n Individual response to bP meds Shows “Substantial” Variation (continued)

events. Each participant was scheduled for 2 months’ treatment in random order with each of four different classes of antihypertensive drugs:

 an angiotensin-converting enzyme (ACE) inhibitor, lisinopril

 an angiotensin II blocker, candesartan

 a thiazide diuretic, hydrochlorothiazide

 a calcium channel blocker, amlodipine

Taking into consideration that lisinopril was found to be on average the most efficacious of the drugs at the selected doses, personalized treatment compared with lisinopril still led to a 3.1 mm Hg improvement in systolic blood pressure. The researchers note that the mean additional blood pressure reduction achievable by using the optimal agent was of a magnitude twice that achieved by doubling the dose of a first drug, and more than half that of adding a second drug on average. While there were only small differences between certain drugs (e.g., candesartan vs lisinopril; amlodipine vs hydrochlorothiazide), for all other comparisons tested, the choice was important, with particularly large gains to be made by personalizing the choice between candesartan vs amlodipine and between lisinopril vs amlodipine. Some people showed very large differences in response to different drugs, whereas others did not have much difference at all.

To identify the best drug for each individual patient two approaches were discussed. In the study, the researchers suggest that personalizing therapy could be achieved either by identifying the phenotypic characteristics that are associated with enhanced response to one treatment vs another or by directly measuring the individual’s responses to a series of treatments to ascertain which is most effective. Sundström explained, “We can analyze the characteristics of patients who did best on each drug. There are many variables we can look at here such as age, diet, baseline blood pressure, exercise levels, smoking status, race, body weight, salt intake, and findings from genetic tests. We are going to try to look into these to see if we can find any predictors of response to various different drugs.” A second strategy, he suggested is that patients starting pharmacologic therapy could try a few different treatments. “For example, we could give patients two different drugs and ask them to alternate treatment periods with each of them and measure their blood pressure with a home monitoring kit and record adverse effects.” Nonadherence “is such a big problem with antihypertensives,” he added. “This approach may allow patients to be more empowered [when choosing] the right treatment, which should help adherence in the longer term.”

Commenting on the study in an accompanying editorial, Robert Carey, MD University of Virginia Health System, Charlottesville, writes: “At this stage, the findings are more theoretical than immediately practical for the implementation of personalized antihypertensive drug therapy, but the study does provide proof-of-principle and the authors suggest a few scenarios in which a personalized approach could be used in the future.” He believes the practical ramifications of personally targeted therapy remain unclear, given that determination of an individual’s response to a series of short test treatments before selecting long-term therapy may be considered too cumbersome, and currently few phenotypic markers are currently available that would be likely to accurately predict the individual response to a particular therapy.

Carey concludes that the results of this study “encourage the further pursuit of larger randomized trials using similar repeated crossover designs to validate this concept and eventually in trials with longer follow-up data to determine whether there is improvement in long-term clinical outcomes compared with current strategies.” He adds that the results also support the possibility that personalized medical treatment of hypertension “may ultimately supplement or even supplant the current method of antihypertensive drug decision-making in the future.”

The study was published April 2023 in the Journal of the American Medical Association and can be accessed through this link: https:// jamanetwork.com/journals/jama/article-abstract/2803518.

n Celiac Disease Clinical Practice Guidelines (ACG, 2023)

n American College of Gastroenterology. (2023, March 2) https://reference. medscape.com/viewarticle/988963

Below are recently published guidelines for the diagnosis and management of celiac disease by the American College of Gastroenterology (ACG) in https://journals.lww.com/ajg/Fulltext/2023/01000/American_ College_of_Gastroenterology_Guidelines.17.aspx

 Esophagogastroduodenoscopy (EGD) with multiple duodenal biopsies is recommended for confirmation of diagnosis in both children and adults suspected to have celiac disease (CD).

 Combination of high-level tissue transglutaminase (TTG) IgA (>10× upper limit of normal) with a positive endomysial antibody (EMA) in a second blood sample is a reliable test for diagnosing CD in children.

 Intestinal healing is recommended as the goal of gluten-free diet (GFD) therapy in CD patients.

 Use of gluten detection devices in food or biospecimens among patients with CD is not recommended.

 Consumption of gluten-free oats in the diet of those with CD is recommended.

 Vaccination to prevent pneumococcal disease is recommended in patients with CD.

 Immunoglobulin IgA anti-TTG antibody (TTG-IgA) is the preferred single test for the detection of CD in children younger than 2 years who are not IgA-deficient.

 Testing for CD in children with IgA deficiency should be performed using IgG-based antibodies.