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This article was edited for clarity on August 30, 2016.
Incretin-based drugs and risk of acute pancreatitis
There is an ongoing discussion about the association between new antidiabetic incretin-based drugs (dipeptidyl peptidase 4 [DPP-4] inhibitors and glucagon-like peptide 1 [GLP-1] agonists) and the risk of acute pancreatitis. This observational study suggests that this risk, if present, is small.
The study was conducted as a nested case-control study identifying all patients with pancreatitis among over a 1.5 million-large cohort of patients from Canada, the US, and the United Kingdom. It enrolled patients who were prescribed for the first time a new noninsulin antidiabetic drug and subsequently analyzed development of pancreatitis among those taking incretin-based drugs versus those who were on at least 2 other oral antidiabetic medications. The analysis was adjusted for additional pancreatitis risk factors (eg, alcohol use).
During almost 3.5 million patient-years of observation, there were slightly over 5,000 patients hospitalized for acute pancreatitis (~1.5 patients per 1,000 patients each year). The use of incretin-based drugs as opposed to the use of at least 2 other oral antidiabetic drugs was not clearly associated with the development of pancreatitis (hazard ratio [HR], 1.03; 95% confidence interval [CI], 0.87-1.22). Similarly, the risk did not vary by drug class (DPP-4 inhibitors vs GLP-1 agonists).
These results are imprecise and still consistent with a 20% increase in pancreatitis risk (upper limit of CI) but taken together with the absolute risk of developing pancreatitis indicate that such additional risk, if present, is likely small. According to the authors, this data could provide some reassurance to patients treated with incretin-based drugs (and their clinicians).
Recurrent stroke with patent foramen ovale
Almost a quarter of all people have some degree of patent foramen ovale (PFO). Some of them will suffer ischemic stroke, and the consequences of subsequent percutaneous PFO closure versus medical treatment are not clear. This practice advisory confirms that uncertainty but also presents available information and provides suggestions based on low to moderate quality of evidence, which may be of use in discussions between patients and their clinicians.
Facts and conclusions highlighted by the authors as applying to patients with PFO and cryptogenic stroke:
- Patients with stroke and PFO should know that PFO occurs in about 1 in 4 people and it is impossible to be certain whether their PFOs caused strokes or transient ischemic attacks.
- The effectiveness of the occluding procedures for reducing stroke risk remains uncertain. The procedures are associated with relatively uncommon, yet potentially serious, complications.
- Clinicians should not routinely offer percutaneous PFO closure to such patients outside of a research setting.
- In the absence of another indication for anticoagulation (like venous thromboembolism or atrial fibrillation), clinicians may routinely offer antiplatelet medications instead of anticoagulation.
- In rare circumstances, such as stroke that recurs while the patient is undergoing antiplatelet therapy, clinicians may offer anticoagulation.
- In rare circumstances, such as recurrent strokes despite adequate medical therapy with no other mechanism identified, clinicians may offer the AMPLATZER PFO Occluder if it is available.
Influenza vaccination: LAIV vs IIV
Influenza vaccination is used in many settings to prevent mortality and morbidity associated with infection with influenza virus. This study suggests lack of difference between intranasal live attenuated influenza vaccine (LAIV) and inactivated influenza vaccine (IIV).
Some earlier reports suggested better protection in children vaccinated with LAIV. This cluster randomized trial was performed in small Canadian rural communities (on average smaller than 100 people). The analysis included both vaccinated children and a 3 to 4 times larger number of nonvaccinated members of the community.
Influenza virus infection occurred at a rate of 5.3% (295 of 5,560 person-years) in communities using LAIV versus 5.2% (304 of 5,810 person-years) in the IIV-using communities. The hazard ratio comparing LAIV with IIV for influenza A or B virus was 1.03 (95% confidence interval [CI], 0.85-1.24). The authors have concluded lack of additional benefit of LAIV over IIV.
