Setmelanotide: A Novel Targeted Treatment for Monogenic Obesity.

Objective: To review clinical data regarding the newly approved drug setmelanotide, an injectable melanocortin 4 receptor (MC4R) agonist, for chronic weight management in adults and children aged 6 years and older with monogenic obesity. Data Sources: A literature review was performed by searching MEDLINE, SCOPUS, and EMBASE for all relevant English-language articles published between January 1, 1996, and November 30, 2021, using search terms obesity, setmelanotide, Imcivree, and MC4R agonist. Study Selection/Data Extraction: This review included two phase 2, two phase 3, and one ongoing clinical trial evaluating the efficacy and/or safety of setmelanotide. Data Synthesis: Setmelanotide demonstrates statistically significant weight loss with at least a 10% decrease in body weight after 1 year and decreased appetite in phase 2 and phase 3 clinical trials. The most common adverse effects included injection site reaction (96%), skin hyperpigmentation (78%), nausea (56%), headache (41%), and diarrhea (37%). Place in Therapy: Setmelanotide is the first and only Food and Drug Administration-approved medication for the treatment of proopiomelanocortin, proprotein convertase subtilisin/kexin type 1, and leptin receptor deficiency in patients with obesity. It may be used in children and adults who have received genetic testing and exhibited extreme obesity before age five. Setmelanotide is a daily subcutaneous injection and may be difficult to afford for patients. Conclusion: Setmelanotide is an effective treatment in patients with obesity and indicated genetic disorders.

Evaluation of Provider Implementation of the 2019 American College of Cardiology and American Heart Association Aspirin for Primary Prevention Guideline Recommendations for Older People.

Design Retrospective chart review study using electronic medical record data from Inova Health System patients. Setting All cardiology, endocrinology, and primary care outpatient clinics operated by Inova Medical Group (IMG) in Northern Virginia. Participants Participants included were 70 years of age or older and taking aspirin 81 mg as of April 1, 2019. They had completed at least one visit with an IMG provider in primary care, cardiology, or endocrinology clinics between April 1, 2019, and February 17, 2020. Main Outcome Measures The primary outcome of this study was percentage of older people seen by a primary care physician, cardiologist, or endocrinologist since guideline publication who were continued on aspirin for primary prevention. Results The percentage of participants continued on aspirin for primary prevention was 92% versus 8.0% who were discontinued (P < 0.0001). Differences in subgroup analyses based on smoking history, diagnosis of diabetes, or history of venous thromboembolism were not statistically significant. Conclusion There was a significantly greater rate of aspirin continuation versus discontinuation among patients 70 years of age and older in the setting of primary cardiovascular prevention. Based on this result, most primary care physicians, endocrinologists, and cardiologists at this institution have chosen to continue aspirin in older people following the 2019 American College of Cardiology/American Heart Association guideline statement publication.

Herpes zoster and vaccination: a clinical review.

PURPOSE: Herpes zoster, herpes zoster vaccine, and the cost-effectiveness of the vaccine are reviewed. SUMMARY: Herpes zoster infection is estimated to affect one in three people during their lifetime. Two thirds of people who develop this disease are over age 60 years. Postherpetic neuralgia (PHN) is the most common complication of herpes zoster, occurring in 10-18% of patients. The associated chronic pain can be very debilitating, affecting patients' quality of life. The pain may last for months or years and is difficult to treat, leading to increased health care costs and morbidity. To prevent herpes zoster, a live attenuated vaccine was developed and approved for marketing in 2006 for individuals age > or = 60 years. The safety and efficacy of the vaccine were evaluated in the Shingles Prevention Study in 38,546 adults age > or = 60 years. Compared with placebo, administration of the vaccine resulted in a 51.3% reduction in the incidence of herpes zoster and a 66.5% reduction in the incidence of PHN (p < 0.001 for both comparisons). A single dose of the vaccine is approximately $162 and is not covered by all insurance plans. Several studies evaluated the cost-effectiveness of the vaccine, which was found to be most beneficial in individuals age 70 years or older. The use of the vaccine appears to reduce health care costs and protect the public health. CONCLUSION: The herpes zoster vaccine is effective in preventing herpes zoster and decreasing the incidence of complications. However, insurance coverage may hinder eligible patients from receiving the vaccination.

Carbamazepine-induced hyperammonemia.

PURPOSE: A case of carbamazepine-induced hyperammonemia is presented. SUMMARY: A 26-year-old man with bipolar disorder, seizures, and mild mental retardation secondary to a traumatic brain injury began treatment with carbamazepine for aggression and seizure control. After three weeks of carbamazepine therapy, the patient arrived at the emergency department (ED) with severe agitation and aggressive behavior. His oral medications included topiramate, carbamazepine, olanzapine, quetiapine, guanfacine, and desmopressin acetate. The patient's medications had been stable for at least six months except for the addition of carbamazepine one month before his arrival at the ED. Upon admission, the patient's vital signs were found to be within normal limits, as were his liver profile results, complete blood count, thyroid-stimulating-hormone level, and serum chemistry panel. His serum carbamazepine concentration was 3.9 microg/mL (reference range, 4-12 microg/mL), and his serum ammonia concentration was 127 microg/dL (reference range, 19-60 microg/dL). Carbamazepine was discontinued upon admission, and the patient was treated with oral lactulose. Since carbamazepine was discontinued and had been prescribed for bipolar disorder, his olanzapine dosage was increased, and trazodone was added at bedtime for insomnia. Of note, the patient had been on carbamazepine therapy one year earlier and had experienced the same adverse event. He had also developed elevated serum ammonia levels while on valproic acid. The patient's serum ammonia level returned to normal by hospital day 4, and he was discharged to his group home. CONCLUSION: A 26-year-old man with bipolar disorder developed hyperammonemia three weeks after initiating carbamazepine therapy.