• It is well known that sodium-glucose cotransporter-2 inhibitors (SGLT-2Is) reduce hospitalizations for heart failure (HF) and mortality in general older populations with type 2 diabetes
  • It is estimated that in people with diabetes 32–48% prevalence of frailty exists.
  • Such people are often excluded from RCTs.
  • Clinicians treating frail older people with type 2 diabetes face challenges selecting appropriate second-line therapy.
  • But systematic reviews have shown people who are frail have over 5-times higher odds of hospitalization and a 35% increased risk of mortality compared to non-frail individuals with diabetes.
  • J.V. McMurray, MD commented recently that frail elderly patients are at high risk but are often poorly treated because physicians think they will not tolerate and may not benefit from pharmacological therapy.
  • There is little evidence that such therapeutic nihilism is justified.
  • In a post hoc analysis of the DAPA-HF trial, it has been found that greater frailty status was associated with more impairment in health status and worse clinical outcomes. It is interesting to note that the frailest patients derived the most benefit from the drug
  • Now, A new study by Wood et al concludes-SGLT-2Is may be preferred to DPP-4Is for preventing MACE, HF hospitalizations and mortality in frail people with type 2 diabetes. (Front. Pharmacol. 13:886834. doi: 10.3389/fphar.2022.886834)

Power of gene therapies: “in an ideal world, there would be no diabetes management, as there would no longer be type 1 diabetes.”

Tim Street, founder of the Diabettech blog, says

  • “The future in this space is not only mechanical/technological. It is also biological, with the idea that glucose-responsive insulin that could be taken once a week could react to variation in the blood glucose levels and not require the use of CGM or a pump, but I’d suggest that’s ten years off. In the meantime, potentially better insulins may help enable technological systems to operate more effectively.” And what if we dream big and look to the far future? He also believes in the power of gene therapies: “in an ideal world, there would be no diabetes management, as there would no longer be type 1 diabetes. This will be driven by suppressing the immune-response and gene-therapies that allow those with the disease to be cured.”

 Moderate alcohol consumption was linked to higher brain iron and worse cognitive function, an observational study showed.

(Topiwala A, et al “Associations between moderate alcohol consumption, brain iron, and cognition in U.K. Biobank participants: observational and Mendelian randomization analyses” PLoS Med 2022; DOI: 10.1371/journal.pmed.100403.)

Dealing long-standing Achilles tendinopathy

  • Corticosteroid injections combined with exercise therapy have been associated with better outcomes in the treatment of Achilles tendinopathy compared with placebo injections and exercise therapy.
  • A combination of exercise therapy and corticosteroid injection needs to be considered in the management of long-standing Achilles tendinopathy.

(JAMA Netw Open. 2022;5(7):e2219661. doi:10.1001/jamanetworkopen.2022.19661)

Optimizing the Time Course of Risks and Benefits of Acute Dual Antiplatelet Therapy for Stroke Prevention

  • Antiplatelet monotherapy is preferred over dual antiplatelet therapy (DAPT) for long-term secondary stroke prevention.
  • This is followed owing at least in part to accumulated bleeding risks that outweigh potential benefits.
  • But just after a minor ischemic stroke or transient ischemic attack (TIA), the short-term risk of recurrent stroke is high, particularly in the first hours and days after the index event.
  • This early period of heightened risk presents an important target for intervention and an opportunity to intensify antithrombotic treatment with DAPT in a more targeted way.
  • A new analysis concludes that a 21-day treatment course of DAPT is optimal.
  • TIA remains an emergency.
  • Any delay in initiating DAPT or other prevention interventions risks missing early golden opportunities to prevent a stroke before it can occur because even the best prevention interventions are ineffective to prevent the stroke that has already occurred.
  • The pattern of front-loaded risks of recurrent stroke and front-loaded benefits of DAPT combined with low but accumulating bleeding risks over time suggests that shortening the duration of treatment is not supported by current evidence.
  • DAPT should be continued for the first few weeks when it is most helpful.
  • Extending DAPT beyond this acute period could have the potential to accrue additional bleeding risk without producing additional benefit.

(JAMA Neurol. 2022;79(8):736-738. doi:10.1001/jamaneurol.2022.1230)