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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.