Clinical Briefs
May 15, 2016 4 minutes read
Home BP Monitoring vs. Ambulatory BP Monitoring
SOURCE: Shimbo D, Abdalla M, Falzon L, et al. Studies comparing ambulatory blood pressure and home blood pressure on cardiovascular disease and mortality outcomes: A systematic review. J Am Soc Hypertens 2016;10:224-234.
For the last several decades, decisions about management of hypertension (HTN) have been based predominantly on blood pressure (BP) recorded in an office, commonly known as “office BP” (OBP). Randomized, interventional HTN trials based on OBP have confirmed important clinical benefits from treatment: reductions in myocardial infarction of about 25%, stroke of about 40%, and heart failure > 50%. Nonetheless, vocal supporters for 24-hour ambulatory blood pressure monitoring (ABPM) have pointed out that ABPM correlates significantly better with cardiovascular disease (CVD) outcomes than OBP, leading to the logical conclusion that treatments based on ABPM might also provide better CVD risk reduction.
The same arguments can be made for home BP monitoring (HBPM). Since both ABPM and HBPM provide the opportunity for many more BP readings than occasional OBP, it’s not surprising that either tool has better positive predictive value than OBP. Additionally, HBPM and ABPM definitions of HTN appear to be more accurate because they eliminate most white-coat HTN.
Shimbo et al performed a systematic review of ABPM and HBPM trials. While the authors were able to confirm that both ABPM and HBPM have stronger association with CVD than OBP, they were unable to determine whether one holds a distinct advantage over the other. Although clinical trials with ABPM seem to indicate a stronger association with CVD than observed in HBPM trials, trial data that include both methods of BP monitoring (ABPM and HBPM) in the same study population are few. Concordant with recent (2015) U.S. Preventive Services Task Force recommendations, clinicians should routinely use ABPM or HBPM prior to initiating treatment for HTN.
Who’s Right About DPP4 Agents and Heart Failure?
SOURCE: Filion KB, Azoulay L, Platt RW, et al. A multicenter observational study of incretin-based drugs and heart failure. N Engl J Med 2016;374:1145-1154.
Opinions about DPP4 inhibitors (e.g., sitagliptin, saxagliptin) and heart failure (HF) have vacillated between “worry” and “don’t worry” for about two years. In the March 24, 2016, edition of the New England Journal of Medicine, results of an analysis performed by the Canadian Network for Observational Drug Effect Studies indicate that there is no demonstrable increase in risk for HF, as indicated by hospitalization for HF, with incretin agents (GLP1 analogues and DPP-4 inhibitors). Their conclusions are based on an evaluation of data from 29,741 hospitalizations for HF among 1.5 million patients in the United States, Canada, and the United Kingdom.
On April 6, the FDA issued a “new alert” about the potential for increased risk of HF with saxagliptin (Onglyza) and alogliptin (Nesina), as well as any combination products that contain either of these two agents.
Who’s right? The FDA warnings should be taken seriously, even if other evaluators disagree — if only to maintain an appropriate standard of care. Hence, avoid prescribing the DPP4 inhibitors saxagliptin or alogliptin to patients with HF until the FDA provides further advice. In the meantime, the association with HF has not been deemed a “class effect.” Therefore, other DPP4 inhibitors such as sitagliptin or linagliptin, which were not named by the FDA as proscribed for patients with HF, should be considered when clinicians wish to use a DPP4 inhibitor in patients with HF.
Severe Hypoglycemia: Identifying At-risk Groups
SOURCE: Pathak RD, Schroeder EB, Seaquist ER, et al. Severe hypoglycemia requiring medical intervention in a large cohort of adults with diabetes receiving care in U.S. integrated health care delivery systems: 2005-2011. Diabetes Care 2016;39:363-370.
There are numerous reasons to show a healthy respect for hypoglycemia in diabetic patients. First, hypoglycemia is responsible for many deaths in diabetics. Second, hypoglycemia may cause consequential injuries from falls and auto accidents. Third, hypoglycemia is included in the American Diabetes Association treatment algorithm list of five issues clinicians should address routinely when advancing pharmacologic treatment from metformin to polypharmacy. Fourth, patients often weigh issues about hypoglycemia risk as highly important in their decision process about advancing and adhering to medication.
Pathak et al reported results of an observational cohort study of almost 1 million adults participating in the Surveillance, Prevention, and Management of Diabetes Mellitus (SUPREME-DM) network who were treated during the 2005-2011 interval. Severe hypoglycemia was diagnosed among inpatients and patients presenting to EDs. Statistically significantly higher rates of severe hypoglycemia occurred in older patients (especially those > 75 years of age) and those with chronic kidney disease, heart failure, cardiovascular disease, and depression. Pharmacologic agents associated with higher risk of severe hypoglycemia included insulin, insulin secretagogues, and beta-blockers.
Because hypoglycemia is such an important obstacle to optimized goal attainment in diabetes, clinicians may wish to factor the above-mentioned demographics into their pharmacologic decision process.
In this section: comparing blood pressure monitoring techniques; DPP4 agents and heart failure; identifying at-risk groups for hypoglycemia.
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