|About half of the warp I'm working on now.|
Next of interest was an article about "Interventions to Improve Adherence to Self-administered Medications for Chronic Disease in the US." Big surprise: reduced out of pocket expenses, case management and patient education with behavioral support are useful. I think I have read other studies that found case management not helpful--even one that found it made mortality worse for (I'm pretty sure) COPD'ers and I think I have also read one study that found surprisingly that the co-pay did not make a difference to compliance (in this one study). I've never read that patient education has had a negative effect on compliance. At the back is an "In the Clinic" article about hep C. I didn't read it in any detail because the way I manage hep C is to get a hepatology consult. I know how to diagnosis, vaccinate and put in the consult request. That has been a successful strategy for me so far.
The final article of interest in the Annals (see what I mean?) was a review of "Comparative Effectiveness of Warfarin and New Oral Anticoagulants for the Management of A Fib and Venous Thromboembolism." So, you may not know that Warfarin stands for Wisconsin Alumni Research Fund (arin added to the end). I did med school in Minnesota, you see. So, the New Oral Anticoagulants (NOAC) are in one of two classes: factor Xa inhibitors or direct thrombin antagonists. Thrombin antagonists' names end in -agatran and there is only one on the market right now, dabagatran. Ximelagatran was taken off the market due to liver toxicity. Factor Xa inhibitors' names end in -xaban. There are four, only two of which I had heard, apixaban, rivaroxaban, edoxaban and betrixaban. It's kind of easy to remember which is which because direct Thrombin inhibitors are the agaTrans and factor Xa inhibitors are the Xabans. The direct thrombin inhibitors may not be all that important to remember because the only one left is being evaluated by the FDA for reports of excessive bleeding especially in elderly and renally impaired patients. Anyway, for Afib, the conglomeration of the evidence slightly favors but with a bar crossing 1.0 NOACs (0.78 to 1.02), best estimate 0.89. For venous thrombo embolism, the range is 0.48 to 2.10 for the risk ratio, best estimate 1.0. For adverse effects of fatal bleeding and major bleeding, NOACs were superior. For GI bleeding, warfarin was superior. With respect to MIs, factor Xa inhibs appear to be about equivalent to warfarin and direct thrombin inhibitors appear to be associated with MIs. People on factor Xa inhibs were about as likely to discontinue the med as people on warfarin due to side effects, but people on direct thrombin inhibitors were more likely. It looks like they are all about equivalent for LFTs greater than 3x the upper limit or normal. It also appears that the studies that showed bigger benefits for NOACs had worse control of the INR in the warfarin arm (not surprisingly).
As for news of the previously leukemic body, I was a little bit sore from yesterday's exertions so I decided to take today off from the gym. I am looking forward to Planet Fitness tomorrow. I also have my second opinion date: January 2. I may have mentioned that I have to see pulmonary too and am working on getting that set up (the reason is that my CT scan is still not normal. Every time we look, it's abnormal in a different way so I'm thinking none of it can be too bad. John thinks it is probably post-chemo stuff. I was very happy to see the nodules go away, speaking of screening for lung cancer).
|I haven't barfed in 48 hours. My family is so proud of me.|
For me, I am hoping for a restorative night's sleep. For you, restorative sleep is not a bad thing either.