin



This would be great because no longer need an echo prior to writing for a doac—a reminder part of this exclusion was bioprosthetic or mechanical heart valve replacement









Effect of Intermediate-Dose vs Standard-Dose Prophylactic Anticoagulation on Thrombotic Events, Extracorporeal Membrane Oxygenation Treatment, or Mortality Among Patients With COVID-19 Admitted to the Intensive Care Unit: The INSPIRATION Randomized Clinical Trial | Critical Care Medicine | JAMA | JAMA Network





What are the effects of intermediate-dose compared with standard-dose prophylactic anticoagulation in patients with COVID-19 admitted to the intensive care unit (ICU)?



Intermediate-dose (enoxaparin, 1 mg/kg daily) (n = 276) vs standard prophylactic anticoagulation (enoxaparin, 40 mg daily) (n = 286),



The primary efficacy outcome was a composite of venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days, assessed in randomized patients who met the eligibility criteria and received at least 1 dose of the assigned treatment.



results



Among patients admitted to the ICU with COVID-19, intermediate-dose prophylactic anticoagulation, compared with standard-dose prophylactic anticoagulation, did not result in a significant difference in the primary outcome of a composite of adjudicated venous or arterial thrombosis, treatment with extracorporeal membrane oxygenation, or mortality within 30 days.



Do the trial and don’t just blindly do it based on what you believe to be true or voodoo magic





But interia takes over and we keep doing the same thing





Lega IC et al. Glycemic control and use of high-risk antihyperglycemic agents among nursing home residents with diabetes in Ontario, Canada. JAMA Intern Med 2021 Mar 1; [e-pub].



We all know no glycemia is a lot worse then hyperglycemia- I also think we all know that



The ADA recommends relaxed glycemic targets for older patients with diabetes and comorbidities





population-based retrospective study, glycemic control among 15,000 Ontario nursing home residents with type 2 diabetes who were receiving at least one glucose-lowering drug. Mean glycosylated hemoglobin (HbA1c) level was 7.3%.



On average, patients were receiving two glucose-lowering agents; about half of patients had HbA1c levels ≤7.0%.





How intertia might be a good thing especially if it comes to semaglutide







Effect of Continued Weekly Subcutaneous Semaglutide vs Placebo on Weight Loss Maintenance in Adults With Overweight or Obesity: The STEP 4 Randomized Clinical Trial | Clinical Pharmacy and Pharmacology | JAMA | JAMA Network



randomized clinical trial of adults with overweight or obesity, 803 participants completed a 20-week run-in of weekly treatment with subcutaneous semaglutide, 2.4 mg, with a mean weight loss of 10.6%, and were randomized to continued treatment with subcutaneous semaglutide vs placebo for an additional 48 weeks.



Lets make no false predictions. 10% weight loss is a ton especially over 20 weeks BUT

what happens when you stop this weight loss drug??



The primary end point was percent change in body weight from week 20 to week 68;



With continued semaglutide, from week 20 to week 68 was −7.9% continued decrease in weight but you gained +6.9% with the switch to placebo (difference, −14.8 [95% CI, −16.0 to −13.5] percentage points; P 


Semaglutide works while you take it but then it goes away. This would be great for weight loss if you can use it as a bridge to get people jump started into healthier lifestyles and more activity and if it were free or pennies on the dollar but it is not and likely will be cash pay as not FDA approved for weight loss yet and in my opinion still requires a serious shared decision making conversation.





A Pragmatic, Randomized Clinical Trial of Gestational Diabetes Screening | NEJM



pragmatic, randomized trial comparing 24,000 pregnant women,

researchers compared a one-step, 75-g glucose load with a two-step, 50-g (followed by 100-g if positive) glucose load for gestational diabetes screening.



The primary outcomes were a diagnosis of gestational diabetes, large-for-gestational-age infants, a perinatal composite outcome (stillbirth, neonatal death, shoulder dystocia, bone fracture, or any arm or hand nerve palsy related to birth injury), gestational hypertension or preeclampsia, and primary cesarean section.



Researchers found higher rates of gestational diabetes diagnosis with the one-step screen!!



maternal and neonatal outcomes (including hypertensive disorders of pregnancy, primary cesarean section, large-for-gestational age infants, shoulder dystocia, stillbirth) were not different between the two groups.



if you’re identifying more cases of gestational diabetes without changing related disease outcomes, this is bad.



identifying more disease, the burden of disease diagnosis is significant with multiple daily glucose checks for the remainder of pregnancy as well as the mental and emotional toll diagnosis can have on a pregnant woman.



Besides who cares if you find more of a number- that is just a LOOs if you are not finding more POOs.