Metabolic syndrome among adults living with sickle cell disease.

Metabolic syndrome (MetS) is a key risk factor for cardiovascular disease (CVD) incidence and all-cause mortality. MetS prevalence among adults with sickle cell disease (SCD) is not well known. We report initial findings from a cross-sectional study that examined MetS risk factors within a cohort of adults living with SCD. 50 adult SCD participants (ages 21-66 years; 72% female) completed demographic and health behavior surveys, health-related family and personal histories, and anthropometric and laboratory measurements. Descriptive and inferential statistics were used to summarize and compare CVD risk factors, stratified in separate analyses by SCD genotype and sex. Triglyceride, blood pressure, and fasting glucose levels were within normal limits. 78% of the cohort reported moderate to high physical activity. However, 46% of this cohort was overweight and dietary saturated fat intake exceeded both the national average (11%) and US Dietary Guidelines (<10%). 14.3% of the cohort fulfilled criteria for MetS with large waist circumference and reduced HDL levels prominently accounting for this status. We evaluated the prevalence of MetS in a cohort of adults living with SCD. Our findings suggest that increased attention to eating habits and physical activity may generate new approaches for decreasing cardiovascular morbidity in SCD.

National trends in hydroxyurea and opioid prescribing for sickle cell disease by office-based physicians in the United States, 1997-2017.

PURPOSE: To identify trends in physician drug prescribing practices for sickle cell disease (SCD). METHODS: We used data from the National Disease and Therapeutic Index to evaluate medications prescribed to children (definition: aged 19 years or younger) and adults (20 years or older) with SCD by office-based physicians in the United States during 1997 to 2017. Prescriptions were evaluated in 3-year intervals. RESULTS: The proportion of SCD visits that included new/continued hydroxyurea prescriptions increased from less than or equal to 8% before 2009 to 33% in 2015 to 2017. The increase was significant in visits by children (2.5% in 1997-1999 to 47% in 2015-2017; P = .003 by Spearman's rank-order correlation) but not in adults (6.9% to 11%; P = .12). Opioids, started/continued in 13% (lowest 3-year average) to 35% (highest) of visits by children and 55% to 81% of visits by adults, remained the most frequently prescribed medications for SCD overall. There were no significant changes over time in opioid prescribing for adults (P = .64) or children (P = .38). Hematologists/oncologists accounted for a higher proportion of visits by children (67.2% over 1997-2017) than adults (25.2%), while emergency medicine visits were higher in adults (14.0%) than children (2.6%). CONCLUSIONS: This study suggests a robust increase in hydroxyurea prescribing for children with SCD. The BABY HUG trial, which demonstrated safety and efficacy of starting hydroxyurea in infancy and informed current SCD guidelines recommending broader use in children, may have contributed to this increase. However, hydroxyurea prescribing for adults remains infrequent and considerably lower than opioids. Barriers in access to specialist care persist for adults with SCD.

Electronic consultation to improve care outcomes in patients with suspected and confirmed heparin-induced thrombocytopenia.

Background: Heparin-induced thrombocytopenia (HIT) is a complication of heparin exposure associated with high risk for morbidity and mortality. Diagnosis and management are complex due to limitations of laboratory testing and the need for nonheparin anticoagulation. Objectives: To increase the delivery of evidence-based care of patients with suspected and confirmed HIT via electronic consultation (e-consult). Methods: We describe the creation and implementation of an e-consult service for patients with concern for HIT at a large academic medical center. Hematology physicians with HIT expertise performed real-time chart review of all patients with a positive screening immunoassay result and provided written recommendations in their electronic health record. Results: Comparison of outcomes for 1 year before and the year after the e-consult service implementation identified improvements in direct thrombin inhibitor stewardship, increased diagnostic accuracy, and decreased length of stay of patients with confirmed HIT. Conclusion: The e-consult platform is a novel method for rapid, targeted consultative guidance, and this single-institution pilot demonstrates its feasibility and effectiveness to improve the care of patients with suspected and confirmed HIT.

Overcoming challenges of venous thromboembolism in sickle cell disease treatment.

INTRODUCTION: Venous thromboembolism (VTE) is a common comorbid condition found in sickle cell disease (SCD) and is associated with increased mortality for adults with SCD. The pathophysiology that leads to the thrombophilic state in SCD has been previously reviewed; however, evidence-based guidelines to aid in diagnosis, prevention, and management of VTE are lacking. Areas covered: This review article will cover the pathophysiology underlying the hypercoagulable state, the epidemiology of VTE, and management strategies of VTE in SCD. Expert opinion: Providers should have a high suspicion for diagnosing VTE to help reduce morbidity and mortality in the SCD population. Unlike other thrombophilias, the risk of life-threatening anemia while being treated with anticoagulation is compounded with the potential complications surrounding red blood cell transfusions in this population (i.e. alloimmunization, hyperhemolysis) and this provides another complexity to managing VTE in this population. Clinical trials evaluating the risk and benefit of treatment and treatment duration are needed.