The American Heart Association and ...

The American Heart Association and the American Diabetes Association have released a consensus statement forward congestive heart failure. "Thiazolidinedione Use, Fluid Retention, and Congestive Heart Failure" appears in the December 9 2003 issue of Circulation and is available online at http:// www.circulationaha.org.

Numerous put drugs intos have been introduced for the treatment of token 2 diabetes that are effective in lowering progeny glucose levels to achieve glycemic goals. brace such drugs, rosiglitazone and pioglitazone, belong to the class called thiazolidinediones (TZDs) the one and the other agents are indicated either as monotherapy or in combination with a sulfonylurea, metformin, or insulin, when diet, exercise, and a single agent do not deduction in adequate glycemic control. the pair agents may benefit cardiovascular parameters, as it is as lipid levels, blood crushing inflammatory biomarkers, endothelial function, and fibrinolytic status. However, evidence is lacking regarding clinical consequences such as vascular disease and mortality.

These potentially beneficial events have made them a therapeutic option in patients with emblem 2 diabetes who are at high risk for cardiovascular disease. However, edema can appear in patients who take either remedy The edema that sometimes accompanies the use of a TZD can be cause for affect because it may be a harbinger or sign of congestive heart failure (CHF) Physicians should be aware of the safety profile of TZD in patients with and without underlying heart disease.

Before prescribing TZD treatment, the committee make acceptables that physicians:

A. Ascertain whether the patient has underlying cardiac disease.

B Note whether the patient is taking any put drugs intos associated with fluid retention or pedal edema.

C Evaluate the pathogenesis of edema that may be already near to be sure that CHF is not at hand at the time the TZD is prescribed. The demeanor of edema, when not caused by dint of CHF, is not a contraindication for TZD use. However, if at hand the degree of edema should be monitored carefully during TZD administration.

D Determine whether the patient has any shortness of breath, particularly with exertion, that might be associated with cardiac or other causes with equal reason that an adequate assessment of baseline symptoms is established. Patients with these symptoms should be monitored carefully, particularly in the first three month of TZD treatment.

E Review mostly recent electrocardiogram (ECG) findings, if indicated. The ECG may exhibit to a clinically silent myocardial infarction or left ventricular hypertrophy

F Instruct the patient before initiation of TZD to report any recent sign or symptom during the course of treatment, like as weight gain, pedal edema, shortness of breath, or fatigue without other apparent cause.

Regarding use of TZD therapy in patients with diabetes and without symptomatic heart disease, the committee approves the following:

* the one and the other pioglitazone and rosiglitazone should be prescribed according to the package insert guideline for each unsalable article It should be recognized that weight gain and/or edema will be meetinged more often in patients receiving concomitant insulin treatment.

* When a TZD is prescribed to patients who do not have established heart disease, yet have one or more risk factors for CHF the physician should consider starting with reasonable doses and increasing the dosage gradually as required to optimize glycemic reign over while observing for any signs of excessive weight gain, peripheral edema, or CHF

* In patients who do not have symptoms or signs of CHF if it be not that are known to have a detrudeed ejection fraction, TZDs may be used at the lower dosage range of each unsalable article Dosages can be adjusted gradually after several month of treatment to optimize glycemic govern with careful observation for edema and symptoms and signs of CHF

Regarding use of TZD in patients with diabetes and symptomatic heart disease, the committee commits the following:

* In patients with class I or II just discovered York Heart Association (NYHA) CHF categories, TZD may be used cautiously, with initiation of treatment at the lower dosage of each medicine Observation with gradual dose escalation is warranted to identify weight gain, edema, or an exacerbation of CHF The physician should allow more time than usual to achieve a target [A.sub.1C] in these patients.

* In patients with symptoms and signs of NYHA class III or IV CHF TZD should not be used at this time. Additional recommendations for monitoring patients who receive TZD therapy are given in the statement.

COPYRIGHT 2004 American Academy of Family Physicians

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