THREAD: Dr. John Mandrola: “The more you see, the harder the medicine gets”

1/7 Some new views on legacy prescriptions: Beta-blockers, ASA & #statins by Dr. John Mandrola

(based on @drjohnm presentation hosted by @drug_evidence Oct 17, 2020: bit.ly/32fsPiA)

#MedED
2/7 Example 1: Beta blockers in heart failure 💊♥️

Observational studies suggest beta-blockers for heart failure tx beyond 3 years are NOT associated with beneficial outcomes 😯

These findings challenge current recommendations: bit.ly/3acX9P7

#MedEd #deprescribing
3/7 Ex. 2: How about beta blockers to treat MIs, looking at research from pre-reperfusion & reperfusion eras?

Large meta-analysis of about 60 trials, with > than 100,000 pts found NO difference from using beta blockers in the reperfusion era: bit.ly/3dfvn6u

#MedEd
4/7 Ex. 3: ASA story changed in 2018 with the ARRIVE trial 📰

12,500 pts with moderate CV risk, randomized to ASA v placebo:

✅ No difference in MI’s or deaths, but:
✅ DOUBLE the RISK of gastrointestinal bleeding in ASA group: bit.ly/32ckA6X 😯

#MedEd #drugsafety
5/7 Ex. 4: What about effect of ASA in pts with #diabetes? 🤔

ASCEND trial of 15k pts with diabetes found 1.1% ↘️ in serious vascular events…
…BUT 0.9% absolute ↗️ in bleeding: bit.ly/3mUxVuc

#MedEd #drugsafety
6/7 Ex. 5: ASPREE trial of 19,000 pts >70yrs, without CVD found:

👉ASA showed NO difference in terms of dementia and persistent disability, BUT
👉1.6 excess deaths per 1,000 person years compared to placebo: bit.ly/3djWvkI 😯

#MedEd #ptsafety
7/7 Conclusion:

@drjohnm: “shared understanding of medicine”= Evidence Based Medicine + Shared decision making + Patient-centred medicine 🩺 🤝 🧑🏾

👉Watch full presentation hosted by @drug_evidence Oct 17, 2020: bit.ly/32fsPiA 💻

#MedEd #drugsafety #ptsafety
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More from @Drug_Evidence

28 Jan
THREAD: Trama-DO or Trama-DON'T?
What to know about #tramadol

1/7 Tramadol has multiple mechanisms of action:
- via serotonin & norepinephrine reuptake inhibition
- after metabolism to M1 metabolite, via opioid agonism

bit.ly/3t5o7jC #chronicpain #arthritis #MedEd
2/7 People metabolize #tramadol variably 🤔💊

- Some who are ‘ultra rapid’ produce more M1 (opioid);
- Some ‘poor’ metabolizers (~20% with inactive CYP2D6) may have more SSRI/SNRI-like effect

Thus, analgesic & adverse effects are unpredictable
ncbi.nlm.nih.gov/books/NBK315950 #MedEd
3/7 Tramadol, once called a ‘safer’ opioid, causes tolerance and withdrawal, and is associated with addiction, overdose, and death

Observational studies show people treated with #tramadol, vs other opioids, are ↗️ likely to engage in prolonged opiate use #chronicpain #arthritis
Read 8 tweets
12 Dec 20
THREAD: Tamiflu for #influenza prevention – the evidence

1/6 In 2019 21,000 BC citizens were prescribed Tamiflu (oseltamivir), many to prevent the flu. Flu prevention guidelines. AMMI Canada ammi.ca/?ID=171

Systematic review of Tamiflu safety: pubmed.ncbi.nlm.nih.gov/27246259/
2/6 Tamiflu for prevention ↘️ symptomatic flu (by 3%, NNT=33) with uncertain effect on asymptomatic flu.

One likely explanation is that Tamiflu has a central symptom lowering effect but may not ↘️ viral transmission.
pubmed.ncbi.nlm.nih.gov/27246259

#influenza #flu #tamiflu
3/6 Tamiflu doesn't reduce risk of developing flu-like illness though it can make people feel better (i.e. fewer self-reported symptoms) & reduces fever.

There is not enough evidence to say it prevents death, hospitalizations, or flu complications
pubmed.ncbi.nlm.nih.gov/27246259/
Read 7 tweets
7 Oct 20
THREAD: Are we using ACEIs & ARBs properly? A TI Tweetorial

1/6: British Columbia doctors give 4.5m scripts/year for ACE inhibitors (ACEIs) & angiotensin receptor blockers (ARBs) to control bp. Goal is to ↘️ mortality & morbidity, not simply to ↘️ bp.

#MedEd #hypertension
2/6 BEST EVIDENCE on ARBs & ACEI for #hypertension

3⃣@CochraneHTN systematic reviews:

ACEs v ARBs for htn bit.ly/34vS0hu

BP lowering efficacy of ACEIs for htn bit.ly/30YNIOX

BP lowering efficacy of ACEIs for htn https://t.co/NCl1dfCCAO

#MedEd Image
3/6 ACEIs over ARBS when considering HARMS 🤔

Both ACEIs & ARBs ↘️ blood pressure to similar extents.... BUT only ACEIs have evidence for a reduction in risk of morbidity & mortality. So they’d be your first choice 🥇

#MedEd #medsafety #ptsafety
Read 7 tweets
25 Sep 20
THREAD: 5 Things You Need to Know About PPIs

For many years, we've dissected the research on Proton Pump Inhibitors (PPIs) 🤔

This thread captures our publications on PPIs that can help you in clinical practice: ti.ubc.ca/?s=ppis

#MedEd #medsafety #DrugEvidence #GERD
2/6 PPI COSTS VARY CONSIDERABLY 💰

Even without differences in efficacy or safety between PPIs, costs can vary x 10. The cheapest in BC? Pantoprazole Mg 40mg or Rabeprazole 10mg. Most expensive: Dexlanzoprazole

More here: ti.ubc.ca/letter99

#MedEd #DrugCosts #GERD
3/6 RESPONSE IS VARIABLE

1 in 2 pts w/ acid reflux get symptom relief with a PPI (NNT~2) w/in 4-8 wks

Responders notice symptom relief w/in 1-9 days. If no relief in ~2 wks consider 🛑 PPI. Non-acid reflux doesn’t benefit from PPI

More here: ti.ubc.ca/letter99

#MedEd
Read 7 tweets
24 Jun 20
THREAD: Ten Commandments for patient-centred treatment 🧾

1/11 A TI Tweetorial on the “Ten Commandments’ of the New Therapeutics

Revisiting timely words of medical wisdom from the BMJ
bjgp.org/content/65/639…

#MedEd #prescribing
2/11 1st Commandment:

Thou shalt have no aim except to HELP patients, according to the GOALS they wish to achieve 👩‍⚕️
bjgp.org/content/65/639…

Shared decision-making lessons from @LessIsMoreMed: lessismoremedicine.com/hands-on

#MedEd #TreatmentGoals
3/11 2nd Commandment:

Thou shalt always seek knowledge of BENEFITS, HARMS, COSTS of treatment & share this knowledge at all times
bjgp.org/content/65/639…

Try these:
ti.ubc.ca/therapeutics-l…
@thenntgroup
medi-mouse.com
pac.bluecross.ca/pharmacycompass

#MedEd #ptsafety
Read 12 tweets
4 Jun 20
THREAD: Painful Evidence: Do Common treatments for pain work❓

1/10 How effective are pain drugs? 🤔

In BC 120,000 ppl take cyclobenzaprine; 160,000 take gabapentin or pregabalin. Many others take duloxetine, venlafaxine, or amitriptyline

#MedEd #TIEvidence #painmanagement Image
2/10 SIDE EFFECTS:

Most 👨🧕on gabapentin/pregabalin/duloxetine/TCAs (e.g. amitriptyline) experience some adverse side effects like sleepiness, dizziness, nausea, dry mouth or constipation

Benefits/harms here: ti.ubc.ca/letter96

#MedEd #painmanagement Image
3/10 COCHRANE pain meds EVIDENCE:

Evidence frm 8 @cochranecollab reviews should ↘️ expectations abt likelihood+size of pain relief frm gabapentin, pregabalin, duloxetine, venlafaxine, amitriptyline, nortriptyline, imipramine, desipramine

ti.ubc.ca/letter96

#painmanagement
Read 11 tweets

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