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Hot Topics in Internal Medicine Molly Cooke MD Chair-elect, Board of Governors Questions Does intensive glucose control improve outcomes in Type 2 diabetes? What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?

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hot topics in internal medicine

Hot Topics in Internal Medicine

Molly Cooke MD

Chair-elect, Board of Governors

questions
Questions
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
questions3
Questions
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
does intensive glucose control improve outcomes in type 2 diabetes
Does intensive glucose control improve outcomes in Type 2 diabetes?
  • ACCORD Effects of intensive glucose lowering in Type 2 diabetes N Engl J Med 2008; 358: 2545-59
  • The ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes in patients with Type 2 diabetes. N Engl J Med 2008; 358:2560-72
  • Duckworth W et al. Glucose control and vascular complications in veterans with Type 2 diabetes. N Engl J Med 2009; 360:129-39.
accord 2008
ACCORD 2008
  • RCT 10,251 patients
  • Intensive therapy HgbA1c 6.4%

vs. standard therapy HgbA1c 7.5%

  • Terminated early after 3.5 years
advance 2008
ADVANCE 2008

RCT 11,140 patients Median follow up 5 years

Intensive control HgbA1c 6.5% Standard control HgbA1c 7.3%

glucose control and vascular complications duckworth 2008
Glucose control and vascular complications (Duckworth) 2008
  • RCT 1791 veterans, median follow up 5.6 years
  • Intensive therapy HgbA1c 6.9% vs. standard therapy HgbA1c 8.4%
  • Adverse effects, particularly hypoglycemia, 17.6% in standard therapy vs. 24.1% in intensive therapy
questions10
Questions
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
long term daily erythromycin and copd exacerbations
Long-term daily erythromycin and COPD exacerbations

Seemungal Am J Resp Crit Care Med 2008

questions14
Questions
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
summary
Summary
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
    • No, and it is associated with excess morbidity and mortality
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
    • Discontinuation of NSAID’s, pre-procedure hydration, possibly possibly sodium bicarbonate > sodium chloride, probably N-acetylcysteine
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
    • Inhaled steroids are associated with increased pneumonia
    • Ipatropium may be associated with increased mortality
    • Daily macrolide prophylaxis appears to decrease exacerbations
acute kidney injury
Acute Kidney Injury
  • Sensitivity and specificity of a single emergency department measurement of urinary neutrophil gelatinase-associated lipocalin for diagnosing acute kidney injury

Nickolas T, et al. Ann Intern Med 2008; 148(11):810-819

neutrophil gelatinase associate lipocalin ngal
Neutrophil Gelatinase-Associate Lipocalin (NGAL)
  • Small protein belonging to the lipocalin family of proteins
  • Expressed by neutrophils and various epithelia, including the renal proximal tubules
  • Functions are not completely understood
    • Upregulated in cells under “stress”
    • Released from secondary granules of activated neutrophils
    • Initially proposed as a marker for infections and certain adenocarcinomas
  • NGAL has an early and dramatic rise in urine

after renal injury

slide19

Print

Nikolas et al Ann Intern Med 2008

slide20

A single measurement of urinary NGAL helps to distinguish acute injury from normal renal function, prerenal azotemia, and CKI

  • This may help patient disposition from the ED to home, observation unit for hydration, versus full admission
acute kidney injury with iodinated contrast
Acute kidney injury with iodinated contrast

McCullough PA. Crit Care Med 2008; 36(4Suppl):S204-211

slide23

Meta-analysis - Nephrotoxicity of high- and low- osmolality iodinated contrast medium

Barrett 1993, as presented in McCullough 2008

acute kidney injury24
Acute Kidney Injury

Prevention, incidence, and outcomes of contrast-induced acute kidney injury

Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32

slide25

Use of preventive therapy is variable

Weisbord SD, et al. Arch Intern Med 2008; 168(12):1325-32

acute kidney injury aki
Acute Kidney Injury (AKI)

Meta-analysis: effectiveness of drugs for preventing contrast-induced nephropathy

Kelly AM, et al. Ann Intern Med 2008; 148(4):284-294.

slide29

Dopamine

Fenoldopam

Furosemide

N-Acetylcysteine

0.62 (0.44-0.88)

Theophylline

acute kidney injury aki30
Acute Kidney Injury (AKI)
  • Bottomline
    • CIAKI is associated with poor outcomes
    • Need to standardize contrast induced acute kidney injury (CIAKI) prophylaxis
    • Patients with risk factors for CIAKI (chronic kidney disease and diabetes) should receive non-ionic contrast
    • NAC is more effective in preventing CIAKI injury than hydration alone
summary31
Summary
  • Does intensive glucose control improve outcomes in Type 2 diabetes?
  • What is the optimal prophylaxis to prevent contrast-induced acute kidney injury?
  • Do inhaled medications increase morbidity and/or mortality in patients with COPD?
slide32
Systematic abstracting of papers from > 130 journals
  • Ratings of each article for quality and newsworthiness
  • Customizable email alerts
  • Cumulative searchable database of alerts from 2003

https://plus.mcmaster.ca/acpjc/Registration.aspx

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