Direct oral anticoagulants: How to choose?

Christophe Scavée Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

Atrial fibrillation (AF) is a major cause of stroke. To prevent this devastating complication, anticoagulants are recommended in some patients. Two classes of oral anticoagulants can be used for this indication: anti-vitamin K (AVK) agents, such as warfarin, and direct-acting non-vitamin K oral anticoagulants, also called new oral anticoagulants (NOACs). NOACs include agents with two distinct modes of action: direct factor Xa inhibitors (apixaban, rivaroxaban, edoxaban) on the one hand and direct thrombin inhibitors (dabigatran) on the other hand. These molecules have been compared individually to warfarin: While showing similar efficacy, they had a better safety profile in terms of bleeding, with a lower risk of hemorrhagic stroke and intracranial hemorrhage. They are therefore preferred over AVKs.

The choice of the anticoagulant is made on a case-by-case basis, always taking into account the risk of stroke (using anticoagulants in patients without thromboembolic risk factors is currently not recommended) and bleeding (dosage!). These two aspects should be assessed prior to any prescription. When choosing an anticoagulant agent, the physician should also consider the presence of coronary artery disease (concomitant use of antiplatelet therapy), the patient's age and weight (dose adjustment!), renal function (important for dabigatran), the patient’s preference (once daily vs twice daily administration), and the patient’s understanding of the treatment, which is decisive for therapeutic compliance. It should be noted that dabigatran is currently the only NOAC for which a specific reversal agent is available that can be used in some cases when emergency surgery is required or major bleeding has to be controlled.

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Arterial hypertension: new guidelines

Jean-Michel Pochet (1), Alexandre Persu (2) Published in the journal : May 2019 Category : ECU-Congrès de médecine générale

The latest ESC/ESH guidelines recommend ambulatory blood pressure monitoring or self-measurement for diagnosing hypertension and advocate early drug therapy using a fixed combination of a renin-angiotensin system blocker and a calcium channel blocker or a thiazide diuretic. Blood pressure should be reduced to 120-129/70-79 mmHg in patients aged <65 years who tolerate it. In patients aged >65 years, blood pressure should be reduced to 130-139/70-80 mmHg, if tolerated.

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Biotherapies in the management of moderate-to-severe psoriasis

Deborah Debois, Marie Baeck, Pierre-Dominique Ghislain (1) Published in the journal : May 2019 Category : Actualité thérapeutique

Psoriasis, a very common systemic inflammatory disease, is potentially disabling from a functional and aesthetic point of view. In recent years, treatments for managing moderate- to-severe psoriasis have significantly evolved since the advent of biologic therapies. Undoubtedly, these latter have favorably impacted the patient quality of life.

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Degludec (Tresiba®): a new ultra-long acting basal insulin analog

Michel P. Hermans, Vanessa Preumont (1) Published in the journal : May 2019 Category : Actualité thérapeutique

Insulin degludec (Tresiba®) is an ultra-long acting basal insulin analog recently marketed in Belgium. Controlled clinical trials have demonstrated that insulin degludec provides similar reductions in HbA1c compared to the basal analogs glargine or detemir in Type 1 and Type 2 diabetes, with superior fasting glucose control in the majority of studies. The data additionally show a clinically relevant reduction in the incidence of hypoglycemia episodes, especially at night. The results of controlled and observational studies point towards the therapeutic added value of degludec in the management of Type 1 and Type 2 diabetes.

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Canagliflozin (Invokana®) associated with exemplary nephro- and cardioprotection in Type 2 diabetes. Synopsis of the CREDENCE study

Martin Buysschaert Published in the journal : May 2019 Category : Actualité thérapeutique

The CREDENCE study sought to compare the efficacy of canagliflozin vs. placebo in preventing clinically-relevant kidney and cardiovascular events in patients with diabetes and established kidney disease. With regard to the primary endpoint (terminal kidney failure; doubling of creatinine; renal or cardiovascular death), the authors reported a 30% reduction in the relative risk (hazard ratio [HR]: 0.70; 95% CI: 0.59-0.82, p=0.00001) after 2.6 years of follow-up. The risk was reduced by 17-39% with regard to secondary cardiovascular or renal endpoints. These results should be integrated in our therapeutic approach for Type 2 diabetes patients, in terms of both nephro- and cardioprotection.

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Diagnostic and therapeutic approaches in case of neurocysticercosis in Belgium

Mike Salavracos Published in the journal : April 2019 Category : Observations cliniques

Brain cysticercosis, or neuro-cysticercosis, is an infection involving the central nervous system caused by larvae of a flat worm called Taenia solium. This infection may give rise to numerous different medical presentations, complicating its diagnosis.

The interest of this clinical case assessment describe in this article lies in the rarity of its diagnosis, its non-specific infectious manifestation, as well as the fact that the patient had not recently travelled to a cysticercosis-endemic area.

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Legionella Pneumophila Pneumonia

Quentin Simon Published in the journal : April 2019 Category : Observations cliniques

Flu-like symptoms with cough may be the manifestation of many differential diagnoses. This article sought to demonstrate the relevance of a complete clinical examination, along with the need to look for underlying etiologies when faced to an unusual evolution of a flu-like syndrome

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Adult-onset Still’s disease: rare cause for prolonged fever syndrome

Omar El-Mourad1, Fabien Roodhans1,2, Valérie Huyge3 Published in the journal : April 2019 Category : Observations cliniques

The adult-onset Still’s disease is a rare cause of fever of unknown origin. The clinical presentation and biological signs are rather polymorphous and non-specific. We herein emphasize the usefulness of measuring serum ferritin and glycosylated ferritin (GF) levels. The diagnosis of adult-onset Still’s disease is based on the Yamaguchi criteria, with three major criteria (high fever for more than 1 week, neutrophilic leucocytosis, and diffuse arthralgia) and three minor criteria (liver enzyme elevation of neither toxic nor drug-related origin, lymphadenopathy identified on PET imaging, and negativity of rheumatoid factors and antinuclear antibodies) to be present. The disease’s pathophysiology is still uncertain, and treatment essentially relies on systemic glucocorticoids. In this paper, we have discussed the usefulness of biotherapies, comprising primarily the monoclonal antibodies directed against the IL-6 receptor.

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Gigant-cell arteritis: discussion on clinical and paraclinical presentations and therapeutic options

Omar El-Mourad (1), Fabien Roodhans (1,2), Valérie Huyge (3), Bruno Guetcho( 4) Published in the journal : April 2019 Category : Observations cliniques

Horton's disease, also termed giant cell arteritis, mainly affects large-caliber vessels within the territories of the external carotid branches. Of note is that this condition can also involve the eye, central nervous system, digestive tract, respiratory system, as well as the arterial system of the lower limbs, and the heart. The diagnosis is confirmed based on the biopsy of the temporal artery, which is not positive in all cases. PET imaging takes an increasingly relevant place in the diagnostic tree, revealing metabolic hyperfixation of large and medium vessels. Treatment is mainly based on systemic glucocorticoids. Of note is the progressively increasing place of biotherapies in the condition’s management, primarily comprising specific antagonists of the IL-6 receptor.

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Perforated neonatal appendicitis: conservative management

Geoffrey Jacqmin (1), Jean-Philippe Stalens (2), Jean-Luc Dutrieux (3), Philippe Malvaux (4) Published in the journal : April 2019 Category : Observations cliniques

Acute appendicitis is very rare in the neonatal period. The diagnosis may be delayed due to the lack of specific clinical symptoms, and because of its rarity in the patient population considered, leading to increased peritonitis and mortality rates. Despite neonatal appendicitis possibly manifesting as an isolated event, in many cases, it proves to be a complication of an underlying disease. While surgical treatment remains the gold standard in this pathological setting, conservative management may be considered in selected patients.

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