Case Studies

Case 1

SD is a 59-year-old man with stable coronary artery disease and exertional angina that is being medically managed. He also suffers from chronic obstructive pulmonary disease (COPD), hyperlipidemia, and is a current smoker. SD has received a trial of metoprolol succinate, requiring the maximal dose for angina relief. Unfortunately, SD was unable to tolerate the exacerbation of his COPD symptoms that resulted. SD has also tried nitrates, but had to discontinue therapy because he suffered intolerable headaches.

What other therapies are available for the treatment of SD’s angina?

Case 2

MJ is a 63-year-old woman with type 2 diabetes, hypertension, and mild heart failure. Her glycemic control is consistently suboptimal (A1C = 7.9%) despite taking metformin 1000 mg twice daily and glyburide 10 mg daily for a few months. Today, MJ comes to pick up her refills and begins to discuss her diabetes control with you. She reports taking her medications daily and that gaining better control of her diabetes is a priority to her, but states, “I am not ready to start injecting myself and prefer to stick to pills.” Her provider would like to initiate a third agent.

What options are available to MJ?

ANSWERS

Case 1 Answer: Beta blockers are the first-line therapy for the medical treatment of angina, however, like many patients with respiratory disease, he was unable to tolerate this therapy. Even the use of cardioselective beta blockers in patients with respiratory diseases may exacerbate symptoms, especially as the dose is increased, which can lead to the loss of cardioselectivity. Guidelines suggest the use of a calcium-channel blocker when a beta blocker is contraindicated or causes adverse events, or in addition to a beta blocker when additional angina relief is needed. SD may benefit from the initiation of a calcium-channel blocker given his intolerance of other therapies. If after trying a calcium-channel blocker he still experiences residual angina symptoms, ranolazine may be added for its additional antianginal effects.

Case 2 Answer: Given MJ’s heart failure (pioglitazone may not be optimal due to fluid retention) and her opposition to injectable drugs at this time, the provider is left with a few options, including dipeptidyl peptidase-4 inhibitors and canagliflozin (Invokana), the first approved sodium glucose-2 (SGLT2) cotransporter inhibitor. SGLT2 is a carrier that facilitates reabsorption of glucose from the urine at the kidney; therefore, blocking SGLT2 enhances urinary glucose loss. As monotherapy, canagliflozin has been shown to lower A1C by 0.91% to 1.16%, and compared to sitaglitpin (100 mg) as add-on therapy to metformin and a sulfonylurea, canagliflozin (300 mg daily) appears to decrease A1C to a greater extent (~0.37%). Canagliflozin use is often associated with weight loss of 2.2 to 3.3kg, while sitagliptin generally has a neutral effect on body weight. Rates of hypoglycemia appear similar between the agents (40.7% with sitagliptin vs. 43.2% with canagliflozin). It is important to note, however, that cangliflozin has been found to be associated with an increased rate of urinary frequency, genital mycotic infections, and urinary tract infections compared to placebo. MJ will have to discuss the trade-off between increased efficacy with canagliflozin and its possible adverse events with her provider.

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Dr. Sobieraj is assistant professor of pharmacy practice and Dr. Coleman is associate professor of pharmacy practice and director of the pharmacoeconomics and outcomes studies group at the University of Connecticut School of Pharmacy.