Podcast Episode 003 – New drug approvals and 1st patient case

Podcast Episode 003 – New drug approvals and 1st patient case


Hello and welcome back to another episode
of the CorConsult Rx podcast. My name is Mike Corvino. With me is Cole Swanson. How’s everyone
doing this week? Cole. How’s your week going? It’s going well man. I’m excited for another
installment of CorConsult Rx podcast. Yes. It’s a real coming of age tale. So, um,
we’re going to do things where we have a couple new segments for you guys, uh, for one, since
we’re so close to the end of the month, we’re going to kind of recap on some of the new
drugs that have come out and had a FDA approval this month just to make sure that everyone’s
aware of some of these new drugs. And then, um, the other thing we’re gonna do is we’re
actually going to come up like discuss a patient case and actually go through the case and
then kind of go with some of our recommendations and then we will upload the pdf file of the,
of the case to the website and um, corconsultrx.com. So you can get a copy of that if you want
to kind of follow along. So if you do want to do that, go ahead and pause the podcast
and then go download it and come back. And uh, hopefully if this kind of works out well
the word we came up with this literally an hour ago. So if this works well, we’re gonna
try to do this more often and we’ll have more elaborate cases and things like that. But
this is a trial run on, so we’ll see how it goes and if you want to go straight to it, probably
corconsultrx.com/podcasts will bring you there. And uh, look for this one. Click on it and
uh, let’s get rolling. Sounds good. So what’s the, uh, what’s the,
what’s your favorite drug that got approved this month? If I had to choose one, I’d probably
say Ozempic one of the first ones of the month. Yeah, I agree. Semaglutide, it’s the, uh,
it’s Novo Nordisk’s once weekly GLP-1. And it actually was compared directly to a Trulicity
(dulaglutide), which for a while there was the only one of the ones weeklies that met
non-inferiority as far as A1c lowering when compared to Victoza, which is the market leader.
So this one’s been compared. It’s actually a little bit better than Trulicity, I think
it was a SUSTAIN-7 trial. And so this is definitely a very, very good option. It’s got strong
weight lowering. We already have cardiovascular data with it from SUSTAIN-6, 5, one of those.
But it does have a cardiovascular benefit to it as well. I think it was superior in that composite of non-fatal MI, non-fatal stroke and cardiovascular
death where Trulicity’s got what the REWIND trial coming out, which I don’t think look
as promising as, um, as Ozempic. So we’ll see others, you know, they’ve kind of been
not so great. Tanzeum. In the HARMONY Outcomes. And then there was the EXSCEL, I think it
was called with exenatide extended release. So those are kind of show that there’s no
cardiovascular risk, but there’s no benefit either. So victoza and Ozempic, are probably
going to be the two “go-tos” and then maybe Trulicity as a secondary, but I’ll tell you
what Novo Nordisk knows how to do some GLP-1s. They are doing it right over there. Do you think, uh, think it’s going to be covered
at all in the new year…Ozempic I think it’ll take a little bit like, always,
but we’ll see, and I mean there’s still some insurance companies that prefer Bydureon and
I just..I don’t understand that Some people, some still prefer tanzeum. I
think. Until I guess July, when it won’t be on the market. But uh, yeah, I don’t…you know, the insurance
companies are always a couple of years behind the actual science. So we’ll see what happens.
What else do we have. Uh, so there was also a new cream called Xepi
(ozenoxacin) that was from Medimetriks sometime early on in the month… used to treat impetigo.
So that’s another new one that came out. Yeah, that’s the non fluorinated quinolone.
Um, it has a coverage against Staph aureus and Strep pyogenes. So it’s kind of cool..
different than the fluoroquinolones I suppose… yeah, get that fluorine out of here. So, uh,
another one is the follow on to insulin Lispro. Um, it was Admelog that was the name of it,
so hopefully this will be another cheaper version of, of Humalog. So the follow on,
so it’s not quite a biosimilar, we can’t call it a bio similar in this country. I think
other countries will still lump insulins in with biosimilars, but uh, this is a determined
a follow on and it’s so it’s not a true generic but it is considered. To be equivalently effective
compared to the humalog, so it’s going to kind of act like the generic in practice in
a way? Yeah, kind of..kind of like a Basaglar is doing with Lantus. So hopefully this is
another option to, for patients to bring prices down a little bit that are out of control
and insulins. Yeah. We also got Macrilen (macimorelin) maybe
macimorelin acetate. Uh, it was approved on the 20th buy Aeterna Zentaris Pharmaceuticals,
which I think is an awesome pharmaceutical name. Um, but it was, it was approved for,
um, diagnosis of adult growth hormone deficiency, so it would help with that. Very cool. Uh, Ixifi is another..this time
it is a considered a biosimilar to Remicade. This is the third biosimilar, I think that’s
been on the market. I did a… a flash briefing on this one. I think the flash briefing is
available on SoundCloud as well..and itunes. So, just a quick recap, but one of the things
just to mention with this is if you are unsure whether or not something is actually considered
a biosimilar, make sure you look at the FDA’s Purple Book It’s their reference. So like
whereas the Orange Book would compare generics and brands, the Purple Book has made specifically
for biosimilars. Awesome. Rhopressa, Netarsudil. I’m getting
all the fun ones to pronounce, approved by Aerie on December eighteenth to treat glaucoma
and ocular hypertension. So that’s going to be another eye drop used to help with that. That one is the Rho kinase inhibitor, um,
specifically for opening angle glaucoma or a ocular hypertension. So what else did we
have? We have, let’s see. Steglatro (ertugliflozin), is the new, SGLT-2 inhibitor on the market
this month. So what do you think that one? uh…you know….I don’t know. I still, I
know they’re… what’s the trial that they’re doing? They’re looking at cardiovascular data. It’s called VERTIS, V E R T I S cardiovascular
study. So, you know, we’ll see what happens when
that comes out. I, I haven’t seen any head-to-head trials with any of the other SGLT-2s. I wish
they would.. like GLP-1s did such a good job with comparing them I guess depending on who
you ask. Drug companies probably weren’t happy but they did such a good job with comparing
them and giving a head to head data. We don’t really have that with the SGLT-2s so we kind
of have to go based on side effects and stuff like cardiovascular data. So, I still lean
more with… if I’m going to use one of these, will move more with jardiance. And they did some meta-analyses looking at
the original three, but I took issue. It pretty much said that, that you can assume that the
cardiovascular, um, safety or efficacy is kind of a class-wide effect. I took issue
with some of the, the things in the trial or in this study, but we can post that on
the website. But yeah, other than that, there hasn’t been anything randomized. Um, so I’d
like to see more with those. I definitely, some people I know are worried
now that Invokana or…. Canaglifozin says that there, there’s an increased risk in amputations,
but, um, you know, I, I don’t think that they’ve officially seen that as a class effect. Uh,
so that is something that kind kinda keep an eye on. Some of the ones we, we assume are, would
be what fractures potentially and um, and genital urinary infections…and ketoacidosis
as well. doesn’t stem from elevated blood sugar. So
that’s kind of interesting. But, so yeah, definitely some side effects with these guys
and I think they have their place, but I still prefer obviously the metformin and GLP-1s.
What else do we have? There’s the oral solution for valsartan. Prexxartan is the brand name
for it now, so that’s going to be approved for hypertension and congestive heart failure.
So that’s um, that’s on the market now. Pretty interesting because, um, last month
in the hospital we had a patient who couldn’t take anything by mouth, um, and his PEG tube
was clogged and they were trying to give them, well I guess that would still have to go in
a PEG tube wouldn’t it still, so…not really any IV ACEs or ARBs are there? Well, wouldn’t solve that problem. But if
you had the same patient and like he couldn’t take anything by mouth…but his PEG tube
worked then I guess….just stick it in there? Yeah, that would work. So there you go. That’s
on the market now. Um, and a couple other random drugs. Let’s see… Speaking of the renin-angiotensin system,
there’s Giapreza which is the, um, angiotensin two, um, but they approve for…to increase
blood pressure. So normally when you hear about the RAAS system, you’re thinking decreasing
blood pressure, but they’re actually doing the opposite and using it in septic or other
types of shock to…kind of as a presser to increase. So that’s pretty interesting. Yes, yes, yes. I forgot about that one. I’m
also Lumify is the, uh, ophthalmic solution. It’s brimonidine, but it’s over the counter,
so it’s going to be used for, um, eye redness is what they actually have it labeled for…
but uh, yeah, it’s over the counter now. So, that’s going to be available. That’s uh, one
of the first of those drugs that I’ve seen that’s gone over the counter. So exciting stuff. You wonder why it’s difficult
to keep up with all the new drugs. They pop them out all the time, don’t they? Yeah, there’s a lot of new ones and we did
and we didn’t even cover all of them, but that’s the majority of them. Um, we ah….this
website, I like is drugs.com and you can just subscribe to a new drugs…as far as their…they
have a news feed and then you can pick new drugs or drugs that have a…they’re in the
pipeline and they’ll send you emails. That’s one of the ways I keep up with it. Cole, what
do you use? And um, they’ve also got, if you’re interested
or as interested in trials and evidence is me and Mike, which you should be, um, you
can sign up for the FDA new drug trial snapshot and it doesn’t send it to you like the day
the drug is approved, but kind of a follow-up in a couple of weeks. It’ll send you a snapshot
of the study or maybe some type of landmark study that followed a GLP-1 or some other
type of medication and you can just run through it quickly and if you’re interested you can
go to the full trial and read the whole thing. Yeah. And that’s, that’s a very good idea.
I didn’t think about that. Awesome. So that’s the new drugs. Um, what do you say? Want to
tackle this case? Let’s do it. So what do we got? Um, we wanted
to do an outpatient case. This is a pretty simple one. Something that you’re going to
see all the time if you’re in a clinic doing primary care, uh, even if you’re doing heart
failure clinics, diabetes clinics, whatever, this is going to be pretty standard for, for
patients, um, in this elderly age group. So we’ve got LS. LS ls has a seventy six year
old white male. He’s coming to your clinic, he’s a new patient for you, but he’s doing
a diabetes and heart failure followup. He just left his old primary care doc. So, uh,
he’s got a past medical history of congestive heart failure, HFrEF with an EF of thirty
percent. He’s got diabetes, he’s got hypertension and uh, he has a history of a CVA and actually
has a little bit of um, left hemiparesis because of that. So a little bit of paralysis. So that’s LS.
He’s taken a few meds. He’s got plavix 75 mg, Pravastatin and he’s on 80 mg, carvedilol
12.5 mg twice a day. So we’ve got the Beta blocker, he’s got lisinopril. So he’s got
an ACE doing 40 mg, lasix 40 mg all those once a day. Uh, he’s doing metformin, extended
release 500 mg, he’s only doing that once a day, so it’s pretty low dose. And uh, he’s
also taking glimepiride we think, ah, he didn’t bring it in with him, but he is….it’s on
his claims history, so we’ve got to do a little more digging about that. So glimepiride 1
mg once a day. What do you want to start? So, um, why don’t we tackle is diabetes first. Sounds good. So he is on metformin 500 mg
once a day, just once a day. Also on glimepiride. So what’s
the, what’s the first thing you want? So, I, it depends, um, you know, his A1c was
what, 7.4%, so, you know…obviously at this, at this age, you know, I don’t know that I
would really push his A1c lower. Um, you know, if it was higher than that and he was in the
8’s, I would be a little bit more, more comfortable pushing his A1c lower. Obviously the ideal,
uh, metformin dose is a 1000 mg twice a day. Um, you know, we, we could consider that with
him. His eGFR is 50, so he’s still still OK as far as being on metformin even though he’s,
he’s a little bit elderly, but, uh, that’s one of those things that, you know, if, if
I was going to increase the Metformin, it’d be more, um, hopefully to prevent some cardiovascular
issues and, you know, going into the future and get a little bit of a legacy effect. But yeah.
Um, a couple things to that one. Um, I totally get what the A1C goal with his heart failure
being as significant as it is. I wouldn’t go much lower than that. The primary, right. That’s the primary issue
with his A1c where it’s at. Um, could we get them off glimepiride completely and if we
need more, he wants to control. Can we just do the metformin? I mean, I, I’m not a fan of sulfonylurea unless
the patient just has to. Cost is an issue. Sometimes If the cost is an issue, absolutely. You know,
you gotta do what you gotta do, but if a person has insurance, if they have, you know, this
gentleman, if he’s got Medicare part D, uh, I definitely wouldn’t recommend using it.
If you needed something else, especially if you needed a meal time coverage instead of
using glimepiride, I would definitely recommend doing like a GLP-1, but instead I’m just not…there’s
too much risk with hypoglycemia, especially in an elderly patient. That’s probably the main thing is hypoglycemia.
Some people mentioned that eventually there’s kind of a cap on the benefit that you can
get from sulfonylureas five, ten years, whatever they say. It kind of wears out the pancreas.
But um, for this guy to take them off the glimepiride and uh, we can see if we, if we
need to, we could always increase the metformin and it’s honestly just as cheap as glimepiride.
Uh, it’s free at some pharmacies and it’s on the four dollar list of most others. So
not really a concern. There he is on the extended release, which is a little bit more expensive,
but generally tolerable. So yeah, if we were going to increase it, I would
say just add a 500 mg tablets for a little bit. And then if you tolerate that, you know,
we could consider going up to a two twice a day eventually. But definitely just adding
one at night with his evening meal and seeing how he does on it. Sure. Yeah. So as far as diabetes goes, this
guy’s not doing too bad or as far as his A1c goes, how do you feel about his statin? So,
he’s on pravastatin 80 mg. So this one, this ones can kind of go a couple
of different ways. Because of his age, you know, he’s over, he’s over that 75 kind of
age cap or we have recommendations on statin use. So we do have some data with the PROSPER
trial that looked at pravastatin in patients that were up to eighty two years old. Um,
the issue with this gentleman though is he’s actually had a stroke in the past. So in that
case we actually have data post…post stroke with atorvastatin 80 mg…when we saw positive
outcomes in that from the SPARCL trial. So this is kind of a, this is a hard one because
based on his age, he still would’ve, he still would have, uh, you know, been accepted into
the SPARCL trial. I don’t believe they had an age cut off on it. And atorvastatin 80
mg he could probably tolerate and he may actually get some benefit. I think it really just kinda depends on what
we think is life expectancy is what, how, you know, well, he’s doing, I’m kind of all
that put together and looking at him, you know, individually and not just saying, oh,
in this case, every time we would start atorvastatin 80 mg… uh, there’s plenty of clinicians
who would be more than happy with keeping him on the pravastatin. So, you know, I think
that, um, if I was going to switch and it would be atorvastatin and I would jump to
the 80 mg because it’d be easier for me to drop to 40, then trying to start at 40, then
titrate up again. I’ve just found within my own personal experience, it’s easier to kind
of cut the dose in half than it is to double the dose. So there’s a lot of placebo effect
with, with statins…with statin intolerance. Yeah, for sure. And um, yeah, I think that
for rates of intolerance in the studies are much lower and you can do a lot of stuff if
this is off topic, but you can do a lot of stuff to, to kind of remedy it. Some people
will give a statin a couple of times a week if they’re really having bad myalgias. Pravastatin
is one of the lowest risks. Um, and interestingly, rosuvastatin is actually pretty low risk even
though it’s considered a high intensity. I think that’s a common misconception is that
the higher intensity it is, the more muscle pain he must have. Simvastatin is actually
the worst for muscle pain and rosuvastatin is one of the lowest. Um, and I think pravastatin
is probably lower than that, but um, so if they’re having it with, with Lipitor (atorvastatin)
you can always try Crestor or rosuvastatin. So I think that’s interesting. Yeah. And you know, if you think about whether,
the statin, is lipophilic or hydrophilic, ah hydrophylic statins we would…like pravastatin
and rosuvastatin, we would think would have less penetration in the muscle. And you know,
we wouldn’t have to worry about that as much in theory and there is a meta-analysis out
there that kind of shows that this does, does seem to play out in practice as well. So that’s
usually where I…. just like Cole said that’s what I would think if, if someone’s having
these muscle pains and um, and you’ve already lowered the dose, that’s not helping. My next
step would be to either switch to rosuvastatin or pravastatin if they’re on atorvastatin
or simvastatin or something, I would switch to one the other two or go every other day. Yeah. And I’m back to the dose. You might
say, well, if you’re that concerned about Myalgias, which I’m not generally, um, why
not just start at a lower dose and creep up. And he talked about that a little bit, but
there’s some evidence to just going straight for the high intensity instead of the lower…TNT
trial compared atorvastatin 80 mg versus atorvastatin 10 mg. It wasn’t post-stroke. It was patients
with CAD and hyperlipedemia. And they did have an age cutoff of 75, which of course
this guy is seventy six. He’s right there. Um, but you know, you might be able to lean
on that a little bit if you to, to support just going straight for the 80 mg. Yeah, I agree. It’s a…I mean, I, I, I personally
would like to see him do, especially if you know he’s doing really well and in good shape
and seems like he’s really wanting to take control of his disease states and he’s doing
well. I would probably say atorvastatin 80 mg would be fine just to kind of see how it
goes. But, uh, you know, it’s one of those things whether or not you want to mess with
it, what, what’s his willingness? Consider changing medications I’d be case by case. Maybe he’s had issues
in the past with statins, you know. So that’s why like, I like doing these because
I don’t want, I, I never want to say blanket statements I have…we always say treat the
patient specifically and not actually just follow the general guideline of how the things.
I’m not a fan of that. That doesn’t mean, you know, ignore evidence
completely or this person doesn’t want to take something for not necessarily a valid
reason that’s not, you know, necessarily a good reason to switch to something like they
don’t want to take a carvedilol and they have heart failure, so we’re just going to do atenolol
because that’s what they’ve had before for hypertension or something like that. Um, anyways, And I think…in that case, just to kind of
add onto that, like I would actually explain the data and show them the data even though
people think that, you know, patients can understand that, you know, put it into terms
that they can understand and explain, explain why you’re doing things. And I think if someone,
most people, if you can say that I can reduce your chances of having a heart attack or stroke
or death, um, just by switching over to this other medication, I think that you’d be hard-pressed
to find people who are like still unwilling to switch. But that’s why I think trials and
evidence is important…even when you’re just speaking to a patient And that’s speaking to patients, but even
if you’re a, um, we’ll, we’ll say mid level provider and you’re, you want to make a recommendation
to your physician or whoever you’re, um, you’re reporting to, or maybe they’re asking you
for your recommendation. You can always, if you can cite evidence, that’s always very
helpful. Cite a trial and tell them why I recommend this. So a hundred percent. Yeah. So we say Beta
blockers.. which, uh, are evidence based beta-blockers. So we’ve got three in HFrEF. We’ve got carvedilol
is one….bisoprolol also, and metoprolol succinate.. so the long acting version, which
is Toprol xl is the brand name. So not metoprolol tartrate, which is, um, I’m blanking on the
brand name..Lopresor..Lopresor. So metoprolol succinate is the one that was shown to reduce
mortality in heart failure specifically. And if you look at the, the trials that had
the, the cardiovascular outcome data with those three Beta blockers, they, they always
pushed the Beta blocker of interest to, to their Max.. to the Max dose or the max that
could be tolerated by the patient. So in this example, this patient’s only at 12.5 mg, assuming
that he’s not above eighty five kilograms, you know, twenty five milligrams twice a day
would be the max he could be on. So, you know, his ejection fraction, ejection fraction is
still 30, so we may consider, um, as long as we were checking his heart rate regularly
and it’s not going too low, um, I would probably consider bumping him up to the twenty five
milligrams. Right. And what else would you want to look
at? Um, especially with carvedilol compared to the other two to make sure it’s OK before
you increase it. So monitoring his blood pressure, because
carvedilol is a Alpha Beta blocker, you’re going to, in theory get a little bit more
blood pressure lowering than you would with bisoprolol or metoprolol succinate. So you’d
want to make sure you’re monitoring his blood pressure, make sure it’s not going too low.
Um, but if you had an, you know, kind of the opposite of that, if you had a patient who
you want to add a Beta blocker to cause of heart failure, but his blood pressure is a
little bit low, then metoprolol succinate, or bisoprolol would probably be a better option.
So keep those in mind. And then you’ll also hear an argument of, well, carvedilol has
been proven better than metoprolol succinate, if you hear…. you know, that’s referring
to the COMET trial. The issue with COMET was they compare carvedilol to metoprolol tartrate
and they only used a metoprolol tartrate 50 mg twice a day, if I remember correctly. It wasn’t a full dose. Well… the dose of
Metoprolol succinate that’s been shown to be effective is two hundred milligrams from
MERIT HF and so COMET, realistically speaking, um, if you were to get a true comparison,
you even assuming that based on evidence you would need metoprolol around 150 milligrams
total daily dose of the tartrate to equal two hundred milligrams of the extended release.
The succinate, um….reason for that is you need a higher concentration of the succinate
because as it’s metabolized by 2D6, it’s going to have longer to chew up the, the drug and
metabolize it so you need a longer…a higher concentration and get through that first-pass
metabolism. Right. So it’s roughly a one to one point
five, um, you know, comparison. So I was thinking like a hundred and fifty
milligrams of tartrate equals two hundred milligrams of succinate. That’s how I kind
of think about it. And I’ve actually seen there was a older cardiologist one time and
he actually had someone on metoprolol, tartrate fifty milligrams, but was dosing it three
times a day. And uh, we had talked about this and we were kind of concerned as to why he
was doing that, but it’s actually in theory, kind of equivalent to the evidence base dose.
So it’s kind of interesting because of the half-life is, is not necessarily
twelve hours, like six to eight or something like that. Yeah. Interesting. So the, um, the other thing is the lisinopril.
So he’s on lisinopril and that’s maxed out, which is good. Forty milligrams, The ATLAS
trial we saw that the maxing out the ace gives better benefit than keeping them in a lower
dose. So that’s another one that we see oftentimes not pushed to where it can be is ACE inhibitors.
Right. And that’s one thing about heart failure is
that we actually have not just goal medications we want people to be on, but goal doses, we
want to reach to see the most benefit because that’s what’s evidence-based, not for all
the medications, but for a fair amount of them that you’re going to put people on. Um,
what about Entresto? Um, I think that that would be an option for him. So his EF his
30%, Entresto we saw in the PARADIGM HF trial that compared that to enalapril. Uh, we saw
a mortality benefit compared to an ACE. It wasn’t the full dose of enalapril, but um,
the, the evidence is pretty compelling to say that it could be first line over an ace
or arb and heart failure. The new guidelines are recommending that, um, but it’s still
relatively expensive. Prices coming down, um, but that’s definitely a hindrance to most
people. I would think The other thing to make sure of, if you do
have a patient that is a candidate for Entresto, which if you’re not, hopefully you’re familiar
with that at this point, but if you’re not, it’s, it’s a fused molecule of sacubitril,
which is a neprilysin inhibitor and valsartan, which is hopefully you’re familiar with that
it’s an ARB and basically one of the higher risks that we have with this is angioedema.
And it’s actually more so, um, because of the sacubitril component, and the naeprilysin,
there’s a little bit higher risk than even just with an ACE because we always think of
angioedema with ace inhibitors, but Entresto that does have a risk of it. So one of the
things that you have to do is if you’re switching a patient from an ACE to Entresto, how you
have to have a thirty six hour wash out period. And this is really, really important. Um,
I’ve actually dealt with this myself where a patient came in, uh, to the retail pharmacy
and was getting the prescription well I guess he had dropped off a prescription for his
Entresto and I was there doing MTM that day and explained kind of what the drug was because
they had just been, just been on the market for like a month at that point. And uh, at
that time I told the pharmacist who was working who was about to dispensing the medication
to put a note on there because currently the patient had been taking enalapril told him
to, to uh put a cap ah a consult on there and explained that the patient needed to basically
stop this, the ACE inhibitor for thirty six hours before going on the interest to, well,
like six days went by and that pharmacist called me and said that the patient’s wife
had come in and he had been given samples at the office from the physician who wrote
the prescription. And I don’t know if it was on a take home
paperwork and he didn’t read it. Or if the physician didn’t tell him or the nurse didn’t
tell him who it was, but he was not informed of this thirty six hour wash out period and
he took his enalapril with entresto and had angioedema. So now we run into a situation
where one of the contraindications to Entresto is it past case of angioedema. So we potentially
cost this guy a medication that is very effective at reducing hospitalizations but mortality
because of a failure to consult. So that’s super, super important. Now it’s a long-winded
story, but super important that we are educating patients on that thirty six hour period. Yeah, for sure. And patients to be indicated
ultimately have tolerated shown to have tolerated an ace, right? Yeah. Typically it’s how they set it
up in the trial that’s how they set it up. Um, and you mentioned
it was a male, but the, the patients at highest risk for angioedema are actually African American
females. So that’s who you definitely want to want to look out for it for. But I mean,
in any patient taking Entresto you wanna you wanna make sure that that’s addressed. Absolutely. Um, what else do we have in this
patient? They’re on daily Lasix for edema Is he gonna get mortality benefit from that? No, I mean not necessarily mortality benefit
that he would you know more get symptom relief. But uh, the other thing to keep in mind too,
in some of you may have seen this if, if you’re not familiar with it, but you may, you may
have run into this at some point. Um, eventually a lot of times you’ll see patients get to
a certain dose of lasix and it’s just not effective anymore and there’s something we
can actually add on to lasix that will work in kind of synergistic way metolazone, which
is a thiazide diuretic now most thiazides work in the distal convoluted tubule of the
kidney, but metolazone actually has activity in the proximal convoluted tubule as well.
And so you kind of shuttle some of those electrolytes down into the loop of Henle. So the lasix
or whatever loop diuretic you’re using works a little bit better. So in heart failure patients
specifically, you will see this combination of furos, usually it’s furosemide along with
metolazone. Yeah. And it generally is very effective.
And uh, I’ve seen you don’t usually use it with every dose of lasix. You don’t usually
use it every day. I’ve seen patients just use it once a week and they’ll call it their
booster is what they’ll say. Um, but it can also be used three times a week just depending
on whatever the, the nephrologist wants. I mean you definitely have to be careful with
that because you can bottom people out and dehydrate them and all that. So he definitely
would have to be, we’d be careful with it. But if you do see it, that’s, that is an option
out there and why they’re, why they’re using it. So we got this guy on carvedilol we got him
on an ACE, he’s on lasix. Is there anything else he needs or could I guess what will be
the next step for, for heart failure? So you know, this gentleman, he’s blood is
155/95. So there’s a couple of things we could do if we were looking more on the, the heart
failure side of things, we could, we could talk about spironolactone. The issue with
that as he is older, depending on…spironolactone is really effective at lowering systolic blood
pressure. I mean you can think that 20 points systolic in some cases with spironolactone
and so if you look at the RALES trial for heart failure, um, we definitely have good
data with that with spironolactone and that’s kind of where that 20 points blood pressure
dropped comes from. But um, you know, that’s something to be because of his age, we have
to be cautious with them and dropping them too low and you know. But that is something
we could definitely consider. What else you thinking? Spironolactone is the biggest one I’m thinking
I don’t think we would look into dig or ivabradine or anything. with this guy, No I’m not a fan of ivabradine
unless they just…I’m not a fan of ivabradine. There’s very few people that I think would
be all that beneficial… agreed. Um, what about if we were going to look as if we were
going to target more the hypertension side of things, what would you do? I mean, you could add on a diuretic or you
could add on a calcium channel blocker potentially. Um, which diuretics would you do? Uh, like indapamide? Yeah indapamide I agree with that for sure.
Or chlorthalidone either one of those. I would, I would like indapamide we have evidence with
the HYVET trial which was patients eighty to a hundred and obviously this guy is actually
almost almost the age where he would qualify for that. Chlorthalidone we have evidence
with ALLHAT and also with SHEP and then indapamide we have the PROGRESS, I believe, which it
might have been post stroke actually. So Cole will look at that real quick for me. I’m not,
don’t quote me on that yet, but I think it might be post stroke which may even fit this
guy even better, but outcome data with both of those thiazides. So I agree with that for
sure. it was post stroke yes winner winner. Awesome. What about um, let’s, let’s talk
about his potassium. So either way, not everybody’s going to which decision to make, right, I was going to say, if we’re considering
adding on spironolactone has already on an ACE then the first lab, you’re probably going
to look at his, his, his potassium. So we actually did get one on this guy. So it is
4.2, so within normal limits and there is a cut off. So if you, if you get that back,
um, for spironolactone you want it below five, right? In an ACE, if you’re going to start
an ACE, you want it below 5.6. So that’s what you’re looking at there. And there’s also,
if we were to add on, um, a diuretic what would, what would be concerning there? You
mentioned the SHEP trial the SHEP trial was involved chlorthalidone
and actually had a uh, add on Atenolol, believe it or not. Um, but one of the things they
noticed with the patients that received chlorthalidone was that if the patient’s potassium, this
was done in a secondary analysis, but at the potato, a patient’s potassium was dropped,
dropped below 3.5, they actually lost all the, uh, outcome data like benefits of chlorthalidone
the mortality benefit was gone. And so there’s gonna be some people based on that that will
actually aim for a potassium of 4 just to be on the safe side that you’re not going
too low this guys on Lasix he’s on a thiazide diuretic, so you’d want to make sure that
you are monitoring that because you don’t want to have a guy on an evidence based thiazide
diuretic and have it not be effective. And a lot of times with pretty much anyone
with any sort of heart condition you could, if you’re above 4 you’re, you’re pretty much
golden. Um, but of course, generally 3.5 for normal people would be the lower limits of
normal. Um, so yeah, that’s his heart failure. Got Anything else for that? No. Um, what about aspirin for this guy. Um, I don’t think so. It’s already on Plavix.
So what would adding on aspirin probably do? Nothing, MATCH I believe, the MATCH trial
they added on aspirin to patient’s already on clopidogrel and didn’t see a difference. They actually saw an increased
risk of bleeds, potentially severe bleeds. So yeah, so I would not recommend an Aspirin,
but even though he’s had an event even if he hadn’t had an event, um, the sweet spot
for aspirin now according to the US preventative service task force is 50 to 70 years old is
kind of the sweet spot, really 50 to 60 and then as long as the benefit outweighs the
risk from sixty to seventy as well. Um, but after 70 a lot of times the benefit doesn’t
outweigh the risks. So you really have to take the aspirin for what is it ten years Yeah they want you have a ten year life expectancy
to really benefit from it because it takes that long to see the benefit, you know, the, they can, it can give you cardiovascular
benefits, but it can also prevent colorectal, colorectal cancer as well as another thing.
So aspirin definitely has its place even in primary prevention, but no, I wouldn’t recommend
it in this guy. Yeah main place we’re really thinking dual
antiplatelet is post-stenting, right. So not necessarily in this guy with just a history
of CVA. Anything else with, with him? That was pretty much it. Maybe immunizations. We
could run through those real quick. Yeah real quick. So let’s just say hypothetically
since we didn’t include this in the case, he, uh, he has never had any immunization
zero then, um, you know, this, this year, it’s getting later in the year, but you know,
I’d still try to give them a flu shot, go ahead and give it. Um, we have three really
three flu shots that he could get well I guess four technically if you want to count quad,
but uh, we have the regular the standard flu shot, which several different brands that
make that. Then we also have Fluzone High Dose and then Fluad are the other ones. Of
those three, which ones do you recommend? I’m trying to remember. We don’t like Fluad. I’m not a fan of Fluad and I think the reason
for that is if you look at the head to head data, it was only, it was only non inferior
to the regular standard flu shot. It didn’t meet the criteria for superiority and there’s…because
it’s got that adjuvant in it, which they use squalene oil emulsion in it it actually can
cause more localized reactions, things like that. And so I’m just not, not a fan. Whereas
Fluzone high dose has been compared the trial I think was done in 2014 but doesn’t have
a cool name so it’s hard to remember but um, that one was compared to a standard and it
actually was statistically different. Now the number needed to treat was 218, so it’s
a little bit, you know, whether or not it’s all that effective. Um, you know, it depends
on your point of view. I guess they did do a cost-benefit analysis
and showed that it is actually cost-benefit of cost-benefit positive if you were to get
the Fluzone over the standard, but the CDC still hasn’t made a recommendation that I’ve
seen. There you go. So it actually does matter which flu shot you get. How’d that do this
year I hear that the people weren’t too happy with it and I don’t think it’s covering very
well you should still get it though. Why not. It’s not going to hurt you. It’s covered almost
all the time. It’s not going to hurt you despite what people may say on Facebook. But uh, yeah.
So the flu shot. And then if you, again, if he’s never had any vaccines, Prevnar 13 would
be first would be first and then a year later because of insurance, we have to get it billed.
But he could get it within eight weeks? Yeah technically you can get it within eight
weeks, but they’ve changed the guidelines now to say a full year just based on, um,
CMS and making sure that patients are having it covered. But so yeah then he’d get Pneumovax
23 a year later after Prevnar what else? Well he could get Zostavax or better yet, he could
get Shingrix how about that? So we don’t have that yet. We’re getting it next month. I would
just wait. Yeah, I would hold off on it because if they do get Zostavax according to the data
anyway, if you’re going to follow that, you’d really have to wait about five years to give
them the uh, the Shingrix and it’s so much more effective this guy is approaching 80
and when you hit eighty you’re looking at about an eighteen percent efficacy with Zosta.
So I wouldn’t really consider Zostavax for this guy. And Shingrix is two doses right?
It is two doses yeah, so you know two doses isn’t…. especially since it’s, it’s pretty… It’s a little bit more expensive but pretty
comparable in cost…in price and I hundred percent I had someone come in yesterday with,
with shingles and just hearing about it again, it’s terrible. So I would definitely, uh,
any, any family member of mine would recommend Shingrix over over Zostavax plus it’s a killed
vaccine so um no more of that life stuff. Yes cool. Also can use a Tdap if he hasn’t
had a tetanus in a while or Tdap or a tetanus booster at least. Um, it depends on if he’s
checking. He’s not really injecting insulin, so, uh, his kidney function is OK, but if
he was looking at like if his kidney function was declining and was looking at hemodialysis,
we could consider a Hep-B vaccine series if he hadn’t had that. Again, you’d have to weigh
his life expectancy and everything else and with, with what we were going to vaccinate
and if he’s even willing to get them in the first place. But yeah, that’s uh, that’s the first case
case number one case numero uno numero uno so hopefully we’ll, uh, we’ll gather some
feedback from some of you and figure out whether or not you liked it or not. Let us know if
you thought we were wrong if you treated him different tell us I would actually really
like that too because I’d like to get more conversations going. I’m… neither one of
us are infallible by any stretch of the imagination. So I’m actually wrong a lot. So now Mike’s
the data king nah I don’t know about all that. I just repeat what other smart people that
actually said, but uh, you know, I think that, uh, I would really, really encourage you guys
to give us some feedback and leave comments if you prefer different strategies and kind
of get the conversation going. Yeah. And if you want to break down on any
of those specific, um, trials we can potentially provide that. Also check out that corconsult.com/podcasts.
We’re going to post pretty much any trial we talked about and maybe if we found a good
summary, we’ll post that on there too with the podcast hyperlinks just click on them
and you can learn more. So check that out. That’s a good feature. I actually didn’t even
realize Cole was doing that until just recently and I went on the website. I was like, Oh
wow, this is a great idea. I wish I would have had this. But uh, yeah. So that’s, that’s
really helpful. But yeah, that’s uh, that’s about it. So make sure you give us a follow
or a like on all the major social media platforms and uh, make sure you subscribe to us on iTunes
or SoundCloud and if you prefer the video side of things, definitely subscribe to the
Youtube Channel and I’m always interested to hear what kind of feedback and also ideas
that you guys have a or if you’re interested in being a guest, if you think of a really
interesting, uh, job or history or whatever it may be, um, reach out to one of us or even
if you’re not that interesting. Yeah. Cause we will still have you on. Yeah because we’re
not that interesting and we’re still doing it. Yeah. We’ll make it interesting they haven’t
told us we can’t be on here yet so. But yeah, it’s definitely reach out to us. Email or
any of the social media platforms. We can…you can reach us at that and let us know and yeah.
Until then we’ll see you guys next time. Thanks for listening.

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