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Allergy and Immunology - Asthma and COPD
Insulin resistance in severe asthma (November 2022)
Several studies have identified an increased prevalence of asthma and difficult-to-control asthma among obese individuals, although the exact reason for the association is not known. A recent study of patients with severe asthma included extensive metabolic phenotyping as well as long-term follow-up.2 Patients with insulin resistance demonstrated more rapid decline in lung function and increased resistance to beta-agonist and oral glucocorticoid therapies compared with patients having normal insulin sensitivity. Whether targeting insulin resistance can impact these severe asthma features requires further investigation.
Cardiovascular Medicine - Arrhythmias
Alternative sites for cardiac resynchronization pacing (November 2022)
For patients with heart failure and reduced ejection fraction (HFrEF) who have left bundle branch block, cardiac resynchronization therapy (CRT) with pacing in the coronary sinus can improve functional status and reduce mortality, but alternative pacing sites may be more physiologic and superior. In a recent trial in 40 patients with HFrEF, CRT with a left bundle branch area pacing (LBBAP) lead resulted in greater improvement in left ventricular ejection fraction at six months compared with CRT with a coronary sinus lead.3 However, other important markers of CRT effectiveness (eg, left ventricular end-diastolic dimension, six-minute walk time) were similar between the two groups. For patients with HFrEF who have an indication for CRT, we suggest initial placement of a CRT system with a coronary sinus lead; in selected patients who cannot undergo coronary sinus lead placement, CRT may be established with conduction system pacing.
Dermatology - Autoimmune and Systemic Diseases
Long-term cardiovascular and metabolic outcomes for rituximab in pemphigus (December 2022)
Combination therapy with systemic glucocorticoids and rituximab has demonstrated greater efficacy for achieving remission in pemphigus vulgaris and pemphigus foliaceus than systemic glucocorticoids given with mycophenolate mofetil. In a population-based, retrospective study of over 1600 patients with pemphigus, risk for myocardial infarction, stroke, peripheral vascular disease, hypertension, hyperlipidemia, type 2 diabetes, obesity, and osteoporosis was lower among the 961 patients treated with rituximab compared with those treated with mycophenolate mofetil or azathioprine.4 Pending additional study, these findings suggest additional benefits of rituximab over conventional immunosuppressant therapy for the treatment of pemphigus.
Allergy and Immunology - Asthma and COPD
Persistence of asthma control after stopping omalizumab therapy (November 2022)
Omalizumab, an anti-IgE monoclonal antibody, is an effective add-on therapy for uncontrolled moderate-to-severe asthma but the optimal duration of therapy and the persistence of benefit after discontinuation are unclear. In an analysis of the French national healthcare database that included over 19,000 patients with asthma (over 2000 children) who received omalizumab for a median duration of approximately 4.5 years, rates of asthma hospitalizations were reduced by 75 percent and the need for oral corticosteroids by 30 percent after two years of treatment.1 Among patients with asthma control during treatment, symptoms remained controlled in a significant percentage one, two, and three years after discontinuation (76, 44, and 33 percent in children and 70, 39, and 24 percent in adults, respectively). These findings indicate a lasting benefit after discontinuation of omalizumab in patients with controlled asthma and provide a basis for anticipatory guidance for those who discontinue treatment.
1. Humbert M, Bourdin A, Taille C, et al Real-life omalizumab exposure and discontinuation in a large nationwide population-based study of paediatric and adult asthma patients. Eur Respir J. 2022;60(5):2103130. [Context Link]
2. Peters MC, Schiebler ML, Cardet JC, et al The impact of insulin resistance on loss of lung function and response to treatment in asthma. Am J Respir Crit Care Med. 2022;206(9):1096. [Context Link]
3. Wang Y, Zhu H, Hou X, et al Randomized trial of left bundle branch vs biventricular pacing for cardiac resynchronization therapy. J Am Coll Cardiol. 2022;80(13):1205. [Context Link]
4. Kridin K, Mruwat N, Ludwig RJ. Association of rituximab with risk of long-term cardiovascular and metabolic outcomes in patients with pemphigus. JAMA Dermatol. 2023;159(1):56-6. [Context Link]
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