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Aspirin and primary prevention in diabetic patients

15,480 patients, 12% reduction of serious vascular events, 29% increase of bleeding. To date, nothing really spectacular albeit controversial.

A good point is that cardio protection is achieved in the presence of many other cardiovascular-effective drugs. Maybe this time it is true that aspirin is good for diabetics.

Read the article.

DOI: 10.1056/NEJMoa1804988

Effects of Aspirin for Primary Prevention in Persons with Diabetes Mellitus

The ASCEND Study Collaborative Group*

ASPIRINA

A stomaco vuoto prima di cena. RCP.

Coumadin e terapia oncologica

cancerCapisco, è il 2 Agosto, io lavoro…e mi imbatto sempre più frequentemente in queste situazioni complicate, soprattutto quando la TAO è stata instaurata per la profilassi tromboembolica nei pazienti con FA o che sono affetti da cardiopatia ischemica. La review che vi allego qui mi sembra abbastanza interessante per la gestione quotidiana condivisa dei nostri pazienti cardio-oncologici. Nello specifico il lavoro non descrive solamente le interazioni farmacologiche, ma spiega come la chemioterapia e lo stato di malattia possano interferire con la terapia anticoagulante antagonista della vitamina K. Un esempio per tutti: il vomito. Per ora i NAO stanno facendo solo chetichella alla porta (rivaroxaban in testa), ma questa è un’altra puntata…

Pangilinan JM, Pangilinan PH Jr, Worden FP. Use of warfarin in the patient with cancer. J Support Oncol. 2007 Mar;5(3):131–6.

Is it only CAD?

79 yo lady with an ill-defined history of stomach ache. Hypertensive on Rx, statins, and nagging as all old ladies do.  

 

DVT/PE treatment and cancer

Case history:

A 68 year old woman presented to my office for LVEF evaluation prior to cancer chemotherapy. Notably, the ejection fraction was normal, but the patient told me about pulmonary embolism she experienced during radiotheraphy following surgical excision of her lung cancer. The patient was on enoxaparin 4000 IU daily since 2013 and to date her clinical history was uneventful as to vascular events. Unfortunately, cancer was discovered in the contralateral lung.

I’d like to point out some issues:

The ACCP guidelines [1]state that LMWH (with full-dosage regimen) is preferred to other agents for extended ( > 3 mo to indefinte) treatment; nonetheless the authors underscore the lack of data when the guidelines were being prepared (Figure 1). ESC guidelines seem to be just a bit more restrictive with respect to rivaroxaban and cancer patients[2]
Prins et al [3]performed a pooled analysis of the EINSTEIN trials, demonstarting that rivaroxaban is effective as LMWH in the treatment of DVT in patients with cancer, as well as cutting down the risk of bleeding.
Please consider also the oral once-daily administration of rivaroxaban as an adjunctive positive feature of the drug itself in such patients.

LMWH cancer

  1. Kearon Clive, Akl ElieA, Comerota AnthonyJ, Prandoni Paolo, Bounameaux Henri, Goldhaber SamuelZ, et al. Antithrombotic therapy for VTE disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e419S–94S.
  2. Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Gali`e N, et al. 2014 ESC guidelines on the diagnosis and management of acute pulmonary embolism. Eur Heart J. 2014 Nov;35(43):3033–69, 3069a–3069k.
  3. Prins MartinH, Lensing AnthonieWA, Brighton TimA, Lyons RogerM, Rehm Jeffrey, Trajanovic Mila, et al. Oral rivaroxaban versus enoxaparin with vitamin K antagonist for the treatment of symptomatic venous thromboembolism in patients with cancer (EINSTEIN- DVT and EINSTEIN-PE): a pooled subgroup analysis of two randomised controlled trials. The Lancet Haematology 2014;1(1):e37–e46.

Number Needed to Treat (NNT) Calculator

Weaknesses of the NNT Metric

The idea of NNT provides clinicians with a method of explaining the relative benefit or harm of a given therapy for a patient. Because of its simplicity, NNT has the following weaknesses:

  1. It is usually described as a point estimate instead of a confidence interval of the observed therapeutic effect. This has led some authors to report NNT with a corresponding confidence interval (eg, NNT 5 (95% CI 3 to 9))
  2. As with other descriptions of benefit, NNT does not account for a patient’s baseline risk. If a patient’s individual risk is higher or lower than that studied in a trial, his or her NNT will be lower or higher, respectively.
  3. When describing NNT, the comparator is an essential component. The NNT of a given treatment will be very different when describing the value versus placebo instead of another active therapy.
  4. The time frame of a given study is important and the benefit of a treatment is usually not linear over time. For example, if a treatment was conducted over a mean of 4 years, its NNT should be expressed with the same time component (eg, 12 patients need to be treated over about 4 years…).

Number Needed to Treat (NNT) Calculator.

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