Highlights for Monday, July 4

Below are the 3 articles selected as suggested reading for this week by McMaster editors.
Please be advised that until the end of August Publications of the Week will be temporarily published in a less frequent, biweekly cycle.

Target SBP in patients with intracranial hemorrhage: less is not always more

The target blood pressure control among people with intracranial hemorrhage is a matter of debate. This study provides reassurance that the current management targeting systolic blood pressure (SBP) of less than 180 mm Hg is not inferior to targeting 140 mm Hg or less.

Close to 1,000 patients with intracranial hemorrhage (volume of parenchymal hematoma, <60 cm³) and at least one measurement of SBP above 180 mm Hg were randomized within 4.5 hours of symptom onset to a target SBP of 140 to 179 mm Hg (standard group) or 110 to 139 mm Hg (intensive group). First-line treatment was intravenous nicardipine, starting at 2.5 mg/hour with the possibility to increase the dose by 2.5 mg/hour every 15 minutes up to 15 mg/hour. Labetalol, diltiazem, or urapidil could be used subsequently, if needed, with the goal to achieve the SBP target within 2 hours. The main outcome measures did not differ between the standard and intensive groups: death was reported in 6.6% vs 6.8% participants, and death or disability, in 37.7% vs 38.7%, respectively.

The authors stressed that their findings may not apply to patients with a larger intracranial hematoma and raised intracranial pressure (>50% patients had a Glasgow Coma Scale [GCS] score of 15, and >80% of patients had a GCS score of at least 12, indicating a relatively low clinical severity of bleeding). The probability that such patients would benefit from more intensive SBP lowering is, however, not high.

Liraglutide in patients with type 2 DM on high-dose insulin: short-term benefits

Adding glucagon-like peptide 1 receptor antagonists is one of the therapeutic options for patients on high doses of insulin.

Obese patients (mean body mass index, >40) using more than 1.5 units of insulin/kg a day in addition to metformin (used in >80% of patients) were receiving placebo or 1.8 mg of subcutaneous liraglutide. Active treatment, in comparison to placebo, was associated with a decrease in insulin requirements by about 11%, glycated hemoglobin (HbA_1c) decrease by about 1%, as well as a small weight loss (2.3 kg). Authors stress the short duration of study (6 months).

Liraglutide: decreased mortality and CV outcomes in patients with type 2 DM

Last year brought the possibility of changing cardiovascular and even total mortality among patients with diabetes mellitus type 2 (type 2 DM) at high cardiovascular risk (See: McMaster Perspective: Empagliflozin, cardiovascular outcomes, and mortality in type 2 DM). Now another medication – liraglutide – finds itself in the same category.

Over 9,000 patients with type 2 DM and a high cardiovascular risk were treated with liraglutide or placebo for almost 4 years. Liraglutide treatment was associated with a decreased risk of death from any cause (8.2% vs 9.6%) with a nonsignificantly lower risk of nonfatal myocardial infarction, nonfatal stroke, or hospitalization for heart failure. The weight loss difference was 2.3 kg in favor of liraglutide. In the liraglutide group, the number of patients who developed pancreatitis was lower (18 vs 23) and the number of patients who developed pancreatic carcinoma was higher (13 vs 5).