Antiphospholipid antibodies and vitamin D deficiency in COVID-19 infection with and without venous or arterial thrombosis: A pilot case-control study.

BACKGROUND: Coronavirus disease-2019 (COVID-19) is associated with thromboembolism. Antiphospholipid antibody (APLa) formation is one of the mechanisms. Vitamin D deficiency has been associated with thrombosis in antiphospholipid antibody syndrome. OBJECTIVE: Measure APLa and vitamin D in hospitalized COVID-19 patients with and without thrombosis to evaluate if thromboembolism is associated with concomitant APLa and vitamin D deficiency. METHODS: Case-control study. Hospitalized COVID-19 patients with a thromboembolic event (ischemic stroke, myocardial infarction, deep venous thrombosis/pulmonary embolism, Cases n = 20). Controls (n = 20): Age, sex-matched without thromboembolic events. Patients with autoimmune disorders, antiphospholipid antibody syndrome, thrombophilia, anticoagulation therapy, prior thromboembolism, chronic kidney disease 3b, 4, end-stage renal disease, and malignancy were excluded. Given the limited current literature on the role of concomitant antiphospholipid antibodies and vitamin D deficiency in causing venous and/or arterial thrombosis in hospitalized COVID-19 patients, we enrolled 20 patients in each arm. Anti-cardiolipin IgG/IgM, beta-2 glycoprotein-1 IgG/IgM, lupus anticoagulant and vitamin D levels were measured in both groups. RESULTS: Cases were 5.7 times more likely to be vitamin D deficient (OR:5.7, 95% CI:1.3-25.6) and 7.4 times more likely to have any one APLa (OR:7.4, 95% CI: 1.6-49.5) while accounting for the effects of sex. Patients with both APLa and vitamin D deficiency had significantly more thrombosis compared to patients who were antibody positive without vitamin D deficiency (100% vs 47.4%; p = 0.01). CONCLUSIONS: Thrombosis in COVID-19 was associated with concomitant APLa and vitamin D deficiency. Future studies in COVID-19 should assess the role of vitamin D in reducing thrombosis.

The clinical utility of professional continuous glucose monitoring by pharmacists for patients with type 2 diabetes.

BACKGROUND: There are limited data regarding the use of diabetes technologies, such as professional continuous glucose monitoring (CGM), as part of a pharmacist-managed diabetes service. OBJECTIVE: To assess how professional CGM affected treatment decisions and glucose control as part of a pharmacist-managed service for patients with type 2 diabetes. PRACTICE DESCRIPTION: Clinical Pharmacy Specialists (CPS's) within an outpatient diabetes management service provide comprehensive diabetes care under a scope of practice that includes prescriptive privileges. PRACTICE INNOVATION: Insight into glucose patterns is paramount for pharmacists to use their medication expertise to its fullest capacity. CGM technology can provide detailed data on glucose trends, including percentage of time spent in a target range. Pharmacists involved in the provision of diabetes care have the opportunity to integrate professional CGM into their practice to acquire data for targeted therapeutic adjustments. EVALUATION METHODS: A retrospective analysis was conducted of patients with type 2 diabetes who had professional CGM used as part of their routine diabetes care with the CPS from 2017-2019. The primary outcome was the percentage of patients meeting their individualized A1c goal at baseline versus 6 months post placement of the professional CGM. A McNemar's test was used to compare the percentage of patients achieving A1c goal pre and postintervention. A P value of <0.05 denoted the presence of a statistically significant difference. RESULTS: Patients who implemented professional CGM had an average duration of diabetes of 15.6 years and an average A1c of 9.1%. The majority (76.7%) were not meeting their individualized A1c goal. Hypoglycemia was identified in 57% of the patients; almost half of patients evaluated had periods of nocturnal hypoglycemia. Hyperglycemia was present on the vast majority of reports (83%) with postprandial elevations being the most common trend identified overall. Mean A1c decreased from 9.11% ± 1.4 at baseline to 8.64% ± 1.3 at 3 months and 8.19% ± 0.8 at 6 months. Compared with baseline, more than 2 times the number of patients were within their A1c goal range at 3 and 6 months (23.3%, 53.6% and 69.6% respectively.) This represented a statistically significant difference at both time points (P = 0.008 at 3 months and P = 0.006 at 6 months.) CONCLUSION: The use of CGM technology may overcome treatment barriers, such as insufficient self-monitoring of blood glucose and lack of discernment of glucose trends with traditional A1c testing. Pharmacists employing professional CGM as part of a diabetes management service were able to achieve targets for significantly more patients with type 2 diabetes on a wide range of treatment regimens at 6 months compared with baseline. Widespread use of professional CGM in pharmacist-managed diabetes services may provide valuable care and improve outcomes more broadly. Larger randomized trials are warranted to examine ideal patient selection and optimal frequency of use.

Anticoagulation Management and Outcomes in Patients With Covid-19 With Propensity Score Matching: A Multicenter Retrospective Cohort Study.

BACKGROUND: Therapeutic doses of anticoagulation have been administered to patients with coronavirus-19 disease (Covid-19) without thromboembolism, although there is a lack of robust evidence supporting this practice. STUDY QUESTION: To compare outcomes between patients admitted to the hospital for Covid-19 who received full-dose anticoagulation purely for the indication of Covid-19 and patients who received prophylactic doses of anticoagulation. STUDY DESIGN: This is a multicenter retrospective cohort study, including 7 community hospitals in Michigan. Patients were >18 years of age, confirmed positive for Covid-19 by polymerase chain reaction, and admitted to the hospital between March 10 and May 3, 2020. Exposed group: Patients receiving therapeutic dose anticoagulation for Covid-19 for any duration excluding clinically evident venous thromboembolism, atrial fibrillation, and myocardial infarction; control group: Patients receiving prophylactic anticoagulation. Propensity score matching was used to adjust for the nonrandomized nature of the study. MEASURES AND OUTCOMES: The primary endpoint: 30-day in-hospital mortality. Secondary endpoints: intubation, length of hospital stay, and readmissions in survivors. RESULTS: A total of 115 exposed and 115 control patients were analyzed. Rates of 30-day in-hospital mortality were similar (exposed: 33.0% vs. control: 28.7%). Controlling for institution, there was no significant association between treatment and 30-day in-hospital mortality (hazard ratio: 0.63; 95% confidence interval: 0.37-1.06). Survivors had statistically similar length of hospital stay and readmission rates. CONCLUSIONS: We found no difference in mortality in patients with Covid-19 without clinically evident venous thromboembolism, atrial fibrillation, and myocardial infarction who received therapeutic versus prophylactic doses of anticoagulation.

Erratum: Short-Term Outcomes for Veterans Receiving Basal Insulin, Metformin, and a Sulfonylurea Who Are Started on a Third Noninsulin Agent Versus Prandial Insulin. Diabetes Spectrum 2018;31:261-266 (doi.org/10.2337/ds17-0068).

[This corrects the article on p. 261 in vol. 31, PMID: 30140142.].

Short-Term Outcomes for Veterans Receiving Basal Insulin, Metformin, and a Sulfonylurea Who Are Started on a Third Noninsulin Agent Versus Prandial Insulin.

AIMS: Despite numerous recent advances in the management of patients with type 2 diabetes, there remains a paucity of data to guide sequential treatment intensification. METHODS: This was a single-center, retrospective cohort study of patients receiving metformin, basal insulin, and a sulfonylurea who were started on a third noninsulin agent or prandial insulin. The primary outcome for this study was change in A1C at 6 months after treatment intensification. Secondary outcomes included change in weight at 6 months, change in A1C at 1 year, percentage of patients achieving an A1C <7.5% at 1 year, documented episodes of hypoglycemia, and time to progression to prandial insulin. RESULTS: A total of 62 patients were identified for inclusion in the study: 28 receiving prandial insulin and 34 treated with a noninsulin agent. There was no significant difference in A1C change between the two treatment arms at either 6 months (-0.53 vs. -0.84%, P = 0.31) or 1 year (-0.67 vs. -0.86%, P = 0.61) after intervention. Patients receiving noninsulin agents gained significantly less weight at 6 months (-2.09 vs. 1.99 kg, P <0.01) and experienced fewer annual episodes of hypoglycemia (1.0 vs. 2.6, P = 0.01). Among patients treated with noninsulin agents, those receiving a glucagon-like peptide 1 receptor agonist were more likely to have an A1C <7.5% at 1 year than patients receiving a dipeptidyl peptidase 4 inhibitor (50 vs. 13%, P = 0.05). CONCLUSION: These results highlight that, in select patients, noninsulin therapies can be added to a backbone of metformin, basal insulin, and a sulfonylurea with similar A1C reductions but improved metabolic parameters relative to intensive insulin therapy.