Journal of the Faculty of Medicine and Dentistry of the Université catholique de Louvain (UCL)

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Actualité thérapeutique

Rivaroxaban (Xarelto®): Update on new clinical data and...

Direct oral anticoagulants (AODs), which target coagulation Factors Xa or IIa, represent a major therapeutic innovation. Even if classical anticoagulants, such as vitamin K antagonists (AVK) and low molecular weight heparins, still play a crucial role in preventive or curative treatment, AODs have revolutionized the medical management of thrombotic diseases, concerning both arterial and venous conditions.

In addition to being able to replace conventional anticoagulants in common indications like atrial fibrillation and venous thromboembolic disease, there is a plethora of Xarelto data from recent and original studies, as well as from registries and Phase III sub-analyses, which are currently revolutionizing the modalities and benefits of oral anticoagulation at all stages of life and in a wide spectrum of indications.

This article provides a synthetic and practical review of these data and their therapeutic implications.

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Médecine Générale

Maintaining the cold chain in general medicine

Keeping vaccines requires maintaining the cold chain, which commonly exhibits weaknesses, even in more developed countries. However, the exposure of most vaccines to high temperatures results in some degree of degradation. Moreover, the freezing itself can cause an immediate vaccine degradation. In this context, the conservation of vaccines in the refrigerator at a constant temperature between 2 and 8 °C is a required framework for the general practitioner, which is designed to preserve the vaccines’ properties. The main characteristics of suitable refrigerators must combine the maintenance of temperature (between 2 and 8 °C), an equal temperature distribution, the availability of an evaporator that prevents freezing, a very rapid temperature recovery device, as well as forced air circulation. Domestic refrigerators may suffice for storing small volumes of vaccines. They must display the minimum characteristics required for good storage conditions and undergo the adaptations necessary to their proper use. Additionally, regular temperature monitoring and reporting must be performed using an outdoor thermometer with a probe. These easily manageable elements enable vaccines to be stored in good conditions, with the eventual outcome of optimizing vaccine coverage of the population.

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Internal Medicine

What should be taken into account from the 2019...

Several members of the Belgian Societies of Atherosclerosis and Cardiology have revisited in the form of 10 questions the main points of the new recommendations of the European Atherosclerosis Society (EAS) and European Society of Cardiology (ESC) concerning dyslipidemia management for preventing atherosclerotic cardiovascular disease (AVD). These new guidelines are underpinned by a number of key concepts, including the certainty that LDL cholesterol is the major cause underlying the development of atherosclerosis, that reducing LDL cholesterol helps diminish cardiovascular risk, that this cardiovascular benefit is the same regardless of how this reduction is met (nutrition, statin, ezetimibe, or PCSK9 inhibitor), and that there is neither a lower limit to this effect nor any danger at all of extremely low LDL cholesterol levels. To effectively put this knowledge into practice, a step-by-step approach is recommended; thereby enabling us to weight the intensity of the preventive approach based on individuals’ overall MCVA risk and their baseline (untreated) LDL-C levels.

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Hépato-gastroentérologie

Pathophysiology of NASH: Have new risk factors been identified?

Due to the rising prevalence of obesity, non-alcoholic fatty liver disease (NAFLD) has become the leading cause of chronic liver disease worldwide. NAFLD refers to a disease spectrum that encompasses steatosis and non-alcoholic steatohepatitis (NASH). NASH, which is the inflammatory subtype of NAFLD, has a clear potential of progression to fibrosis and cirrhosis, and can be associated with the need for transplantation. Identification of NAFLD and NASH is important in order to prevent disease worsening and to provide adequate tools for counteracting the causal factors. Risk factors associated with NAFLD and NASH include clinical comorbidities such as the metabolic syndrome, which is more relevant than high body mass index. Further recently identified characteristics, such as dietary composition, intestinal dysbiosis, genetic predisposition, altered brown adipose tissue, muscle alterations, circadian clock disruption or environmental chemicals, are presented in this review.

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Médecine interne et maladies infectieuses

COVID-19: SARS-CoV-2 infection

The world is facing a serious pandemic. The disease called COVID-19 is caused by a new coronavirus, SARS-CoV-2, which started to spread in China in December 2019. COVID-19 is a condition that may be particularly serious and even fatal in elderly people, as well as in patients with comorbidities such as high blood pressure, cardiovascular diseases, chronic obstructive pulmonary disease, diabetes, chronic kidney disease, and cancer. The clinical presentation is mild in approximately 80% of cases, moderate to severe in 15% of cases, and critical in 5% of cases. The most common symptoms of COVID-19 are fever, fatigue, muscle aches, and dry cough. Some patients may exhibit nasal congestion, chills, sore throat, or diarrhea. Severely ill patients can develop an acute respiratory distress syndrome (ARDS), shock, thrombosis, and multiple organ failure, and they are at risk of death. COVID-19 patients with ARDS have a poor prognosis, with an estimated mortality rate of more than 10%. SARS-CoV-2 is primarily transmitted through respiratory droplets. Airway and hand hygiene is therefore essential. The diagnosis is made by reverse transcription-polymerase chain reaction on a nasopharyngeal or oropharyngeal swab and, in suggestive cases, by chest computed tomography, which has a high sensitivity. There is currently no effective specific treatment for COVID-19. Many molecules have been tried or are under investigation. The treatment currently remains supportive.

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Diabétologie

COVID-19 and diabetes

Diabetes is one of the most commonly reported comorbidities in COVID-19-infected patients. According to current data, diabetic patients do not appear to be at increased risk of contracting SARS-CoV-2 compared to the general population. However, diabetes is a risk factor for developing severe and critical COVID-19 forms, which often require intensive care unit admission and, eventually, invasive mechanical ventilation, which are associated with high mortality rates. The characteristics of COVID-19 diabetic patients and prognostic impact of diabetes on SARS-CoV-2 infection are currently under investigation. Obesity, the main risk factor for incident Type 2 diabetes, appears to be more common in patients with critical COVID-19 forms that require mechanical invasive ventilation. In diabetic patients, COVID-19 is associated with poor glycemic control and acute metabolic complications like ketoacidosis. At present, there are no recommendations in favor of discontinuing antihypertensive medications that interact with the renin-angiotensin-aldosterone system. Owing to the risks of lactic acidosis and ketoacidosis, metformin and SGLT2 inhibitors should be discontinued in patients with severe COVID-19 forms. Finally, we advise a systematic screening for (pre)diabetes in patients with proven SARS-CoV-2 infection.

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STOPP/START.v2

The tool STOPP / START.v2 allows evaluation of drug treatments prescribed to patients age 65 and older.

 

This tool, designed for all care settings, stimulates thinking and challenging medication taken by patients, especially drugs forcardiovascular and nervous system.

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