Comparing approaches to diabetes screening

The Buzz: ADA guidelines outperform the updated USPSTF approach to screening for diabetes

Citation: A Sheehy et. al. Analysis of Guidelines for Screening Diabetes Mellitus un an Ambulatory Population.  Mayo Clinic Proc. January 2010; 85(1):27-35

Summary: Of the estimated 25 million Americans currently with diabetes, approximately 40% continue to be undiagnosed, and determining the most effective screening method may prevent significant morbidity and mortality. Currently, the American Diabetes Association (ADA) and the US Preventative Services Task Force (USPSTF) have issued vastly different guidelines for screening for diabetes. This retrospective study included 28,842 patients from a large, Midwestern primary care practice, comparing the performance of both approaches to screening. The study found that adhering to USPSTF guidelines would have identified 33% fewer new cases of diabetes, and the authors recommended using the ADA guidelines due to their superior performance. One caveat is the population of patients under 45 who are non-obese with hypertension, for whom the USPSTF recommends screening and the ADA guidelines do not. Study authors point out this is an important group to screen as well.  The study also found that a history of pre-diabetes or polycystic ovarian syndrome conferred the highest risks for developing diabetes.

Commentary: This study suggests we combine USPSTF and ADA guidelines in an effort to identify more cases of diabetes.

By: Maxwell Jen, MSIII & Spencer Blackman, MD

New study assesses risk-reduction of mammography

The Buzz: A novel study from Norway suggests that risk reduction from mammography may be much lower than previously thought.
Citation: M Kalager et. al. Effect of Screening Mammography on Breast-Cancer Mortality in Norway.  N Engl J Med 2010; 363:1203-1210

Summary: Previous observational attempts to quantify the benefit of mammography have relied on historical data for control groups, making it difficult to control for the effect that time (increased breast cancer awareness, better treatment methods, e.g.) may have on improvement in breast cancer survival. Norway has a national public health system which rolled out a program for breast cancer screening (mammography every 2 years for women aged 50-69) and treatment (multidisciplinary treatment teams offered to all women with a new diagnosis of breast cancer) staggered region by region from 1996 to 2005. Using data from 40,075 women, this study compared similar groups in counties where the new program simultaneously was and was not available, thus eliminating possible confounding effects of time.  The study also looked at geographically matched groups from 1986-1995 when the new program was not available. Absolute risk reduction from the combined screening and treatment program in women 50-69 years old was found to be 10%, though it was not possible to say how much of the benefit was from mammography itself.

To address this question, the study included analysis of women aged 70-84 who did not undergo mammography but who were treated by the new teams. In this group, the benefit of the new treatment teams was an 8% reduction in risk.

According to an accompanying editorial, these data suggest that "2500 women would need to be screened over a 10-year period for 1 to avoid death from breast cancer." Moreover, of those 2500, 1000 would be expected to have a false positive on mammography, and 5 to 15 would be wrongly diagnosed and treated. The editor suggests that the decision to initiate or continue screening mammography might be best decided by an informed patient, and that its use should not be a measure of quality in our current health care system.
By: Spencer Blackman MD

Time 2 take ur pill

The Buzz: Text message-based reminder system for OCP use does not seem to improve adherence.
Citation: Hou MY et al. Using daily text-message reminders to improve adherence with oral contraceptives: A randomized controlled trial. Obstet Gynecol 2010 Sep; 116:633.
Summary: Study authors randomized 82 predominantly white, all high-school graduate new or resuming OCP users to to receive daily text-message reminders or no reminders for three cycles. The number of missed pills per cycle was the same in both groups (around 4.5/month). There were no pregnancies in either group.
Commentary: The high rate of missed pills reported in this study suggests that even with advanced reminder systems, many women on OCPs are at higher risk for pregnancy then we might think. OCPs are still a valid option, but this study may aid in shared decision-making around optimal methods.  
By: Spencer Blackman MD

Rosiglitazone (Avandia) and increased risk of CV events

The Buzz: FDA advisory committees recommend removing rosiglitazone
Citation: AAFP News Now, 7/20/2010
Summary: Members of two FDA advisory committees have expressed concerns over the safety of rosiglitazone (Avandia) and have recommended removing the medication from the list of approved drugs. While investigation into the safety of rosiglitazone has been ongoing since 2007, two recent studies from JAMA and the Archives of Internal Medicine
reported significant elevation in CV risk associated with its use. Of note, GlaxoSmithKline, the maker of Avandia, has said that it will record a $2.36 billion legal charge in the second quarter of fiscal year 2010 for settlements related to rosiglitazone.
Commentary: While FDA has yet to make a decision, we should consider getting our patients off rosiglitazone, and certainly not write new prescriptions for it. Pioglitazone (Actos) is considered safer than rosiglitazone, though it should be considered only in patients refractory to or intolerant of first- and second-line therapies.
By: Spencer Blackman MD

UPDATE (9/25/2010): Rosiglitazone has been pulled from the European market, and will only be offered to US patients in whom "every other" diabetes medication has been tried.

Update on guidelines for osteoporosis screening

The Buzz:  Our models for osteoporosis screening are not as robust as we might think.

Citation:  “Screening for Osteoporosis:  An Update for the U.S. Preventive Services Task Force”.  Annals of Internal Medicine. 153 (2); July 20, 2010. 99-111.

Summary:  In 2002, USPSTF recommended bone density testing for women 65 or older, as well as women 60-64 with increased risk for fractures.  No recommendation was made for or against screening other women or men. This review article updates the evidence since their 2002 USPSTF guidelines. Key comments include: 

• No trials exist to establish the effectiveness and harms of osteoporosis screening in decreasing fractures, morbidity or mortality .
• The  Osteoporosis Self-Assessment Screening Tool (OST), based only on age & weight, is the simplest tool for risk stratification.  While more complex models have been validated, no model has been shown to be superior to another.
• Only 2 good quality trials evaluated DEXA scans in men and found comparable results to those in women. 
• Calcaneal Quantitative Ultrasonography (QUS) can predict fractures of femoral neck, hip and spine, but variation exists across studies and correlation with DEXA is low.
• Only 1 study evaluated the optimum screening interval for osteoporosis. Using a cohort of post-menopausal women, it found that repeating BMD up to 8 years after the initial screening did not significantly improve risk estimates for fractures.
• For women, bisphosphonates (such as alendronate, etc), parathyroid hormone (PTH), raloxifine and estrogen decreased the risk of vertebral fractures.  Bisphosphonates decreased the risk of non-vertebral fractures.  Medications were shown to be effective in patients whose BMD was -2.5 or less.   BMD > -2.5 showed a trend of decreasing risk, but was not found to be statistically significant.
• For men, only 1 study evaluated effectiveness of a medication, PTH, and found that  PTH was associated with a trend towards decreasing fractures, but was not found to be statistically significant.
• Case reports have linked serious GI events, atrial fibrillation, osteonecrosis of the jaw, severe musculoskeletal pain, and esophageal adenocarcinoma to use of bisphosphonates.  However, when the data for these adverse events were examined, the association was tentative.
• Raloxifine and estrogen have been shown to increase thromboembolic events.  Estrogen increases the risk of stroke.  Estrogen with progestin increases the risk of coronary heart disease as well as breast cancer. 

 Commentary:  No direct evidence exists that screening for osteoporosis actually improves outcomes, although indirect evidence suggests a benefit.  

By: Jennifer Young, MD

Should we use aggressive medical treatment to stop the progression of diabetic retinopathy?

The Buzz: In type 2 diabetics, intensive glucose and lipid control (but not intensive BP control) prevents the progression of diabetic retinopathy (DR), but the approach may harm more patients than it benefits.
Citation: NEJM 363;3 July 15, 2010
Summary: As part of a sub-study of the large multi-center RCT ACCORD trial, researchers evaluated 10,251 diabetic patients randomly assigned to intensive (A1c < 6.0%) vs standard therapy (A1c < 7.0-7.9%), and were followed to monitor progression of DR, including the need for laser surgery or vitrectomy. Decreased rates of progression of DR were seen in the intensive glucose (7.3 vs 10.4%, P = 0.003) and lipid (6.5 vs 10.2%, P = 0.006) groups, but not the intensive BP group (10.4 vs 8.8%, P = 0.29). However, the trial was halted early, and a large portion of patients with higher LDL levels and alb/creat scores and lower visual acuity scores did not receive 4 year follow-up.

Commentary: These findings need to be interpreted in conjunction with the ACCORD trial, since DR is only one CV endpoint that is seen in diabetics.  In fact, the trial was stopped early when results suggested intensive glucose lowering was found to have no benefit in MI/CVA prevention and increased all-cause mortality. These findings were not replicated in the newer ADVANCE trial, which used different glucose lowering agents.  However, despite this newer trial and the benefit seen in DR, it is likely most prudent to maintain an A1c goal of 7.0-7.9%. In addition, this study suggests adding fenofibrate therapy to a statin may be useful to slow DR progression, particularly if the patient is male and has high trigylcerides or low HDL, as CV risk reduction with fenofibrate was found in these subsets.

By: Elizabeth Haskins, MD

Dietary sugar intake and risk of hypertension

The Buzz: Could the rise in rates of hypertension in industrialized nations be correlated with excess dietary sugar? 

Citation: Journal of American Society of Nephrology 21: 2010, “Increased Fructose Associates with Elevated Blood Pressure.” 

Summary: The prevalence of hypertension has risen dramatically in the last century, going from 5-10% of the population in at the turn of the century, to approximately 31% of the adult population today.  Consumption of dietary sugar has also spiked, though the two have been inconsistently linked. To further investigate that connection, this cross-sectional analysis used data from 4528 adults without history of hypertension participating in  the National Health and Nutrition Examination Survey (NHANES 2003-2006), reporting  that consumption of excess sugar equivalent of  2.5 soft drinks per day was “independently and significantly associated with higher odds of elevated blood pressure (odds ratio 2.10; 95% CI 1.20 to 3.61).”  Speculated mechanisms included stimulation of the sympathetic nervous system, inhibition of endothelial nitric oxide synthase activity, and stimulation of uric acid. Study authors noted a few limitations, mainly that cause-effect relationships cannot be deduced from cross-sectional analysis and that self-reporting of consumption could have led to mis-classification or under-reporting.  However, the large sample of participants was representative of the US adult population and researchers made attempts to isolate the impact of fructose intake by controlling for a large number of confounding factors. 

Commentary: This research provides more weight to the suggestion that added sugars have a deleterious effect on cardiovascular health. 

By: Jeannie Bianchi, L.Ac.

Controversy Alert: Statins for Primary Prevention of CVD

The Buzz: Should statins be used to prevent CVD in patients without known disease? 
Citation: Arch Intern Med 170:12 June 20, 2010 
Summary: Three quarters of the patients who are taking statins are using them for primary prevention, i.e. to delay or prevent the onset of atherosclerosis and to reduce the incidence of heart attacks, strokes and other sequelae. The debate over the evidence for this use has been simmering for some time, and a recent issue of Archives of Internal Medicine presents two new papers which add significant fuel to the fire.

The first, by Ray et al, is a meta-analysis of 11 RCTs involving 65,229 patients (including the recent JUPITER trial) which found no significant reduction in risk associated with the use of statins. The strengths of this study include its large size, exclusion of patients with known CVD, and apparent lack of authors' conflict of interest. However, the average period of follow-up among the studies included in the report was just 3.7 years, and it is possible that longer term use may confer additional benefit no found in this report, though evidence for this is lacking.

The second, by de Lorgeril et al, is an analysis of the 2008 JUPITER study, a controversial trial which was ended early after just two years and reported a significant reduction in CVD-related events with the use of rosuvastatin (Crestor). In this current reappraisal of JUPITER, the authors point out a number of serious flaws with the methodology and results, including:

• The premature termination of the JUPITER trial due to the "clear benefit" in the treatment arm was based on unclear criteria, and truncated trials have been shown to be associated with greater effect sizes than those which are not stopped early.
• Significant conflicts of interest existed in the JUPITER trial. It was sponsored by the makers of Crestor, 9 of 14 authors have financial ties to the sponsor, and the principle investigator is a co-holder of the patent for the CRP test, which would be used much more frequently if the results of the trial are to be believed.
• The all-cause mortality curves were converging when the trial was stopped, suggesting the difference between the two groups may have disappeared with more time
• The authors found a number of inconsistencies that suggested major limitations to the data set. For example, the number of participants who had an MI who died (the case-fatality rate) was extremely low in the study (5-18%) as compared to the expected rate of 40-50%. Moreover, treatment with rosuvastatin appeared to triple the case-fatality rate, an effect which does not seem credible.

The papers were accompanied by an editorial which concluded that "we do not know" if there is any benefit of statins in primary prevention of CVD.
Commentary: These papers call into serious question whether we should be prescribing statins to patients without known CVD, especially if it decreases the importance we place on improvements in lifestyle, including smoking cessation, exercise, and diet. 
By: Spencer Blackman, MD

Genetic test predicts lifespan? Not ready for prime time.

The Buzz: Researchers report a study identifying genetic markers for longevity
Citation: New York Times; July 2, 2010
Summary: A study published in this week's issue of Science reports the identification of genetic markers associated with living to 100, and claims a 77% acuracy rate. Researchers analyzed the DNA of 1,055 centenarians and identified a pattern of 150 genetic markers which seemed to confer longevity. They then looked at another group of centenarians and found 77% of them had the same pattern. While the study authors admit the biology behind these findings has yet to be explained, they feel this may be an importnat step towards understanding the genetics of longevity. Of special interest, the centenarians had equal numbers of disease-related genetic markers, suggesting these 150 may be protective factors that delay the onset of diseases of old age.
Commentary: The bottom line - this is simply a statistical analysis that correlates a certain genetic make-up with longevity. The test is not available to the general public and is likely not to be any time soon. But given the amount of press it is getting, understanding the implications, and lack thereof, may be helpful in talking to our patients.
By: Spencer Blackman MD

Avoid Nitrofurantoin and Sulfa for UTI in pregnancy

The Buzz: A recent study suggests nitrofurantoin (Macrobid) and sulfonamides (eg Bactrim) are teratogenic and should be avoided in pregnant and possibly-pregnant women. 
Citation: Journal of Family Practice: April 2010 · Vol. 59, No. 04: 220-222

Summary: Asymptomatic UTIs are routinely treated in pregnant women because of the risks to mother and fetus. The study reviewed here used data from the National Birth Defects Prevention Study and compared interviews with mothers of babies with 30 kinds of birth defects (n = 13,155) with matched controls (n = 4941) and found significantly increased risks for multiple birth defects associated with both drugs. While the study design risks errors due to recall bias, women who expressed uncertainty were excluded and the size of the study suggests the findings may be real. The authors recommend avoiding both medications and using 1st- or second-generation cephalosporins (cephalexin 500 mg bid x 3 days, cefpodoxime 100 mg bid x 3 days) first-line until culture results are in.

Commentary: Remember that pregnant women require a urine culture for test of cure 1-2 weeks after treatment ends. 

By: Lisa Mihaly NP

Homocysteine-lowering fails to prevent CV events

The Buzz: A new study published in JAMA provides further evidence against the use of folic acid & B12 to prevent cardiovascular events
Citation: JAMA. 2010;303(24):2486-2494.
Summary: Elevated homocysteine has been found to be associated with increased risk for cardiovascular events (MI, stroke, revascularization, death) but lowering homocysteine levels has not been shown to improve outcomes. This double-blind, placebo-controlled study followed 12,064 British survivors of MI over an average of 6.7 years and found no reduction in CVD events for those on the vitamins. This is consistent with a 2009 Cochrane meta-analysis which included people with and without known CVD.
Commentary: While the more recent study was funded my Merck, who makes cholesterol-lowering drugs, the results are consistent with previous data and suggest we should not be recommending these vitamins for CVD prevention.
By: Spencer Blackman MD

Saxagliptin (Onglyza) for DM2 - Not first line.

The Buzz: Saxagliptin is not as efficacious or cost-effective as metformin
Citation: "STEPS: New Drug Reviews" AFP June 15, 2010 81:12 1483-84
Summary: Saxaglipatin (Onglyza) is an oral dipeptidyl peptidase-4 inhibitor that works by slowing degradation of incretin hormones in the gut. Incretins contribute to post-meal insulin secretion, inhibit glucagon release, improve satiety and slow gastric emptying. Few side effects have been reported with saxagliptin and it does not seem to increase the risk of hypoglycemia or cause weight gain. On average, monotherapy with saxagliptin lowers A1C levels by 0.4-0.9 % and adding it to metformin or glyburide will lower A1C levels by an additional 0.6-0.9%. Of note, efficacy trials with saxagliptin were no longer than 6 months and long-term safety and effectiveness studies are currently ongoing. Morbidity and mortality effects are still unknown. No studies have evaluated the effects of combining saxagliptin with insulin. 
Commentary: At $200/month (vs $32/month for metformin), saxagliptin use should be limited to patients who are intolerant or refractory to other treatments.  
By: Spencer Blackman MD

Does substitution with whole grains reduce diabetes risk?

The Buzz:  Whole-grain carbohydrates are recommended in lieu of refined grains to help prevent T2D.
Citation: “White rice, brown rice, and risk of type 2 diabetes (T2D) in US Men and Women” Arch Intern Med. 2010;170(11):961-969

Summary:  Using pooled data from the Health Professionals Follow-up Study and the Nurses’ Health Study I and II, researchers found that substituting brown rice for white rice was consistently associated with a lower risk of developing T2D, and that this effect could be extrapolated to other whole grains.  These associations were independent of lifestyle and dietary risk factors for T2D, as well as ethnicity.  Glycemic index (GI) values differed by variety, but in general they found that white rice consumption generated a relatively stronger postprandial glucose response than the same amount of brown rice.

Commentary:  Recommending whole grains, and whole foods (as nature intended) in general is likely a matter of course for most of us at this point, but for those looking for further substantiation this may prove helpful.  It is also worthy of note as we work with increasing populations of gluten-intolerant patients – we need to ensure we’re not solving a GI related issue, and potentially creating another one in the form of T2D.
By: Karyn Duggan, CNC

Vitamin D levels and viral illness

The Buzz: Raising serum 25(OH)D3 levels above 38 ng/ml may significantly reduce susceptibility to viral respiratory illness
Citation: Sabetta JR et al. "Serum 25-hydroxyvitamin D and the incidnece of acute viral respiratory tract infections in healthy adults." PLoS ONE 5(6):e11088 June 2010
Summary: This past winter, researchers at Yale University prospectively measured serum 25(OH)D3 concentrations in 198 healthy adults and tracked the incidence of acute respiratory tract infections, reporting a two-fold reduction in risk of developing infection for those with concentrations > 38 ng/ml.
Commentary: A high quality (blinded, prospective) trial which suggests a new way to reduce the burden of viral respiratory illness. A better study design would be placebo-controlled, but these findings are suggestive of a benefit.
By: Spencer Blackman MD

Which oral medications are best for obese patients with DM2?

The Buzz: Multiple classes of oral diabetes medications are weight-neutral or even beneficial for weight loss.
Citation: "Managing Type 2 Diabetes: Balancing HbA1c and Body Weight " Postgrad Med  2010 May  122(3):106-117.
Summary: Attempts at managing type 2 diabetes in the obese are often sabotaged by weight gain as a side effect of therapy. Weight loss has been shown to improve insulin resistance, improve glycemic control, and decrease the need for medication. Appropriate choice of medications in this population can help minimize weight gain and perhaps lead to weight loss, thus improving glycemic control and hopefully leading to improvements in overall cardiovascular risk. This review revealed that the antihyperglycemic agents most likely to be weight neutral or to promote loss were the biguanides (e.g. metformin), α-glucosidase inhibitors (e.g. acarbose), incretin mimetics (e.g. exenatide), amylin mimetics (e.g. pramlintide), DPP4-inhibitors (e.g. sitagliptin/saxagliptin). In addition, providers may consider the use of orlistat and sibutramine to target weight loss as adjuncts to conventional antihyperglycemic therapies.

Commentary: Further studies are needed to determine if these effects will translate into clinically relevant improvements in CV outcomes.
By: Sue Kim MD

PPIs - time to rethink our use?

The Buzz: Benefits of PPIs may not outweigh the risks for many patients
Citation: Arch Int Med 170(9) May 10, 2010
Summary: The May 10, 2010 issue of Archives of Internal Medicine is centered around the theme "Less is more", and a number of articles focus on PPI use. "A staggering 113.4 million prescriptions for PPIs are filled each year, making this classs of drugs, at $13.9 billion in sales, the third highest seller in the United States," one editor points out. He goes on to suggest that "between 53% and 69% of PPI prescriptions are for inappropriate indications." Other highlights from this issue include:

• Evidence-based indications for PPIs include errosive and ulcerative esophagitis, Barrett esophagus, Zollinger-Ellison syndrome, severe GERD, short-term treatment of ulcers, eradication of H. Plyori, and ulcer prevention with NSAID use.
• A study of 130,487 postmenopausal women with 7.8 years of follow-up found PPIs were associated with and increased rate of spine, lower arm, and total fractures. (HR = 1.25)
• A study of more than 1,000,000 hospital discharges found daily PPI use contributed to a 73% increased risk of C difficile infection
• PPIs also significantly increase the risk of hospital and community-acquired pneumonia

While this seems very convincing, those of us on the front-lines deal with the reality that 25% of adults report dyspepsia and PPIs do help. Moreover, PPI use fits our current medical model of naming symptoms and treating them with a pill. The authors suggest we should instead offer other treatments than PPIs for functional dyspepsia, prescribe short courses of PPIs (after disclosure of possible risks and benefits), and consider a trial of discontinuing PPIs in asymptomatic patients.

Commentary: Improving health care often means doing less, and this is one example where we may be helping our patients by steering them away from PPIs when not indicated.
By: Spencer Blackman MD

What is the best way to diagnose GERD?

The Buzz: A simple point-of-care tool can help with the diagnosis of GERD
Citation: "Diagnosis of Gastroesophageal Reflux Disease" AFP  2010 May 15;81(10):1278-1280.
Summary: Upper abdominal symptoms are common in primary care, and this article presents two clinically-validated point-of-care tools for the diagnosis of GERD. The first, called "GerdQ", is a 5-item survey which predicts the likelihood of the diagnosis of GERD. This can be given to the patient at registration and was shown to be comparable to diagnosis by a specialist. The second is a clinical scoring guide which uses BMI and a few other data points to predict response to omeprazole. While calculating the score is slightly more time-consuming, the authors point out that in patients of average or increased weight, nighttime pain or recent antacid use predicts a good response to omeprazole*, a rule which provides an even more efficient way to decide if its use is worth recommending.
Commentary: Any shortcuts to the diagnosis and management of this common condition are welcome. *See recent post on PPIs.
By: Spencer Blackman MD

What are the most effective lifestyle changes for improvements in lipid profiles?

The Buzz: Various lifestyle modifications can benefit lipid profiles

Citation: "Diet and Exercise in the Management of Hyperlipidemia" AFP, 81;9 May 1, 2010 1097-1101

Summary: This review article is a compilation of various primary studies and meta analysis regarding specific life style modifications and their affect on lipids. Data summarized below:

• Limit saturated fats to < 7% of calories and eliminate trans fats = LDL ↓9-12%
• Increase intake of soluble fiber (3 oz oats per day, psyllium supplement) = LDL  ↓ 5 mg/dL  
• Isocalorically increase consumption of tree nuts ( .5 oz almonds, walnuts, or pecans per day) = LDL ↓ 2-19%
• 1.5 oz soy protein per day - tofu and soy foods to replace meats = ↓ LDL 5mg/dL
  ↑ HDL 0.8 mg/dL 
•  One alcoholic drink for females, two for males = ↓  LDL 7.8 mg/dL
  ↑ HDL 9-13 mg/dL 
• 1 oz Promise, Active, or Benecol spread per day  = ↓ LDL 10% 
• Increase intake of marine omega-3 fatty acids (EPA/DHA) = ↓ Triglycerides in a dose-dependant fashion
• Mediterranian Diet = ↓ total cholesterol:HDL ratio > 12% 
• Portfolio Diet  = ↓ LDL 29-35% 
• Aerobic exercise >120 min/week = ↓ LDL 4mg/dL
  ↑ HDL 1.9 - 2.5 mg/dL

Other pearls include:

• Dietary advice from physicians results in ↓ cholesterol 6.2/ mg/dL and ↓ LDL 7.0 mg/dL.
• Dietary advice from a dietitian results in and additional ↓ cholesterol 9.7 mg/dL.
• The greatest reduction results from avoidance of saturated and trans fats, increase in polyunsaturated and monunsaturated fats, moderate ETOH intake, supplementation with plant sterols or stanols (eg Promise spread), and isocalorically increasing consumption of tree nuts

Commentary: This study helps to quantify the effects of commonly recommended lifestyle modifications on lipid levels. Some of the recommendations, although showing impressive reductions in lipids, require a motivated patient. 

By: Steven Winiarski D.O.

Cochrane: Opioids for OA?

The Buzz: In OA of the hip and knee, opioids provide modest benefits that do not outweigh the risks
Citation: "Cochrane for Clinicians: Opioids for Osteoarthritis of the Knee or Hip" AFP May 1, 2010 81:9 1094-95 
Summary: The study authors reviewed ten outpatient trials involving 2,268 patients, reporting a response rate of 35% of patients in the treatment group, vs 31% in the control group (number needed to treat [NNT] = 25), as defined by a reduction of at least half of their pain. This was offset by adverse effects, though major adverse events were rare. No one opioid was found to be superior. The article authors recommend clinicians consider other interventions as outlined  by the Osteoarthritis Research Society International. They also recommended tramadol, as well as codeine, in patients with refractory pain.
Commentary: This seemingly focused review brings up a number of larger issues, including the overuse of narcotic medications (hydrocodone is the most prescribed medication in the US), and the approach to chronic pain. In addition, it points out a very useful resource available to California clinicians, the California Prescription Drug Monitoring Program (register here), which allows real-time controlled prescription reports on individual patients.
By: Spencer Blackman MD

Hgba1c as an independent risk factor for diabetes, CVD and death?

The Buzz: Glycated hemoglobin may be a useful marker for predicting development of diabetes, cardiovascular risk and death
Citation:  "Glycated Hemoglobin, Diabetes and Cardiovascular Risk in Nondiabetic Adults." NEJM 362;9 March 4, 2010 800-11

Summary: This multi-center study followed 11,092 middle-aged adults without diabetes over a 15 year period in order to study the use of glycated hemoglobin to predict risk of diabetes, coronary heart disease and death. Using thawed blood samples taken during subjects' earlier visits, researchers calculated adjusted hazard ratios for those with HgbA1c values below 7.0%, ie nondiabetics. HgbA1c values were as good as fasting glucose values for predicting risk of developing diabetes, and appeared to be better than fasting glucose as a predictor of long-term macrovascular event risk. For A1c values of <5.0%, 5.0%-<5.5%, 5.5%-<6.0%, 6.0%-<6.5% and >6.5%, the multivariable-adjusted hazard ratios were 0.52, 1.00, 1.86, 4.48 and 16.47, respectively for developing diabetes, and 0.96, 1.00, 1.23, 1.78, and 1.95, respectively for coronary heart disease (all values significant). Similar findings were reported for stroke and death from any cause.The authors concluded that not only does this study further support the use of glycated hemoglobin values to predict diabetes risk, but that values over 6.0% may be an independent risk factor for cardiovascular disease and death.
Commentary: This study, while observational, suggests we have another tool to help establish risk for developing diabetes, heart disease and death. However, the authors do not suggest which patients this would be useful for, nor do these findings change the approach to patients at elevated risk. Modifying lifestyle factors is still key in this battle.
By: Spencer Blackman MD