Diabetes: how to manage patients experiencing hypoglycaemia.

Hypoglycaemia is a complication associated with the management of both type 1 and type 2 diabetes. Despite newer technologies to help minimize the risk of hypoglycaemia, it remains a barrier for some patients to achieve optimal glycaemic control. In this review, the definitions and risk factors for hypoglycaemia will be briefly discussed and an in-depth review of the management for a conscious or unconscious patient in the outpatient and inpatient settings is provided. Rapid-acting glucose is the preferred treatment for a conscious patient regardless of the setting. For an unconscious patient, glucagon is preferred if the patient does not have intravenous (IV) access and dextrose can be used for patients with IV access. Until recently, there was only one formulation of glucagon, which had limitations due to the multiple steps required for reconstitution prior to administration in an emergency setting. This review also discusses the different glucagon formulations currently available for the management of hypoglycaemia.

Contraceptive Use in Women of Childbearing Ability With Rheumatoid Arthritis.

BACKGROUND/OBJECTIVE: Rheumatoid arthritis (RA) is a complex disease that may require treatment with one or several disease-modifying antirheumatic drugs (DMARDs). Many DMARDs have potential teratogenic effects or are newer agents with limited safety data in pregnancy. This study evaluated 20 common RA medications and the rate of contraceptive prescribing and counseling patterns in women with RA of childbearing ability. METHODS: This was an observational study of women with RA and childbearing ability aged 18 to 44 years who were seen at an academic rheumatology clinic from April 1, 2014, to March 31, 2016. Descriptive statistics and univariate logistic regression were used for analysis. RESULTS: One hundred fifty women were included in the analysis. The majority of patients were taking methotrexate (55.3%), followed by chronic prednisone (31.3%) and hydroxychloroquine (28.7%). A documented method of contraception was noted in 64/150 (42.7%). For women on contraception, most used combined oral contraceptives (31/64, 48.4%) or levonorgestrel intrauterine device (10/64, 15.6%). Of the 86 patients not on contraception, 19 (22.1%) received counseling regarding a pregnancy plan. CONCLUSIONS: Most women with RA of childbearing age and ability were not using contraception. Among these patients, only a minority prescribed DMARD therapy had documented pregnancy or contraceptive counseling. Women with RA who were prescribed with a DMARD should discuss the use of effective contraception with their provider if sexually active and not desiring pregnancy or wanting to avoid potential teratogenic effects. Potential strategies are discussed to improve healthcare delivery to this population in hopes of avoiding unintended pregnancy and potential teratogenic effects of RA medications.

Utilization of acute gout prophylaxis in the real world: a retrospective database cohort analysis.

OBJECTIVE: Determine the real-world incidence of acute gout prophylaxis (AGP) prescribing when a xanthine oxidase inhibitor (XOI) is initiated and describe characteristics of AGP prescribing. METHODS: Retrospective cohort analysis from 2007 to 2017 using medical and prescription claims from an administrative database (IQVIA™ Health Plan Claims Database) among adult patients with a diagnosis of gout. Primary endpoint was the proportion of patients receiving AGP among all patients newly initiated on XOI therapy. Secondary endpoints included incidence proportions of acute flare and of XOI discontinuation among patients who received AGP compared to those who did not. Chi-square and Fisher's exact tests were used in univariate analysis of proportions between treatment groups. RESULTS: A total of 7414 patients were included for analysis. There were 697 patients (9.4%) who received AGP with XOI initiation and colchicine alone was the most common medication used among patients who received prophylaxis (n = 303, 43.4%). The incidence proportion of patients with an acute gout flare within 3 months of index was 21.5% in the AGP cohort and 12.7% in the no prophylaxis cohort (p < 0.001). The proportion of patients who discontinued XOI within 12 months of initiation was 38.7% in the AGP cohort and 46.2% in the no prophylaxis cohort (p < 0.001). CONCLUSION: In the real world, the proportion of patients who receive AGP with initiation of XOI therapy is low and discontinuation of XOI within 12 months of initiation is significant. In this analysis, use of AGP was not associated with a lower risk of acute gout flare after initiation of XOI therapy. Key Points • Real-world acute gout prophylaxis (AGP) prescribing with xanthine oxidase inhibitor (XOI) initiation is very low despite current guideline recommendations • More than one third of patients discontinue XOIs within 12 months of initiation regardless of AGP prescribing.

Less is more when it comes to ketorolac for pain.

It's time to review our dosing with ketorolac for acute pain management.

Patient considerations in the management of gout and role of combination treatment with lesinurad.

Gouty arthritis is one of the most common rheumatic diseases, and the prevalence continues to rise, which is likely related to increased incidence of comorbidities, lifestyle factors, and suboptimal utilization of urate-lowering therapy. In recent years, multiple new guidelines have been published along with the approval of novel drug therapies. Still, gout remains a poorly controlled disease state that is accompanied by a reduced health-related quality of life, increased health care utilization, and overall negative socioeconomic effects, all of which have a negative impact on patient-related health outcomes. The key to success in gout management is utilization of urate-lowering therapy to prevent recurrence of acute gouty arthritis and to resolve tophi, if present. Xanthine oxidase inhibitors are first-line medications for the prevention of recurrent gout followed by uricosurics, including lesinurad (a uric acid reabsorption inhibitor) as an add-on option. The recent US Food and Drug Administration Safety Communication related to cardiovascular risk with febuxostat may result in increased use of allopurinol in combination therapy with a uricosuric agent such as lesinurad. In this review, we discuss gout management, clinical end points, and patient-related outcomes for consideration, summarize the evidence for combination therapy to achieve serum urate targets, and focus on lesinurad as a novel newer medication for the prevention of gout.