Sodium-Glucose Cotransporters as Potential Therapeutic Targets in Patients With Type 1 Diabetes Mellitus: An Update on Phase 3 Clinical Trial Data.

Objective: To review phase 3 trials of sodium-glucose cotransporter (SGLT) inhibitors in type 1 diabetes mellitus (T1DM) patients. Data Sources: A literature search of Ovid MEDLINE databases (1946 through May 17, 2019) limited to English-language human clinical trials was conducted using the following terms: sodium-glucose transporter 2 inhibitors, canagliflozin, dapagliflozin, empagliflozin, sotagliflozin, ertugliflozin, ipragliflozin, or remogliflozin combined with type 1 diabetes mellitus. Results were verified via Google Scholar and clinicaltrials.gov. Study Selection and Data Extraction: Articles were included if they were phase 3 trials in adults with T1DM. Data Synthesis: Phase 3 trials are available for dapagliflozin, empagliflozin, and sotagliflozin. All 3 drugs demonstrated statistically significant reductions in hemoglobin A1C, weight, and total daily insulin dose without an increased risk of hypoglycemia in up to 52 weeks of therapy. The incidence of diabetic ketoacidosis (DKA) was higher in patients on a SGLT inhibitor at all doses, with the exception of empagliflozin 2.5 mg (0.8% vs 1.2% with placebo). Relevance to Patient Care and Clinical Practice: SGLT inhibitors are potential adjuncts to insulin in T1DM patients, providing clinically meaningful benefits. Regulatory bodies have either approved or are reviewing these agents for use in T1DM. Clinicians should be familiar with the DKA risk associated with SGLT inhibitors and utilize DKA risk-mitigation strategies. Empagliflozin 2.5 mg warrants additional investigation given its efficacy without an increased incidence of DKA. Conclusions: Phase 3 trial data of SGLT inhibitors provide evidence for sustained efficacy in T1DM patients. Appropriate patient selection for therapy and routine monitoring are essential to minimize associated risks.

Drug interactions with aprepitant or fosaprepitant: Review of literature and implications for clinical practice.

Purpose Aprepitant and its parenteral formulation fosaprepitant are widely used for the prevention of chemotherapy-induced nausea and vomiting. Aprepitant exerts modest inhibitory effect on CYP3A4 and modest inductive effect on CYP2C9 substrates such as some antineoplastics and multiple other medications. This article is aimed to provide pharmacists and other healthcare professionals with an updated summary of drug-drug interactions of aprepitant/fosaprepitant and implications for clinical practice. Method We reviewed publications reporting drug-drug interactions between aprepitant/fosaprepitant and other medications. Results Coadministration of aprepitant with antineoplastics or opiods may result in significant elevations in the serum levels of the agents metabolized via CYP3A4, with the best documentation for cyclophosphamide, ifosfamide, erlotinib and oxycodone. These alterations did not translate into adverse outcomes and/or necessitate dosing adjustments. The levels of warfarin were significantly decreased by aprepitant requiring prolonged monitoring after discontinuation of aprepitant. Among direct oral anticoagulants, a theoretical interaction between aprepitant and rivaroxaban or apixaban exists. Interactions between aprepitant and quetiapine or diltiazem or sirolimus required dose reductions to avoid adverse outcomes. The intravenous route had a weaker inhibitory effect on CYP3A4 than the oral pathway. Conclusion The evidence on drug interactions of aprepitant with other medications is limited, and the impact on therapeutic outcomes remains to be determined. The intravenous regimen may be a preferred option. As utilization of aprepitant is expanding, practitioners and patients need to be educated about the potential for drug interactions and a need for careful monitoring of patients concurrently receiving aprepitant and CYP2C9 or CYP3A4 substrates, especially those with a narrow therapeutic window.

Evaluating Diabetes Group Medical Visits in a Family Medicine Residency Program.

Background: Group medical visits (GMV) have been shown to improve metrics in patients with type 2 diabetes mellitus (DM). Overlook Family Medicine, a teaching residency program, anticipated that medical residents trained in the GMV model of care by interdisciplinary team members may improve cholesterol, HbA1C, BMI, and blood pressure in patients. The objective of this study was to compare metrics between group 1: GMV patients with DM whose primary care provider (PCP) was an attending physician/nurse practitioner (NP) and group 2: GMV patients with DM whose PCP was a family medicine (FM) medical resident receiving GMV training. We seek to provide guidance on implementation of GMV in residency teaching practices. Methods: We performed a retrospective analysis to evaluate total cholesterol, LDL, HDL, TG, BMI, HbA1C, and BP in GMV patients between 2015-2018. We used a t test to compare outcomes between the two groups. Diabetes training was provided to family medicine residents by an interdisciplinary team. Results: There were 113 patients enrolled in the study: 53 in group 1 and 60 in group 2. There was a statistically significant decrease in LDL and triglycerides, and an increase in HDL in group 2 (P<.05). There was a clinically significant decrease in HbA1C in group 2 (-0.56, P=.0622). Conclusion: Sustainability of GMV can be achieved with a champion diabetes education specialist. Interdisciplinary team members are integral in training residents and addressing patients' barriers. GMV training should be incorporated into family medicine residency programs to improve metrics for patients with diabetes. FM residents who received interdisciplinary training had improved metrics in GMV patients compared to patients whose providers did not. Therefore, GMV training should be incorporated into family medicine residency programs to improve metrics for patients with diabetes.

Pediatric atopic dermatitis: a review of the medical management.

OBJECTIVE: To evaluate the available treatment options for pediatric atopic dermatitis. DATA SOURCES: A literature review was performed in MEDLINE (1950-February 2010) using the key word atopic dermatitis. The references identified were evaluated in comparative treatment. The references included in this review were limited to studies conducted in children less than 18 years of age and written in the English language. STUDY SELECTION AND DATA EXTRACTION: All of the literature retrieved that was published within the last 5 years (2005-2010) was included in this review. Other pertinent articles published prior to 2005 were also included. DATA SYNTHESIS: Atopic dermatitis is a chronic inflammatory skin disorder that usually begins during infancy. Potential causes include irritants such as soap and detergents, food allergens, contact allergens, and skin infections. Emollients, moisturizing agents that inhibit water loss and provide a protective coating, are recommended in all patients with atopic dermatitis. Additionally, emollients may reduce the need to use topical corticosteroids. Patients receiving desonide 0.05% plus an emollient achieved significant reductions in severity scores compared to those receiving desonide 0.05% as monotherapy (80% vs 70%; p < 0.01). Topical calcineurin inhibitors are not recommended as first-line therapy in pediatric patients with atopic dermatitis; however, their use in children above 2 years of age who fail to respond to topical corticosteroids may be considered. CONCLUSIONS: Emollients are recommended in pediatric patients with a diagnosis of atopic dermatitis regardless of symptoms. Topical corticosteroids reduce the inflammation and pruritus associated with atopic dermatitis and are available in several formulations and strengths. Calcineurin inhibitors may be an alternative in children older than 2 years of age who do not respond to topical corticosteroids.

Use of Non-Vitamin K Antagonist Oral Anticoagulants in Special Patient Populations with Nonvalvular Atrial Fibrillation: A Review of the Literature and Application to Clinical Practice.

Atrial fibrillation is a commonly encountered arrhythmia associated with increased risk for thromboembolic events. Anticoagulation is necessary to decrease the risk of ischemic stroke. Traditionally, warfarin has been the only oral pharmacotherapeutic option for long-term anticoagulation in patients with nonvalvular atrial fibrillation (NVAF). Recently, non-vitamin K antagonist oral anticoagulants (NOAC), including dabigatran, rivaroxaban, apixaban, and edoxaban, have become available as alternatives for warfarin in the prevention of stroke in patients with NVAF. Recently published atrial fibrillation guidelines contain new recommendations for risk stratification tools in determining the need for anticoagulant therapy and incorporate NOAC pharmacotherapy options for stroke prevention in patients with NVAF. NOACs offer several advantages over warfarin, including the elimination of routine laboratory monitoring, fewer drug and food interactions, and rapid therapeutic onset and offset. However, the lack of antidote in the case of serious bleeding and lack of data for long-term use in patient populations at risk for bleeding is problematic. Older adults are at high risk for thromboembolic and bleeding events as a result of anticoagulation and require special consideration when selecting anticoagulant therapy. The risk of drug accumulation and bleeding is concerning in the presence of renal impairment. The objective of this review is to provide the clinician with an update on the use of NOACs for NVAF, focusing on older adults and patients with renal impairment in light of recently published atrial fibrillation guidelines. Available data on using NOACs in coronary artery stenting, cardioversion, and ablation are also reviewed.