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Changing Treatment: Established Cardiovascular Disease

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. Peter L. Salgo, MD: Well, we do have these little worrisome things in the IRIS study. You mentioned weight gain, heart failure, bladder cancer.

We’re talking about interesting stuff that we never really were able to get at before well i think that’s what’s fascinating is and in my opinion i’m here as a colleague says i actually think that there probably was never very good data that we ever needed to do these trials to begin with um but thank god we did very specific witch trials well i think i think

That there was the signal for the t’s e ds that turned out not to be true and it’s certainly a huge amount of machinery the fda and billions and billions of dollars to do cardiovascular outcomes safety trials i’m not sure that that that needed to be done but it ended up being a great sort of boon for the these patients because we now are talking about drugs that

May be beneficial we would have never had that day to have the fda about the fda doesn’t approve statins just because they lower ldl why are we approving other classes on surrogate markers when we have notes it’s as if it’s a valid point well we do have these these little worrisome things right in the irish study you mentioned weight gain heart failure bladder

Cancer fractures and fractures and i think the big thing is the edemen heart failure because we know that that diabetics up to 50% could at some point develop heart failure and so you know there’s a big chunk of the diabetic population that t’s eds are never going to be an appropriate therapy this is off topic but i do think that’s gonna be a really big thing in

The future there seems to be some kind of micro vascular just myocardial dysfunction so they have really stiff heart really prone to her fitness so who’s the appropriate population for a tzd and what populations should you avoid tc ds anybody want to do you think we already alluded to the ones that we would avoid it you’re you’re individuals would congestive heart

Failure or most of our patients yeah but not most i think the thing is is that that it is generic and and it’s effective so i think as part of you know as part of the oral armamentarium they can have an important role yeah i do think also elderly patients who are already at risk fractures this probably is a drug i would think more carefully about if i could use

Another agent mm-hmm i don’t want to leave this topic without talking about dpp-4 inhibitors cardiovascular safety a christian can you read can you lead us down yes so there are three dpp-4 inhibitors they’ve all been studied in large cardiovascular trials we have saxagliptin ala clipped and acidic lipton and the drugs on unlike the glp-1 a receptor agonist and

The sglt2 there doesn’t appear to be a cardiovascular benefit to these drugs and for the most part these drugs are also very safe from a cardiovascular signal there was one trial the saver to me 53 study with one of the drugs that seemed to show there was an increased risk of heart failure now this was in patients who are at risk for developing heart failure the

Either at heart failure at baseline or they had elevated markers or bad kidney function for the other two drugs one of them look like it there was no signal and there was a retrospective study for alig lipton that said that there may have been in patients who were in heart failure when the study was involved so i do think there the drugs are pretty clean from a

Cardiovascular perspective there is some data that one of the drugs is associated with heart failure though not heart failure related deaths and but for the most part i think a pretty clean cardiovascular sitting boxed warnings on two of the dress correct right but but i do think the data for alig lipton is is a post hoc analysis and only in patients who showed

Up with heart failure so are the dpp-4 inhibitors gonna slowly be relegated to i don’t think for a safety perspective but i think for the fact that you have other cardiovascular drugs that have because the the patient that would be the ideal candidate for a dpp-4 inhibitor will probably be also for a gop one right so you other than the injection part of this

You would gravitate towards the increase in therapy that gives you the cardiovascular benefit i think the stephens point the like maybe you’d use a tzd because the efficacy on the glucose side where the p p force don’t give you any benefit for the glycaemia the issue is this simple to use and i think that’s why people use it it still shocks me that about a few

Percentage of people are using gop when i guess where where you get much more bang for the buck if you will in terms of all of these benefits but it’s very easy to as either add-on therapy to edit ap for even though as you mentioned you don’t get the efficacy yeah and the injections are barriers to patients it’s actually more of a problem for us as clinicians

Because patients don’t don’t pay if you tell patients particular if you say and you will lose weight they’ll check themselves in the eye so it’s a question of i think we think it’s gonna is it’s a barrier and i think we also it just because takes a bit longer to explain how to use it but is there safe that they’re effective you know it’s shocking that they’re

Not using more freedom what is the typical reaction in your office you say to a patient look there’s this great drug we’ve got this new data it’s 50% better in many ways but you’re gonna have to have an injection either daily or weekly or monthly or whatever what do they say well i i think if you if you say but you’re gonna have an injection i’m already putting

A negative on it what i do is i say frankly this is you know it’s a tiny needle and i’ll inject myself in the office and you know i’ll try not to cry and and and then oh and i will inject them in the office and i’ll but i’ll do it i wasn’t close awry and told me which arm they’re being injected in and i’ll pinch one arm and i’ll inject me other and the vast

Majority can’t even tell so i think once they see that it’s not that big a deal it’s much easier to progress but the gop want to have some gi issues as well right there are some right it’s of sites over time for the vast majority and it’s a little bit different depending on whether you’re using a short-acting versus a long-acting agent but again all these things

Are part of the education and i think more than anything from a patient’s point of view is more the injection issue and in you have to meet them where they are their concept of what the injection can be and may not be your 6 millimeter needle it might be they’re thinking about this needle which was insane pains and the issue of the gi is frankly also you can it

May even help your lifestyle because people you i tell people eat half but you normally eat because a lot of the feeling of gi distress is actually well is a feeling of fullness which is one of the benefits all of the gop ones i have said that a million times i think that’s part of the benefit of why they lose weight you feel full tell me a little bit about just

The pragmatic use of these drugs storage do they have to be refrigerated do you pick them up once a week do you in terms of patients dealing with this well you know there’s different you know the ragga type is you can use that’s available six for six weeks without being refrigerated you you have the minute itis is is really kind of what is good for four weeks

That the problem is is that that now we have once monthly injections that make it so much easier and even one of the one of the agents you can’t even see that the needle so basically the inject the person it it’s so intuitive that it makes it much easier and it really depends frankly on what’s covered as well as as kind of working into the patient’s lifestyle

But really i don’t see it as a barrier frank is very easy in particular you mentioned if you mentioned and by the way you you may actually get your blood pressure blood pressure decrease and you may actually lose weight that’s it done let’s do it ridiculously good what am i missing anything here i don’t think so well we remember every medication as a potential

Adverse effect just like you said but we can’t get cavalier we have to remember and they’re relatively shorter i like all clinical trials relatively shorter duration so i do think you know it’s important to say when you roll these out broadly into the community and we look at people been using these drugs 10 years 15 years there are sometimes signals that emerge

That were unanticipated from there and there’s a new agent actually that is actually even beyond quote the injections where where you actually have an implantable system that can last for six months and and it holds blood sugars very stable that will be coming out in the feet in the future and that overcomes a lot of that a lot of

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Changing Treatment: Established Cardiovascular Disease By SuperTv SuperTv