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A systematic review and meta-analysis of randomized control trials (RCTs) found that sodium-glucose cotransporter-2 (SGLT2) inhibitors reduce hospitalizations and may reduce cardiovascular deaths among people experiencing heart failure regardless of the presence of diabetes. These findings support existing guidelines that recommend SGLT2 inhibitors for preventing incident and worsening heart failure in people with type 2 diabetes, heart failure, or both. The authors caution that treatment with SGLT2 inhibitors should be balanced against the potential harms of increased genital infections. The analysis is published in Annals of Internal Medicine.
Many heart failure patients do not receive optimal therapy until they present to a hospital with exacerbations, and patients who receive a diagnosis in the hospital have a twofold increased risk of death and recurrent hospitalization. Previous randomized trials have shown that SGLT2 inhibitors reduce the risks of hospitalization for heart failure and cardiovascular death for people with diabetes. Other trials have also shown that these benefits may extend to patients with heart failure but without diabetes.
Researchers from Sichuan University, Chengdu, China conducted a systemic review and meta-analysis of 8 RCTs totaling 15,022 participants that investigated dapagliflozin, empagliflozin, or canagliflozin to evaluate the effect of these medications in patients with heart failure, regardless of the presence of type 2 diabetes. The authors found that in patients with heart failure—both those with preserved and those with reduced ejection fraction and regardless of the presence of diabetes—SGLT2 inhibitors demonstrated relative benefits in reducing hospitalizations for heart failure and cardiovascular death with high to moderate certainty. However, the authors warn that these reductions were associated with increasing rates of genital infections. They say the amount of potential benefit of SGLT2 inhibitors is determined by both the relative benefit for heart failure hospitalizations and the patient's baseline risk and the relative benefits of SGLT2 inhibitors for reducing heart failure hospitalizations may be greatest within the first year and may attenuate later.
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2. Hematologists debate best pain management strategy for patient with sickle cell disease
‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center
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In a new Annals ‘Beyond the Guidelines’ feature, two hematologists discuss the care of a patient with sickle cell disease (SCD) experiencing acute and chronic pain. All ‘Beyond the Guidelines’ features are based on the Department of Medicine Grand Rounds at Beth Israel Deaconess Medical Center (BIDMC) in Boston and include print, video, and educational components published in Annals of Internal Medicine.
An estimated 100,000 people in the United States have SCD. Most patients have frequent, debilitating, and very painful vasoocclusive crises (VOCs) due to sickle cell–induced infarction. To combat the severity of these crises, SCD patients are prescribed NSAIDs, tricyclic antidepressants, serotonin-norepinephrine
reuptake inhibitors, and oral opioids. While data on adverse effects are limited for patients with SCD, death from opioid overdose appears to be rare. The updated guidelines from the American Society of Hematology (ASH) suggest the use of ketamine infusion as an adjunctive treatment for acute pain in the hospital that is refractory or not effectively treated with opioids alone. The guidelines also suggest that for adults with emerging or recently developed chronic pain, chronic opioid therapy should not be used unless pain is refractory to multiple other treatment modalities.
BIDMC Grand Rounds discussants, Maureen Okam Achebe, MD, and Wally R. Smith, MD, recently debated the case of Mr. S, a 34-year old man with SCD experiencing acute and chronic pain who uses opioids long-term to manage his symptoms.
In their assessment, Drs. Achebe and Smith disagree about treatment plans for the acute and long-term pain management of Mr. S. Dr. Achebe would recommend ketamine infusion for his acute pain, citing evidence of both lowered pain scores and reduced opioid use. She would also have attempted to delay or entirely avoid initiation of long-term opioid therapy for his chronic pain, citing the high rate of adverse effects associated with long-term opioid use. She would also recommend a discontinuation of long-term opioid therapy for patients not experiencing sustained and clinically meaningful improvements. Dr. Smith would not start ketamine infusions partially because of limited evidence supporting its use and the possibility of bothersome side effects. For Mr. S’s chronic pain, he would recommend the use of long-term opioids because they may reduce VOCs, which are associated with reduced survival. Dr. Smith also favors continuing long-term opioid therapy for Mr. S as long as the drugs remain safe and effective, particularly considering the absence of universally effective and safe nonopioid pharmacologic alternatives.
A complete list of ‘Beyond the Guidelines’ topics is available at www.annals.org/grandrounds.
Also in this issue:
Now Is the Time to Make Screening for Lung Cancer Reportable
Ideas and Opinions
Gregory C. Kane, MD; Julie A. Barta, MD; Christine S. Shusted, MPH; and Nathaniel R. Evans, MD
Community-Acquired Pneumonia Update
In the Clinic
Michael B. Rothberg, MD, MPH
Annals of Internal Medicine
Method of Research
Subject of Research
Sodium–Glucose Cotransporter-2 Inhibitors in Patients With Heart Failure
Article Publication Date