Diabetes Care 12/23/09 – “Insulin is the most effective hypoglycemic agent in our treatment armamentarium and is now recommended by the American Diabetes Association (ADA) guidelines as the second agent added after metformin” (FTA). Despite this fact (or because some of us were unaware of this guideline), physicians often prefer to max out that second and third oral medication before turning to insulin. An article in Diabetes Care looks at a comparison between a three drug regimen and insulin + metformin for newly diagnosed DM.
The study compared 2 groups of 29 subjects that were newly diagnosed diabetics (not a very large study). All patients had a 3 month lead-in with insulin (novolog 70/30 bk, ln) and metformin. The lead-in ensured that all subjects had controlled blood sugar when starting the comparison phase, and all were exposed to insulin administration. Subjects were then randomized to receive metformin + glyburide + pioglitazone or to continue metformin and insulin. Groups were compared on A1C, Quality of Life, and treatment satisfaction.
They found that A1C was similar in both treatment groups. But I think the other endpoints were just as, if not more important to the relevance of the study. Weight gain, quality of life, and compliance are major factors that sway physician and patient choices on when to start insulin.
The study showed that the weight difference was not significant in the 2 groups – however looking at the raw numbers weight increased by about 4kg in the insulin group and about 7kg in the oral group. This seems like a big difference to me to end up being statistically insignificant. The CI was 0.89 – 8.04kg so I really wonder if the study was adequately powered to look at this. QoL and patient satisfaction were similar in the 2 groups, however I wonder if the patients that really had a problem with insulin were lost during the lead-in period. No information was provided about drop out during the lead-in time and the study ends up being selective for those patients that tolerated a 3 month period on insulin and agreed to enter the study, so I think there is a selection bias going on here.
Overall I think the study shows for those patients with new onset DM that need initial insulin to get them under control, there is little point to switching them back to orals if they are going to require 3 medications. The more perplexing scenario, however, is those patients that the physician believes does not necessarily need insulin as initial therapy but for which insulin or triple oral therapy may be options. And this study does not really address that because all patients were put on insulin for 3 months prior to study onset.
Diabetes Care October 2009 vol. 32 no. 10 1789-1795
JAMA 8/19/09 – In case the Gardasil vaccine wasn’t already surrounded by enough controversy – now there is concern over its safety profile and the marketing practices of Merk. An article in JAMA presents the safety surveillance data for qHPV, finding that “Most of the AEFI rates were not greater than the background rates compared with other vaccines, but there was disproportional reporting of syncope and venous thromboembolic events”
An accompanying editorial discusses the extensive marketing to and through medical professional organizations via the use of manufacturer – designed educational matierials (i.e. brochures, posters, etc)
Some of the adverse event rates can sound pretty scary, especially the 32 reports of death and the elevated rates of VTE. But there are big problems with the use of VAERS data to assess risk because the reporting comes from a variety of sources, with differing levels of detail and its hard to take away any understanding of causation at all. For example 90% of the patients with VTE had at least one other risk factor. It would be great to rely solely on the controlled safety trial data but they will never have the raw numbers to catch rare events that is found with broad observational data.
The other issue with Gardasil is that there are still many unanswered questions about efficacy. It is unclear what impact this will truly have on cervical cancer rates for many reasons. First, the duration of immunity is unclear. Second, there are several oncogenic strains of HPV that are not covered in the vaccine. And third, proper routine screening is readily available and significantly decreases the risk of developing cervical cancer. Just the fact that screening still has to be done regardless of vaccination status is going to make patients wonder about the point of even getting the vaccine.
All of this seems to add up to many potentially difficult conversations with parents to try to address in the context of a 15-minute office visit – but I’m pretty used to running behind at this point….
NEJM 3/26/09 – The NICE-SUGAR investigators published the latest of several trials that show no benefit to intensive glucose control (see meta-analysis). In fact, this study shows increased mortality from tight gylcemic control in the ICU.
This appears to be a well done study – over 6,000 subjects, multicenter, both medical and surgical patients, 90-day follow up. Withdrawals were slightly higher in the treatment arm (10 vs 7 percent) but intent-to-treat analysis was used. Insulin use was non-blinded.
So should the intensive glucose control protocol be shelved next to blood-letting and COX-2 inhibitors?
What could be crazy enough to end a 4 month hibernation of CTE?
Archives Int Med 4/08 – The UCSD Statin study yielded further evidence that statin treatment reduces blood pressure (although not by much) The RCT enrolled over 900 subjects without known CVD or diabetes. The idea was to independently assess the effect on BP. There was no inclusion / exclusion criteria regarding baseline BP. Subjects were randomized to pravastatin, simvastatin, or placebo.
Treatment with a statin resulted in about a 2-2.5 point drop in SBP and DBP. The treatment was stopped at 6 months, and the blood pressures returned to baseline by month 8 – further suggesting that this was a true effect.
JAMA 12/5/07 – House of God Law #13: “The delivery of good medical care is to do as much nothing as possible.” The last time we saw this rule at work was with otitis media.
A study in JAMA by Williamson et al. sought to see just what good comes from the common practice of prescribing antibiotics and nasal steroids for acute bacterial sinusitis. The study included 240 patients seen by family practitioners in the UK. To be included, the patients had to have 2 or more of the classic clinical diagnostic criteria. No radiology or lab studies were used in diagnosis.
Treatment groups were randomized to receive either antibiotics and nasal steroids, a placebo of one plus the other, or a placebo of both. Patients kept symptom diaries to track outcome.
The findings showed that symptom severity scores were similar for all groups on each of the 10 days following initiation of treatment. In short – symptoms improved by day 10, and at the same rate, regardless of whether the patient received antibiotics and/or steroids vs placebo. The hard part is now to convince patients that they dont need either.
Interestingly – the study does mention the Cochrane review on this subject which DID find a treatment effect for both antibiotics and steroids. However, they point out that the studies included in the review used radiographic evidence as diagnostic criteria – which does not commonly happen in the community. (And the utility of which is whole other bag of worms that will have to be covered another day)
NEJM – The latest issue contains a study and two editorial articles on the link between Thimerosal and neuropsychological dysfuntion such as autism. Short story – there is no connection. However, I think the need to find somewhere to place blame will cause many families to continue believing that there is some sort of cover-up no matter how many studies are produced.
NEJM 7/26 – Not an original research article, but a worthwhile read. An article by Daum reviews skin and soft tissue MRSA infection in the Clinical Practice section of the current NEJM. An increasingly common issue for which a refresher is always helpful – I thought the paper was so solid it deserved a mention anyway.
Daum, RS. Clinical practice. Skin and soft-tissue infections caused by methicillin-resistant Staphylococcus aureus. N Engl J Med. 2007 Jul 26;357(4):380-90. Review. PMID: 17652653
JAMA 7/4/07 – Maybe some wizard medicine applies to muggles as well… An article in JAMA by Taubert et al. tests the theory that flavonols found in dark chocolate may lower blood pressure.
The study population consisted of 44 otherwise healthy subjects with upper-range prehypertension or stage 1 hypertension. Patients with any other major medical problems including CVD, diabetes, hyperlipidemia, etc were excluded. Study design was an RCT with investigators blinded, but subjects not – because they couldnt disguise the white and the dark chocolate. Patients were also counseled to abstain from any other cocoa products during the study. Participants were instructed to take one 5.6(white) or 6.3(dark) gram piece of chocolate per day.
At 6 weeks – no statistical difference between groups.
12 weeks: dark chocolate group BP was down 2.4/1.3 mmHg from baseline.
At 18 weeks the BP difference in the dark chocolate group was – 2.9/1.9 mmHg.
The white chocolate group: no change.
Looks like we have a winner.
For the basic science portion of the study, researchers measured plasma S-nitrosoglutathione. Basically they postulate that this compound is an intermediary between nitric oxide stores and active NO in the endothelium. They also measured 8-isoprostane, a measure of oxidative stress. Levels of S-nitrosoglutathione were significantly increased only in the dark chocolate group. 8-isoprostane levels were unchanged with intervention in both groups. Investigators concluded that the effect of dark chocolate was more likley from stimulation of endothelial NO production rather than changes in redox equilibrium between thiol and nitrosothiols. Big words aside – it seemed to work… at least in a healthy, homogenous, untreated population with mild HTN – although I dont seem to have alot of those in my practice….
ArchivesIM 6/25 – The current issue contains a pair of articles that make a connection between SSRI use and bone mineral density (BMD). The pair of observational studies by Diem et al. and Haney et al. seperately studied a cohort of men and women respectively. The study involving women showed a greater yearly decrease in BMD when compared to nonusers as well as trazodone and TCA users. The study of men simply showed overall lower mean BMD associated with SSRIs as well with no effect seen from TCAs. Obviously both studies suffer from the typical observational methodology pitfalls – but definitely merit further investigation. The main question to be answered is whether this effect translates into a greater clinical risk of fracture or other negative outcomes. Given the large burden of both depression and osteopenia in the elderly, clearly the interaction needs further study.
NEJM 5/17/07- I can’t help but wonder if this is a “welcome mat for new drug cocktail” study. Papi et al in the BEST study group publish a paper showing that using a steroid inhaler on an as-needed basis might be just as good as twice daily use.
The double-blind, double dummy design seems pretty robust, although makes the data a little complicated. In short – all subjects took a regular inhaler twice daily, plus an as-needed inhaler – the design just varied what was in the inhalers among groups. The most relevant comparison was – twice daily beclamethasone plus rescue albuterol (old skool method) versus twice daily placebo and rescue beclamethasone and albuterol combo.
It looks as if using a PRN steroid was just as good as the old twice daily method. The money graph seems to show that time to first exacerbation was the same in both groups and clearly better than albuterol rescue alone. Frankly the comparisons of PFTs and symptom scores got a little too crazy for me to handle but a cursory look seems to confirm the equivalence in most comparisons.
Any guesses as to what new combo inhaler we might be seeing soon? Check out the laundry list of financial disclosures at the end – Im sure one of those companies is planning to cash in on this one.