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Blood clot in a blood vessel

ACCP UPDATES PERIPROCEDURAL ANTITHROMBOTIC RECOMMENDATIONS

The American College of Chest Physicians (ACCP) recently published updated guidelines for managing antiplatelet agents and anticoagulants in patients undergoing surgery or procedures that may involve bleeding; the previous guidance was from 2012 and did not include direct oral anticoagulants (DOACs). We added the new guidelines to our Periprocedural antithrombotic recommendations page, which also includes guidance from the AHA, ASGE, and SEC. Recommendations are grouped by indication and available at the links below.



Picture of obese child watching TV and eating

AAP RECOMMENDS WEIGHT LOSS DRUGS FOR OBESE CHILDREN

For the first time, the American Academy of Pediatrics is recommending that providers offer obese children 12 years and older weight loss drugs as part of their initial treatment, as opposed to considering them only after other interventions fail (AAP obesity guidelines). With the recent approval of Wegovy in adolescents, there are now four FDA-approved drugs available to treat childhood obesity - Wegovy, Saxenda, Qsymia, and Orlistat. The guidelines also mention metformin as an option, which seems odd since studies have never found it to have a meaningful weight-loss effect.

Adolescent weight loss trials:
Emotional support animal laws - what providers should know
Dog on an airplane
By now, most primary care providers have been asked to fill out paperwork declaring a patient's pet an emotional support animal. These requests have become so common that an entire industry of online businesses that provides these designations for a fee has come to exist. So what makes an animal "emotionally supportive," and why are patients often anxious to get the paperwork completed? We review the relevant housing and airline laws surrounding these requests so that providers understand their genesis.

Illustration of brain

FDA APPROVES BIOLOGIC FOR ALZHEIMER'S DISEASE

Leqembi® (lecanemab-irmb), a monoclonal antibody that binds with high affinity to amyloid-beta soluble protofibrils, was approved to treat Alzheimer's disease in patients with mild dementia; beta-amyloid pathology should be confirmed by PET or CSF measurements before therapy. It is given as an IV infusion once every 2 weeks, and periodic MRIs are required to monitor for amyloid-related imaging abnormalities (e.g. brain edema, microhemorrhages, superficial siderosis). In its pivotal trial (N=1795), average change from baseline in the CDR-SB score (scale 0 - 18, with higher being worse | average baseline score 3.2) was +1.21 in Leqembi-treated patients and +1.66 in placebo-treated patients after 18 months (p<0.001) [PubMed abstract].

The effects of Leqembi were very modest, with a difference compared to placebo of 0.44 on an 18-point dementia scale, which equates to a 2.5% improvement. Alzheimer's is an dreadful disease with few options. Hopefully, longer-term use of Leqembi will show a greater benefit.
How effective is acetazolamide at preventing acute mountain sickness?
Picture of man on top of a mountain
Acute mountain sickness (AMS), also called altitude sickness, can develop when someone rapidly ascends from near sea level to more than 3000 meters. Symptoms include headache, lightheadedness, nausea, insomnia, and fatigue. AMS is believed to occur from hypoxia-induced respiratory alkalosis. The carbonic anhydrase inhibitor acetazolamide, which promotes renal bicarbonate loss, has been prescribed for years to people who are planning a high-altitude trip. Two recently published studies compared acetazolamide to placebo for the prevention of AMS; Study one enrolled healthy adults, and Study two involved patients with COPD. Acetazolamide was effective in both studies, although subgroup analyses showed that women saw a much greater benefit.

LATEST NEWS

Vuity® (pilocarpine) eyedrops for age-related farsightedness

picture of an eye
Vuity® (pilocarpine) is an eyedrop recently approved to treat age-related farsightedness, a condition people often address with reading glasses. Even though it's a new drug with no generic, cash-pay prices are around $80 per bottle, which provides about 25 days of treatment. See the link below for a brief review of its effects.

Drug that delays type one diabetes approved

Vial of Tzield (teplizumab)
Teplizumab (Tzield®), a monoclonal antibody that alters T-cell affinity for pancreatic beta cells, was approved to delay the onset of type 1 diabetes (T1DM) in pediatric patients 8 years and older with two or more islet cell antibodies and dysglycemia. The drug is an IV infusion given once daily over 14 consecutive days.

Over-the-counter Naloxone may soon be here

Narcan nasal spray
An article in The Wall Street Journal reports that several versions of over-the-counter naloxone may be available as early as this Spring. See FDA fast-tracks Naloxone, WSJ 12/26/2022 for more.

Empagliflozin (Jardiance®) improves CKD outcomes

Jardiance (empagliflozin) box
In a trial (N=6609) that included diabetics (46%) and nondiabetics, empagliflozin improved renal outcomes in patients with chronic kidney disease (EMPA-KIDNEY trial). An earlier study with dapagliflozin (DAPA-CKD trial) had similar results that earned it a CKD indication.

Generic Pradaxa available at pharmacies

Pradaxa (dabigatran) box
Pradaxa® (dabigatran), a direct thrombin inhibitor approved for A fib and venous thromboembolism, is the first direct oral anticoagulant to have a generic. GoodRx shows cash prices as low as $160/month.


NEW DRUGS

POPULAR BUT UNPROVEN

  • Meniscal surgery - It's one of the most common orthopedic procedures performed, but does it do anything?
  • CPAP for sleep apnea - Sleep doctors are on every corner it seems, but what are the benefits of diagnosing and treating sleep apnea?
  • Knee injections - these treatments are popular among orthopedists and primary care doctors, but are they effective?
  • Pneumonia vaccines in adults - vaccine manufacturers, the CDC, and Medicare want everyone to get a pneumonia vaccine, so they must be highly effective, right?

Are Noncompete Clauses Going Away?
picture of a contract with pen
Noncompete clauses are common in physician contracts, although people have different opinions on their legality. Multiple news outlets are reporting that the Federal Trade Commission is considering banning them.
Cologuard Pros and Cons
Cologuard cartoon box
Cologuard commercials run nonstop, and it's not hard to talk people out of a colonoscopy. So what should patients know before they skip the gastroenterologist and take advice from a talking box with arms and legs?

CLINICAL CHALLENGE

A 65-year-old male who had a CABG two years ago comes to see you for follow-up on a recent hospitalization for new-onset atrial fibrillation. In the hospital, he was started on Eliquis, and when you review his med list, you see that he is still taking a daily low-dose aspirin. Should you tell him to stop the aspirin now that he is on Eliquis? Should he take aspirin and Eliquis together since he has an indication for both? Are there any guidelines or studies that address the issue? Find out more at the link below.