Welcome to qMonthly, a blog written by Dr. Mike Fralick edited by Katarina Zorcic. Mike is a general internist at Sinai Health in Toronto and The Sault Area Hospital in Sault Ste Marie and a Deputy Editor with NEJM Evidence.
The headliner: Semaglutide reduces osteoarthritis pain in adults with obesity and knee osteoarthritis.
Unless you’ve been living under a rock, you’ve heard of semaglutide. This GLP1 analogue, better known as Ozempic, leads to a 10% drop in body weight, an 8 mmHG reduction in blood pressure, and a 1% drop in A1C. Large-scale trials have shown it also reduces a person’s risk of heart attack, stroke, or death from CV causes in both diabetes and obesity. Enter this new trial that aimed to assess its ability to reduce OA-related knee pain. The clinical trial included 407 patients who were randomized to semaglutide versus placebo and followed for 68 weeks. Patients who received semaglutide had a 42 point reduction in their OA-related knee pain. Remember, knee replacement generally reduces pain by 30 points! Side effects included what you would expect with semaglutide: nausea, vomiting, diarrhea. These results add another reason to recommend semaglutide in adults who are obese.
The hidden gem: For adults with stable CAD, should aspirin be continued or held pre-operatively?
Anyone who has spent time in a pre-operative clinic knows this is a common question that comes up. Like most of peri-operative medicine, the decision-making for what to do in this scenario is based on expert opinion (i.e., the lowest possible quality of data). However, we now have data from a randomized trial to inform decision-making here. The ASSURE-DES randomized 1000 adults with upcoming non-cardiac surgery and a drug eluting stent more than 1 year prior to either continue aspirin or stop aspirin. The most common type of surgery was intraabdominal (40%) followed by orthopedic (25%) and genitourinary (19%). The primary outcome was a composite of death from any causes, MI, stent thrombosis, or stroke, and was nearly identical in the two groups (difference -0.2%, 95% CI -1.3 to 0.9). The secondary outcome of major bleeding was slightly higher and the risk of minor bleeding was markedly higher among those who were randomized to continue ASA. Two main caveats with this trial. The overall event rate was low, so we should take these results with a small grain of salt. Second, most patients had their DES inserted more than 4 years ago.
The take home points:
[1] If your patient has obesity and associated knee osteoarthritis, semaglutide will markedly reduce their knee pain.
[2] For patients on ASA and a drug eluting stent that is at least 1-year old, it’s likely safer to stop their aspirin before their upcoming non-cardiac surgery.
Summary Table
| STEP-9 | ASSURE DES | |
|---|---|---|
| TLDR | In individuals with obesity and knee osteoarthritis, once-weekly injections of semaglutide led to significantly greater reductions in body weight and knee pain compared to placebo. | In stable patients with prior coronary stenting undergoing noncardiac surgery, discontinuation of aspirin was safe (i.e., no increased stroke, MI) and associated with less bleeding. |
| Research Question | Does treatment with once-weekly injectable semaglutide result in greater reductions in body weight and knee osteoarthritis-related pain compared to a placebo in individuals with obesity? | In stable patients with a history of coronary stenting, does continuing aspirin monotherapy before noncardiac surgery reduce the risk of adverse cardiac events compared to temporarily holding all antiplatelet therapy? |
| Population | Key inclusion criteria:
Key exclusion criteria:
|
Inclusion criteria:
Exclusion criteria:
|
| Intervention | Once-weekly semaglutide (2.4 mg) | Continuation of aspirin monotherapy |
| Comparator | Once-weekly placebo injections | Discontinuation of all antiplatelet therapy |
| Primary Outcome | % change in body weight and the change WOMAC pain score from baseline to week 68 | Composite of death from any cause, myocardial infarction, stent thrombosis, or stroke between 5 days before and 30 days after noncardiac surgery |