Sucheta Gosavi

A Review of Sodium Glucose Co-transporter 2 Inhibitors Canagliflozin, Dapagliflozin and Empagliflozin.

Sodium glucose co-transporter 2 (SGLT2) inhibitors are a new class of anti-diabetic medications. Canagliflozin was the first drug approved in this group in 2013 and subsequently dapagliflozin was approved in January 2014 and empagliflozin was approved in August 2014. Preclinical studies have demonstrated safety, tolerability, and efficacy in terms of glycemic control and HbA1c level in type 2 diabetes mellitus (T2DM) patients in comparison to other anti-diabetic drugs. The U.S. Food and Drug Administration (FDA) recently released a warning that some of the patients who used SGLT2 inhibitors developed diabetic ketoacidosis (DKA). Empagliflozin has showed safety in type 2 diabetics with renal impairment. Each of these medications can be used as a single treatment or in combination with other anti-diabetic medications.

Review of Newer Anticoagulants and Anti-platelet Agents in Acute Coronary Syndrome and Cardiovascular Diseases

In the last few years three new oral anticoagulants-Dabigatran, Rivaroxaban and Apixaban and two new antiplatelet agents Prasugrel and Ticagrelor have been approved for use. Dabigatran, Rivaroxaban and Apixaban have been approved for the prevention of stroke and systemic embolism in non valvular Atrial Fibrillation in the United States. Rivaroxaban is also approved for the prevention and treatment of venous thromboembolism, including pulmonary embolism. These drugs have been shown to be non-inferior to Warfarin. These drugs do not need monitoring and have lesser drug interactions compared to Warfarin. The newer antiplatelet agents Prasugrel and Ticagrelor are more potent than Clopidogrel and are more effective in patients with CYP2 C19 enzyme deficiency. Both of these drugs are approved in acute coronary syndrome and Prasugrel is approved only in acute coronary syndrome with percutaneous coronary intervention.

Systemic Hypertension in Patients with Aortic Stenosis: Clinical Implications and Principles of Pharmacological Therapy.

The treatment of systemic hypertension (HTN) in patients with Aortic stenosis (AS) requires a careful balance of lowering the systemic blood pressure without compromising vital organ perfusion and worsening of the symptoms of AS. Treatment of systemic HTN is beneficial because the combination of HTN and AS provides additional overload to the left ventricle. This leads to secondary Left ventricular hypertrophy (LVH), which has been shown to increase cardiovascular risks and mortality and thus early presentation of symptoms of AS. Additionally, presence of HTN may affect the accurate assessment of AS. Different treatment options are available, however no specific treatment guidelines have been established for patients with concomitant AS and HTN. Improved control of HTN is the key to prevent symptom progression and inadvertent early surgery. Angiotensin converting enzyme inhibitors (ACEi) and Angiotensin receptor blockers (ARB) appear to be beneficial. Reassessment of the aortic valve by echocardiography is recommended after HTN is well controlled before deciding on aortic valve replacement (AVR).

Natural History of Saphenous Vein Grafts

Aortocoronary saphenous vein graft is an effective treatment of coronary artery disease and a means of markedly improving long-term prognosis in certain patient subgroups. However, there is a significant failure rate with these conduits. Early failure occurs within the first 1-2 months, most likely from primary thrombosis. Intermediate failure is usually caused by the development of neointimal hyperplasia. Late failure occurs after 3-5 years and results from accelerated atherosclerosis. The impact of saphenous vein graft failure on cardiovascular outcomes is significant, and it is important to implement appropriate therapeutic strategies to prevent or minimize failure rates.

Clinical Pharmacology and Role of Edoxaban in Contemporary Antithrombotic Therapy

Edoxaban is a factor Xa inhibitor that is approved for prevention of stroke in individuals with atrial fibrillation and treatment of venous thromboembolic disease at once daily 60 mg dose for individuals with normal renal function. A decrease of dose to 30 mg is recommended for those with moderate renal insufficiency, weight ≤ 60 kg or simultaneous administration of strong P-glycoprotein inhibitors. At this time, it is not recommended for use in persons with either end stage renal disease or with GFR exceeding 95 mL/min. Shorter half-life averaging 8-10 hours may translate into a safer profile. With a fast onset of action of ~1.5 hours and relatively high bioavailability, edoxaban is an alternative for patients who may not be good candidates for warfarin therapy due to multiple limitations that vitamin K anticoagulation entails. No clear benefits of edoxaban have been reported to date compared to the other available factor Xa inhibitors.

Rare Etiology of Arachnoiditis in Patient with Uncontrolled Diabetes

Pyogenic Spondylodiscitis (PS) is an uncommon infection representing approximately 3-5% of all osteomyelitis cases, male-tofemale ratio 3:1. PS occurs commonly from hematogenous speeding. It typically involves disc and anterior corners of the adjacent vertebral bodies. Staphylococcus aureus is the most frequent microorganism accounting for half of the cases. Gram-negative rods account for 7-33% and coagulase-negative staphylococci were reported in 5-16% of cases. The incidence has increased recently due to a more elderly population, chronic use of steroids and other comorbidities. The disease is characterized by unremitting back pain. When the clinical presentation is suggestive, blood cultures should be performed. Magnetic resonance imaging is the modality of choice due to its high sensitivity and specificity.

Pyridostigmine-Induced High Grade SA-Block in a Patient with Myasthenia Gravis

Myasthenia gravis requires a long-term treatment with a parasympathomimetic agent, which may result in bradycardia and asystole. Pharmacologic treatment with a reversible inhibitor of Inosine Monophosphate Dehydrogenase (IMPDH) and Methylprednisolone are seen to improve the muscular symptoms but may reinforce potential bradyarrhythmias. This potential side effect can be treated with the levo isomer of atropine, Hyoscyamine, or Glycopyrollate in an intact conduction system. Case presentation:A 70-year old Caucasian female patient with a family history of myasthenia gravis presented with mild weakness of the bilateral facial muscles, moderate dysarthria, dysphagia, diplopia predominantly on the right side and difficulty tracking ocular movements bilaterally. The treatment with pharmacological agents was initiated. Subsequently she developed asymptomatic bradycardia and SA-block. An improvement on Hyoscyamine failed to appear. A dual chamber pacemaker was placed. Conclusion: In symptomatic bradycardia or asymptomatic, however, significant high grade SA-block in patients with myasthenia gravis the insertion of a permanent pacemaker can be the definitive solution.

Medical Management of Type a Aortic Dissection in a Setting of Atrial Fibrillation

Compared to an acute type A aortic dissection, a chronic type A aortic dissection is a much rarer occurrence that may not necessarily require surgical intervention. A 71 year old male presented with a Stanford type A thoracic aortic dissection extending from the sinotubular junction to the distal

An Immunocompetent Patient With a Vesicular Rash and Neurological Symptomatology

Viral infection is the most common cause of aseptic meningitis with the majority in the United States being caused by enteroviruses. In viral meningitis, cerebrospinal fluid (CSF) shows a mild pleocytosis with a lymphocytic predominance , elevated protein and normal glucose level. Nucleic acid amplification methods have greatly improved the detection of viral pathogens. In our case, a 47-year-old Caucasian female patient presented with a persistent throbbing headache for six days, localized to the frontal area, associated with photophobia, exacerbated by bright lights and loud noises. Physical examination revealed nuchal rigidity and a vesicular rash at the right T4-T6 dermatome region. CSF findings were consistent with aseptic meningitis and polymerase chain reaction (PCR) was positive for VZV. Clinical improvement in meningeal signs and symptoms occurred after the initiation of acyclovir to complete a total 10 day course. There are no published data revealing that acyclovir will modify the course of VZV meningitis, but it is important to recognize the potential clinical benefit with the early initiation of antiviral therapy, especially if a zoster rash is discovered on examination. However, this is rarely the case because the majority of VZV meningitis will not present with a rash. Even though the reactivation of VZV is not usually associated with clinical meningitis; it is important to consider VZV in the differential diagnosis of a patient presenting without a rash with CNS disease. PCR has been proven to be useful and quick diagnostic tool in the early diagnosis of VZV associated neurological disease. doi: http://dx.doi.org/10.4021/jmc1405w