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Dr Aju Mathew picks 3 clinical updates you should not miss

M3 India Newsdesk Jul 23, 2021

If you have been absorbed in your daily practice and not had any time to catch up on some notable developments on drugs and diseases, here are 3 recent practice updates brought to you by Dr Aju Mathew from renowned peer-reviewed journals. This new weekly series will deliver a short synopsis on new happenings in medicine, therapies and interventions that will help doctors stay up to date in practice.

Aspirin for primary prevention

Aspirin is not a very effective drug for the primary prevention of cardiovascular events. Use it cautiously and for only those patients who have a high risk for cardiovascular events and low risk for bleeding.

One of the most commonly prescribed medicines worldwide is aspirin. The use of aspirin for the primary prevention of cardiovascular diseases is a contentious area, for e.g., a person with diabetes taking aspirin to prevent myocardial infarction or an elderly individual with no comorbidities taking it to prevent a heart attack. In a recent study in the JAMA Open journal, we see that around 50% of older adults in the US take aspirin for primary prevention [1]. Clearly, a large section of individuals who should not be taking it was on the medicine.

Fortunately, in India, such preventive therapy using aspirin has not found much uptake. Three recent clinical trials found no benefit with aspirin use for primary prevention [2]. One must always balance the risk for bleeding events when you prescribe aspirin for an anti-thrombotic effect. We must be cautious about the risk-benefit balance before we consider using aspirin for primary prevention from cardiovascular diseases.

Systemic amyloidosis

Systemic amyloidosis from light chain disease has effective therapies now.

Immunoglobulin light chain amyloidosis is a dangerous disease that is often diagnosed at a very late stage when patients present with heart and kidney failure. Survival rates are dismal. The outcomes began to change a decade ago when newer drugs such as bortezomib, which was used to treat multiple myeloma, was used to treat this disease. Both myeloma and amyloidosis have a common mechanism of clonal expansion of CD38+ plasma cells. Sometimes, rapid and deep hematologic responses achieved using anti-myeloma drugs can reverse the organ damage. Now, research has shown that a CD38 targeting monoclonal antibody drug called Daratumumab has produced a three-fold response in blood parameters and nearly doubled the response in involved organs as well when compared to the current standard of care (ANDROMEDA trial) [3].

Truly, advances in medicine have changed this once fatal disease to a manageable one and have given a glimmer of hope to patients with the disease. The challenge for clinicians is in diagnosing the condition at its earliest stage. Check out the amyloidosis foundation website for a good summary [4].

Vaccine-induced immune thrombotic thrombocytopenia (VITT)

Think of HIT if a patient is on heparin and presents with a very low platelet count. VITT has a similar mechanism.

Adenoviral anti-SARS-CoV2 vaccines have been associated with a very rare adverse effect. Patients develop thromboses and when the platelet count is checked, it is very low. In a Nature publication, investigators have found that the VITT resembles Heparin-induced thrombocytopenia (HIT) in that both conditions have platelet-activating antibodies against platelet factor 4 (PF4) [5].

I was immediately reminded of my own experience treating several patients with HIT. In fact, HIT is one of the most common reasons haematologists’ get sued in the USA. There are law firms in the USA that specialise in litigating doctors for a HIT diagnosis. [6] HIT happens when patients who are on heparin suddenly experience a dramatic drop in their platelet count. They are at an incredible risk of getting a fatal thromboses event. If you suspect HIT, one has to immediately stop heparin and switch to another anti-thrombosis agent while you send the immunoassay to test for PF4 antibody. There is a way to test for the probability of a HIT - 4T score. You are liable especially if you feel the pre-test probability is high and you have ordered the test but have not started empirical treatment for HIT while you await lab confirmation [7]. As we await more information on VITT, it will be important to learn how we can diagnose and treat HIT.

A note from Dr. Aju Mathew

Dear colleagues,

I have always enjoyed reading up on the latest research happening around the world. When I was in medical school, I neither had the skill to understand research nor did I have the access to it. However, times have changed and I can say that I now have both. That's when I thought of starting a weekly series summarising the latest research in key medical journals for the busy practitioner. In this weekly series, I will cover articles that interest me, that I think can enthuse you as well. Please let me know if there is an article that you wish I highlight in this series.

Click here to see references


Disclaimer- The views and opinions expressed in this article are those of the author's and do not necessarily reflect the official policy or position of M3 India.

Dr Aju Mathew is a medical oncologist, haematologist, internist and epidemiologist practising in Kochi.

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