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