January’s double continuing education event kicked off the start of NYCSHP 2015! Members gathered at Montefiore Medical Center in the Bronx, NY. President-elect, Dr. Yi Guo, introduced herself and welcomed us all to Montefiore Medical center. She thanked the exhibit sponsor prior to the evening, Samsca, who discussed tolvaptan, a vasopressin antagonist used in hyponatremia. She introduced NYCSHP’s board members and NYSCHP board members who were present in the audience. President-elect, Dr. Guo, proceeded by introducing the evening’s first speaker, Allen Jeremias, MD, MSc, from Stony Brook University Medical Center. Dr. Jeremias is an Associate Professor of Medicine as well as the Director of Cardiac Intensive Care and Cardiac Acute Care Units at Stony Brook University Medical Center. Dr. Jeremias presented “Cardiology Grand Grounds.”
The first objective was to elucidate the current role of oral antiplatelet therapy in the treatment of acute coronary syndromes and prevention of stent thrombosis. The second objective was to differentiate between currently approved P2Y12-inhibitors in terms of pharmacokinetics, pharmacodynamics, clinical outcomes, indications, contraindications, and drug-drug interactions. The final objective was to explore unanswered questions concerning the clinical management of patients treated with P2Y12-inhibitors including: optimal duration of therapy, platelet function testing, proton pump inhibitor treatment, cessation of therapy before surgery, and the consideration of “triple therapy.”
Dr. Jeremias compared and contrasted clopidogrel, prasugrel, and ticagrelor and proceeded to discuss which agents have better efficacy and less bleeding risk through clinical trials. The TRITON-TIMI 38 trial studied invasive acute cardiac syndrome showing prasugrel has a better survival rate than clopidogrel. From a safety point of view, clopidogrel showed less bleeding risk than prasugrel. The PLATO trials demonstrated that ticagrelor has a higher survival rate than clopidogrel. Ticagrelor had more incidences of bleeding than clopidogrel in patients with no CABG, but had less incidences of bleeding than clopidogrel in patients with a CABG. The TRILOGY ACS study compared prasugrel with clopidegrel in patients with medically managed UA/NSTEMI. TRILOGY ACS demonstrated that prasugrel has significant inhibition of platelets, but is not recommended in patients undergoing a PCI, due to the greater incidences of bleeding. The ACCOAST trial tested if pre-loading with prasugrel 30mg will provide benefits in CV death, MI, stroke, and UR, but pre-loading with prasugrel showed increase risks of bleeding with minimal efficacy.
The 2014 ESC have recommendations for patients undergoing PCI. Patients with stable CAD who are undergoing elective stenting are recommended to receive clopidogrel. Patients with NSTE-ACS who are proceeding to PCI are recommended to receive prasugrel. Patients with NSTE-ACS with moderate-to-high risk of ischemic events are recommended to receive ticagrelor. Patients with STEMI are able to receive clopidogrel, prasugrel or ticagrelor as long as there are no contraindications. In patients with clopidegrel resistance, it is not safe to double the dose because there is increase bleeding risk. For patients with clopidogrel resistance, the patient should receive ticagrelor. Next, Dr. Jeremias discussed the role of triple therapy for patients with atrial fibrillation with high risk (CHADS2 >2) of stroke who are undergoing stenting. Triple therapy increases the risk of bleeding, but it is preferential to use a low dose ASA, a BMS stent over a DES stent, clopidogrel, and a PPI. Dr. Jeremias concluded his very informative presentation with a question and answer session from the audience.
President-elect, Dr. Guo, introduced Maabo Kludze-Forson, Pharm.D., MBA, CDE. Dr. Kludze-Forson is a clinical pharmacy specialist at GNYHA Services. Her presentation was titled “Oral Agents in the Treatment of Type 2 Diabetes: The New Frontier.” Dr. Kudze-Forson discussed the current blood glucose and A1C goals and distinguished how the 2015 American Diabetes Association goal are than previous guidelines. Current goals separate patients based on co-morbidities, the duration of a diabetic history, and life expectancy. Next, she discussed which agents are used as first line and which agents are not used as first line based on their adverse effect profiles. Dr. Kludze-Forson preceded by presenting studies that demonstrated Rosiglitazone’s cardiovascular profile. After significant data, the FDA mandated that new anti-diabetic medications have to perform studies about cardiovascular Risk Evaluation and Mitigation Strategy (REMS). By 2013, published findings showed that rosiglitazone does not add cardiovascular risk leading to death.
Different anti-diabetic agents are utilized for their characteristics. Repaglinide and Starlix are recommended for patients with erratic eating habits because of its short half-life. Bromocriptine (Cycloset) is a dopamine agonist which mediates the circadian rhythm to regulate insulin resistance and obesity. Bromocriptine should be taken in the morning when the dopamine level is high. Metformin is being studied in Type-one diabetics for its beneficial cardiovascular effects, but is not currently FDA approved in Type-one diabetics.
Sodium-Glucose Co-transporter 2 (SGLT2) inhibitors include Canagliflozin (Invokana), Dapagliflozin (Farxiga), and Empagliflozin (Jardiance). The SGLT2-I work in the kidneys to prevent glucose from being absorbed back into the blood. A disadvantage is that SGLT2-I have a high rate of gastrointestinal adverse effect. The SGLT2-I can be used as monotherapy or as adjunct therapy in patients with Type two diabetes. SGLT2 inhibitors are contraindicated in patients with creatinine clearance less than 30ml/min and in dialysis.
Afrezza is a new inhaled insulin powder for adults. Each cartridge contains a dose of 4 units or 8 units. Afrezza is to be used in Type one diabetics as a prandial insulin. Patients still need to take their long acting insulin. Afrezza is contraindicated in patients with chronic lung disease such as asthma or COPD. It should not be used in diabetic ketoacidosis or in patients who smoke or recently have stopped smoking. Dr. Kludze-Forson’s presentation ended with a question and answer session. The educational evening concluding with further networking amongst members.
Written by Jamie Chin
Photos by Jamie Chin