Questioning Medicine

Bottom line   Omalizumab does seem to improve allergic reactions to peanuts but comes at a steep price tag. Likely only allergist will prescribe this drug but it is worth know about If you know or take care of anyone with severe peanut allergy. After 16 weeks, 67% of patients who took omalizumab could tolerate a 600-mg peanut protein challenge (≈2 peanuts) versus 7% of controls. Variability among...

At ~24 weeks, ~80-90% of females report improvement in their acne with COCs, compared to 50-80% placebo, and 30-50% will have clear-almost clear skin versus 10-40% on placebo. Efficacy appears similar between individual COCs. Limitations: Most COC RCTs unblinded, many COC RCTs prohibited concurrent topical agents, no RCTS comparing COCs to topical agents, many industry-funded. https://cfpclearn.ca...

QM on Spring Break-- but do you like the new format? Andrewbuelt@gmail.com

Diabetic patient- Empagliflozin prevents death from cardiovascular causes: NNT 46 per 3.1 yrs ($600 a month, 1 million dollars per life saved) -HFpEF- SGLT2 inhibitors do not prevent death and cost roughly $364,000 to prevent one hospitalization -HFrEF -Using Cox models, only Dapagliflozin has mortality benefit (NNT 53) and comes at a cost of $229,914 prevent one cardiovascular death. (117,126$$$...

These findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. They combined HFpEF and HFrEF They used win ratios Individual trials didn’t show mortality benefit but now there is? https://pubmed.ncbi.nlm.nih.gov/35228754/

Primary Outcome: Composite of deaths from cardiovascular causes or hospitalizations and urgent visits for heart failure Death was not improved! NNT of 5 for hospitalizations and urgent visits -- However, results are not reported separately for hospitalizations and urgent visits, which are not equal events  https://www.nejm.org/doi/full/10.1056/NEJMoa2030183

NNT of 20 to prevent 1 hospitalization at 16 months of follow up They composite outcome was driven by decrease hospitalizations NOT death https://www.nejm.org/doi/full/10.1056/NEJMoa2022190

NNT of 21 over 18 months to prevent a composite of worsening heart failure or cardiovascular death NNT for hospitalization = 27 NNT for Cardiovascular Death = 53 N Engl J Med 2019; 381:1995-2008

Dapagliflozin and HFpEF did happen to improve the composite outcome but this was based mainly on hospitalizations not on death and comes at a big price tag with the NNT around 36 at 2.3yrs.  N Engl J Med 2022; 387:1089-1098

Hospitalization for heart failure occurred in 8.6% of patients in the empagliflozin group and 11.8% patients in the placebo group (hazard ratio, 0.71; 95% CI, 0.60 to 0.83) number needed to treat [NNT] = 32 per 26 months   But the drug company did a great job of writting the paper so you think there is mortality benefit https://www.nejm.org/doi/full/10.1056/NEJMoa2107038

EMPA-REG OUTCOME back in 2015 this was the first SGLT2 trial to set the world on fire with Primary Outcome:  death from cardiovascular causes: NNT 46 per 3.1 yrs (at $600 a month, 1 million dollars per life saved) nonfatal myocardial infarction: NS∞ nonfatal stroke: NS∞ https://www.nejm.org/doi/full/10.1056/nejmoa1504720

Forty-two percent of patients had a PPI on their medication list without indication 8 weeks after discharge, and more than half of these patients still were using PPIs 1 year later.     Compared with propensity-score matched patients without PPI use after discharge, patients with continued PPI use were 27% more likely to develop pneumonia, 17% more likely to develop experience cardiac events, 34%...

These results are reassuring for management of both underweight and overweight patients with AF.   That said, I would still have reservations about prescribing DOACs in the small minority of patients with BMI >45 kg/m2 or body weight >330lbs due to their underrepresentation in the pivotal trials and when you look at the supplementary data you will see a weight of 262 was 95% tile so >330...

Nurse Practitioners prescribe medications off the beers list at the same rate at primary care physicians, hard to tell what this means for patient care and patient outcomes.  https://www.acpjournals.org/doi/10.7326/M23-0827?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed

Using the Brain Care Score seem to be effective in predicting the risk of dementia For participants under 50, each five-point higher BCS is associated with a 50% lower risk of dementia or stroke For participants under 50, each five-point higher BCS is associated with a 59% lower risk of dementia  THE SCORE IS HERE ---->. https://www.massgeneral.org/assets/mgh/pdf/neurology/mccance-center/brain-...

Even when starting DAPT within 72hours of symptom onset for individuals with minor stroke or TIA the benefit of DAPT for the first 21 days was still seen at 90 day follow up in the form of less recurrent stroke https://www.nejm.org/do/10.1056/NEJMdo007334/full/

In those high risk patients -- usually with lung or GI cancer they did benefit from primary prevention VTE prophalaxis with a NNT of 6-7 for VTE and death at 6 months.  https://pubmed.ncbi.nlm.nih.gov/37733336/#:~:text=Conclusions%20and%20relevance%3A%20In%20this,safety%20concerns%2C%20and%20with%20reduced

Just get he biopsy at less than 6 weeks after starting therapy as the yield was the same at 2 weeks as it was at 4-6 weeks https://pubmed.ncbi.nlm.nih.gov/36642440/

Evidence against baby walker is not enough regarding its negative effect on child development. This subject needs to be addressed more, considering a large number of baby walker users worldwide. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5703622/ Surveillance System data from 1990 to 2014   230 676 children <15 months old were treated for infant walker–related injuries in US emergency departm...

During average follow-up of in this study the incidence of prostate cancer was less than 1% — and not significantly different   Remember most of these pts had testosterone levels around 350 ish give or take so the safety of longer-duration treatment — or treatment resulting in higher blood levels of testosterone — remains unclear. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/281329...

From a mean score of 45 points at baseline, mood improved by about 5 points in the placebo group and 6 points in the testosterone group — a statistically significant but small difference. I think you will be hard pressed to find anyone that thinks this is clinically significant except for maybe the authors of the paper when they write that it is beneficial in their conclusion https://academic.oup....

Erectile disfunction should be treated with the appropriate medications like the PDE5 inhbitors—not testosterone—testosterone may make it so you flirt half a time more a day but that is not likely worth the harm that comes with even in the placebo small doses seen in the traverse trial https://academic.oup.com/jcem/article-abstract/109/2/569/7244351?redirectedFrom=fulltext&login=true

even at very small some would argue barely even treating doses of testosterone patients had an increase rate of fractures with a NNH of 100—when you add this to the 1 risk of aki and 2 percent risk of arthymia the harms vs benefit conversation to use testosterone seems to be leaning heavy towards harms https://www.nejm.org/doi/full/10.1056/NEJMoa2308836?query=recirc_curatedRelated_article

Risk of progression from prediabetes to diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 months of follow up Not to sound like a broken record but Risk of progression from diabetes to not having diabetes did not differ significantly between testosterone and placebo groups- and they looked for a change at 6,12,24,36,48 mont...

Take away The drug companies will say look how safe testosterone therapy is there was no difference in death from cardiovascular causes or myocardial infarction or stroke in those individuals randomized to testosterone therapy over placebo but in actuality this trial really showed nothing and it did show that when using placebo or minimal doses of testosterone -- ones that barely change blood leve...