Chiefs’ Inquiry Corner – 7/7/21

July 7, 2021

Chiefs' Inquiry Corner 2 min read

Chief residents of the NYU Langone Internal Medicine Residency give quick-and-easy, evidence-based answers to interesting questions posed by house staff, both in their clinics and on the wards.

 

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New guidelines released by the IDSA in June 2021 now state that for patients with an initial Clostridium Difficile Infection (CDI) episode, fidaxomicin is the preferred treatment, rather than a standard course of vancomycin, with moderate-certainty evidence. Furthermore, for patients with recurrent CDI, fidaxomicin is also preferred over vancomycin (low-certainty evidence). Fidaxomicin is preferred due to its minimal resistance pattern, minimal systemic absorption, and limited activity against other enteric bacteria. Studies also show a better sustained clinical response when compared to vancomycin (i.e. less subsequent recurrent symptoms).

References: IDSA and SHEA Guidelines for C. Diff  
Given the relative rarity of this disease process (1/100,000 people treated with statins), there is little data on whether it is safe to challenge these patients with an alternate statin. A case series of 122 patients who follow at the Johns Hopkins Myositis center examined whether those with confirmed IMNM could tolerate and have clinical improvement with a PCSK9 inhibitor. Patients were followed for an average of 1.5 years. They demonstrated improvement in CK levels and antibody titers, with two patients actually weaned off immunosuppressive therapy. Whether these agents can play a direct role in ameliorating the immune process remains to be investigated. 

References: Use of Proprotein Convertase Subtilisin/Kexin Type 9 Inhibitors in Statin-Associated Immune-Mediated Necrotizing Myopathy: A Case Series; Statin-Induced Necrotizing Autoimmune Myopathy  
Until recently, liraglutide was the only approved GLP1-agonist approved for weight loss, based on supportive findings from the Evidence from the Satiety and Clinical Adiposity — Liraglutide Evidence in Nondiabetic and Diabetic Individuals Obesity and Prediabetes (SCALE) trial. More recently, a combination of diet and lifestyle, plus once-weekly semaglutide at a dose of 2.4 mg was studied in obese patients (BMI >30 or >27 if they had a comorbid condition) without diabetes. With follow-up to 68 weeks, patients had a mean change in body weight of -14.9% (compared to -2.4% with placebo). As of June of 2021, semaglutide (Wegovy) is now FDA-approved for weight loss in patients with a BMI >30 or >27 with a weight-related comorbid condition. 

References: Weekly Semaglutide in Adults with Overweight or Obesity