Anil Makam

The Pros and Cons of the Latest FDA Actions on COVID Vaccines In case you missed it, last week the FDA granted full approval for the Novavax COVID-19 vaccine. This vaccine, which uses a more traditional protein-plus-adjuvant strategy instead of the mRNA approach...

Recent FDA actions on Covid vaccines:
1. Novavax approved (👏)
2. Narrowed indications for all (pros and cons)
3. Called for clinical trials (👍)
No doubt we're relying too much on old data to inform clinical practice. Some thoughts on what we gain… and what we risk. blogs.jwatch.org/hiv-id-obser...

Medicaid Patients with Type 2 Diabetes Face Hurdles Getting Cardioprotective Meds Medicaid Patients with Type 2 Diabetes Face Hurdles Getting Cardioprotective Meds sciprian@crf.org Fri, 04/25/2025 - 16:56 Michael O'Riordan SGLT2 inhibitors and GLP-1 agonists are class 1 medications, but many Medicaid patients have challenges with access.

Medicaid Patients with Type 2 Diabetes Face Hurdles Getting Cardioprotective Meds

Agree for commercial insurance or Medicare

Too expensive within Medicaid

If there is one clinical driver of practice and it's not accounted for in any analysis I can't in any confidence trust the observational comparative effectiveness

Other than the rate of ODS is very very low which is most important part of evidence base

No, it does

It's just pseudo random but may correlate with other practice patterns and serve as a marker

FWIW I do fast correction for most

And if they live in low 120s from chronic badness I don't bother fixing it unless underlying issues fixable

Remains the sole clinical driver of speed

Rest is practice variation

Can't omit it and trust evidence at all

None of these adjust for chronicity

It's the major confounded here between an acute episodic thing vs chronic badness

Availability of Cardioprotective Medications for Type 2 Diabetes in the Medicaid Program | Annals of Internal Medicine Background: Sodium–glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are the only type 2 diabetes medications that reduce cardiovascular disease an...

🚨New Study in Annals🚨

GLP1ra & SGLT2i are the only diabetes meds that reduce heart attacks & death

But can't work if can't prescribe

TLDR

40% Medicaid enrollees have restricted access to GLP1 & 25% to SGLT2i

much state/plan variability

GLP access plateaued in '22

bit.ly/3Y72K2z

Copied from my Twitter thread:

NOW WHAT?

removing restrictions would improve access w/o step therapy (which makes no sense here) or prior auth

But $$$ is a real concern

Here is our pitch why may be less of an issue in Medicaid

AND

Restricting DPP4i instead of GLP/SGLT can offset some costs

Availability of Cardioprotective Medications for Type 2 Diabetes in the Medicaid Program | Annals of Internal Medicine Background: Sodium–glucose cotransporter-2 inhibitors (SGLT2is) and glucagon-like peptide-1 receptor agonists (GLP-1 RAs) are the only type 2 diabetes medications that reduce cardiovascular disease an...

🚨New Study in Annals🚨

GLP1ra & SGLT2i are the only diabetes meds that reduce heart attacks & death

But can't work if can't prescribe

TLDR

40% Medicaid enrollees have restricted access to GLP1 & 25% to SGLT2i

much state/plan variability

GLP access plateaued in '22

bit.ly/3Y72K2z

Shared without comment.

This was inspired by an amazing study that I did a very popular Twitter thread on

x.com/AnilMakam/st...

Text in pictures

Link here
papers.ssrn.com/sol3/papers....

This matters because different skills translates to different probabilities for the same patient

A key take home is that Doctors are unique diagnosticians

There is NO single 'doctor' with fixed abilities

What this means is that doctors can be the "master of their ROC" and strive for diagnostic excellence in both ruling in AND ruling out badness

I've been thinking more and more about evidence-based diagnosis

Penned this piece with Gurpreet & Oanh on the SSRN preprint server titled:

Striving for Diagnostic Excellence: "The Median Is Not the Message"

Tell me what you think

Agree. Not enjoyable so far. Place is great if you like echo chambers, especially ones that celebrate an assassination because of the industry. Thought the selling point was more sanity and compassion? Will lurk time to time to see if gets better, but find me at the other place

0. HTN is mostly a risk factor, not a disease. Decide whether benefits>risks and life expectancy >2 years.

For many I see #1-10 won't matter

LRs & references?

Likely poor LR- with these sensitivities

They are part of risk stratification scores for mortality

May not exclude any PE but may exclude PEs of clinical significance

With ubiquity of modern imaging, a lot more "PEs" so may differentiate better then VQ scan days

Just ask them if would they recommend a rate of correction without knowing chronicity

Glad the kidney community recognizes it

I'd take a well done case series with proper accounting of risks (not saying they are since i havent reviewed em) than a horribly confounded uninterpretable mess, even if 25k people

Well done science of lower study design always better

Network effects may change and willing to see

But more importantly

Meta analyzing studies that don't consider chronicity of hypoNa is a mess

I thought nephrologists would care more about such things

Although he is similarly wrong on both platforms :)

Better thinkers & discussion on the other

Not a great example

Experts at UCSF presented hydroxychloroquine as a treatment to consider

30-50% of patients at leading academic medical centers were prescribed it during the same time

Oz and Trump were not writing the Rx

Here. But really there