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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

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Hot Topics in Internal Medicine

Molly Cooke MD

Chair-elect, Board of Governors


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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?


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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?


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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.


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Background


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ACCORD 2008

  • RCT 10,251 patients

  • Intensive therapy HgbA1c 6.4%

    vs. standard therapy HgbA1c 7.5%

  • Terminated early after 3.5 years


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ADVANCE 2008

RCT 11,140 patients Median follow up 5 years

Intensive control HgbA1c 6.5% Standard control HgbA1c 7.3%


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ADVANCE 2008


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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


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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?


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Risk of death associated with medications for recently diagnosed COPD

Lee 2008


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Inhaled corticosteroids in patients with stable COPD

Drummond Ann Intern Med 2008


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Long-term daily erythromycin and COPD exacerbations

Seemungal Am J Resp Crit Care Med 2008


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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?


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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


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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


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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


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Print

Nikolas et al Ann Intern Med 2008


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  • 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


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Acute kidney injury with iodinated contrast

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


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Acute Kidney Injury


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

Barrett 1993, as presented in McCullough 2008


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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


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Use of preventive therapy is variable

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


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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.


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Dopamine

Fenoldopam

Furosemide

N-Acetylcysteine

0.62 (0.44-0.88)

Theophylline


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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


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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?


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  • 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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