geoffrey modest medical blogs

​​Per the manufacturer, liraglutide just received a new indication by the FDA: "to reduce the risk of major adverse cardiovascular (CV) events, heart attack, stroke and CV death, in adults with type 2 diabetes and established CV disease". see  http://press.novonordisk-us.com/2017-08-25-Victoza-R-liraglutide-is-approved-in-the-US-as-the-only-type-2-diabetes-treatment-indicated-to-reduce-the-risk-of-three-major-adverse-cardiovascular-events   will append my blog below from 6/22/16, which reviewed the original article leading to this indication, and my commentary: there was a recent article from a paper at the Am Diabetes Assn annual meeting finding decreased cardiovascular events in patients on the glucagon-like peptide 1 (GLP-1) agonist liraglutide (see  DOI: 10.1056/NEJMoa1603827).  details : --9340 patients with type 2 diabetes and high cardiovascular risk, randomized to liraglutide vs placebo, with mean follow-up 3.8 yrs. Drug-company sponsored study begun

 the CDC just published their findings on antibiotic use in the US, showing significant decreases (see  https://www.cdc.gov/getsmart/pdf/stewardship-report.pdf ​ ) Details: -- outpatient settings (clinics, doctors' offices, ERs):      --47 million unnecessary antibiotic prescriptions/yr​     ​-- overall antibiotic scripts decreased by 5% in period 2011-14 from 75 million scripts to 64 million in children <19 yo, though has increased from 192 to 198 million in adults (especially high prescribing rates in kids <2 and adults >65). however, more often antibiotics prescribed may be "less effective and carry more risk over more targeted first-line drugs recommended by national guidelines" (in 2010-11, only 37% of adults received guideline-recommended antibiotics for sinus infection or pharyngitis, more like 60% in kids for these infections and otitis media.)     --the CDC still feels that 30% of outpatient antibiotic prescriptions are unnecessary, and 50% of tho

​ The CDC just came out with their 2017-18 vaccine recommendations (see  https://www.cdc.gov/mmwr/volumes/66/rr/rr6602a1.htm ​ ): --vaccine should be given to all >6 months old, unless contraindicated (then consider chemoprophylaxis with influenza antivirals) -- vaccine viruses included in the 2017–18 U.S:     ​-- Trivalent influenza vaccines: A/Michigan/45/2015 (H1N1)pdm09–like virus, A/Hong Kong/4801/2014 (H3N2)-like virus, and B/Brisbane/60/2008–like virus (Victoria lineage). This is a change in the vaccine composition from last year in the A(H1N1)pdm09 component     --Quadrivalent influenza vaccines will contain these three components and also cover the additional influenza B vaccine virus, a B/Phuket/3073/2013–like virus (Yamagata lineage). - -vaccines recommended include: Afluria Quadrivalent (IIV4, if ≥18 years, but Afluria Trivalent IIV3 can be used for those ≥5 years);  Flublok  Quadrivalent (RIV4); and FluLaval Quadrivalent (IIV4, previously licensed for ≥3 ye

​ ​a recent systematic review/meta-analysis looked at the benefits and safety of gabapentinoids  for chronic low back pain, finding not much benefit yet significant adverse effects (see   http://journals.plos.org/plosmedicine/article/file?id=10.1371/journal.pmed.1002369&type=printable ​ ). Results: --only 8 studies found:     ​--3 compared gabapentin (GB) with placebo (n=185): minimal improvement in pain with gabapentin. mean difference 0.22 units, not statistically significant, quality of evidence very low     ​--3 compared  pregabalin  (PG) alone vs other analgesics: amitriptyline, celecoxib, tramacet (a combo of tramadol and acetaminophen ); n=332, studies combined. Greater improvement in cominaiton of the non- pregabalin  groups (mean difference 0.42 units,  quality of evidence very low, though I really doubt that 0.42 means anything clinically in a scale from 0-10 ). the biggest study compared 200 patients on  amitriptylin e ​ 50mg vs PG 600mg/d for 14 weeks

​A recent analysis documented the lack of effectiveness of the live attenuated influenza vaccine (LAIV) in  children during  the 2015-2016 season, despite normal effectiveness of the inactive vaccines (see   DOI: 10.1056/NEJMoa1700153). Details: --6879 eligible people were evaluated through the Influenza Vaccine Effectiveness Network (5 sites across the US) --5570 tested negative for flu, 1309 positive; 2668 were unvaccinated and 2902 vaccinated --22% were 6 mo-8 yr old, 13% 9-17 yo, 35% 18-49, 17% 50-64, 13% >65; overall 30% were 2-17 yo. 75% white, 8% black, 8% Hispanic --1309 (19%) tested positive for influenza virus (case patients): 11% had A(H1N1)pdm09 (58% of the case patients) and 7% influenza B (34% of case patients). these flu-infected patients were more likely to be 9-64 yo, male, black, have "excellent" general health, and less likely to be obese or to have gotten the flu vaccine. --all strains of the flu that were  genetically sequenced  were similar to

the NY Times had a really poignant editorial about the opioid epidemic, noting that there continues to be a very very strong racist bias in framing it and in punishing those with opioid use disorders. in fact, the current approach (eg per Atty General Jeff Sessions) could well lead to further incarcerations, especially for minorities, and further set back the necessary effective approaches to helping people. see  https://www.nytimes.com/2017/08/18/opinion/sunday/opioids-drugs-race-treatment.html?ref=opinion ​  geoff

There are several studies finding that influenza vaccine effectiveness may wane over time, suggesting that it might be better to delay vaccination to closer to the onset of the influenza outbreak. A new study looked at the effectiveness of vaccines from the 2011-12 through the 2014-15 seasons in the US (see  DOI: 10.1093/cid/ciw816 ). Details: -- the US Influenza Vaccine Effectiveness Network compiled data on adults and children seeking outpatient care for acute respiratory illnesses at 5 different locations scattered through the US, after influenza was confirmed in those communities -- eligible patients had illness with cough, or cough and/or fever of less than 7 days duration, and had nasal specimens tested for influenza/PCR done. -- patients who tested positive for influenza were compared with patients who tested negative. -- they only included patients if they were greater than 9 yo and had received the influenza vaccine at least 14 days before illness onset. -- there