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Update From the Medical Journals: December 2005
December 30, 2005  By Mary Pickett, M.D.
Harvard Medical School What's the latest news in the medical journals this month? Find out what your doctor is reading. Antipsychotic Medicines (Tranquilizers) Unsafe in Elderly Many older adults with dementia become unsettled or agitated at night, and they may appear paranoid or fearful. These symptoms can be treated with antipsychotic medicines, sometimes known as tranquilizers. Antipsychotic drugs can stop a person from having as many unrealistic fears. These medicines are very commonly used in hospitals, nursing homes and family settings. New drugs have been developed because older antipsychotic drugs caused more noticeable side effects, such as drowsiness, constipation, blurred vision, drowsiness or dulled thinking. This year, researchers have closely reexamined the safety of antipsychotic drugs. The newer drugs were the subject of a U.S. Food and Drug Administration (FDA) warning this April. Now, an important study published December 1 in the New England Journal of Medicine has found that elderly people using antipsychotic medications have an unexpectedly high chance of dying within the six months after beginning the medicine. This occurred whether they used old or new antipsychotic drugs. Newer antipsychotic drugs include aripiprazole (Abilify), clozapine (Clozaril), olanzapine (Zyprexas), quetiapine (Seroquel), risperidone (Risperdal) and ziprasidone (Geodon). Older drugs include haloperidol (Haldol), perphenazine (Trilafon), fluphenazine (Prolixin) and others. The December study observed approximately 23,000 older people who took an antipsychotic medicine. Almost half had dementia. People diagnosed with dementia, such as Alzheimer's, generally don't live as long as healthy older people. On average, women survive fewer than six years after a diagnosis of Alzheimer's, and the average for men is close to four years. Presumably, many of the people with dementia who required an antipsychotic drug already were several years into their illness. But even though long survival was not expected, the number of deaths soon after beginning medication was surprisingly high. Close to 1 out of every 6 or 7 elderly people taking a newer antipsychotic drug was dead within six months, and the rate was 1 out of every 5 or 6 for people using the older drugs. These are higher rates than expected for people this age, with or without a diagnosis of dementia. None of the studies has proven that these medications directly cause death. Instead, it is possible that worsening agitation and altered thinking are signs of accelerating decline in brain function, and this decline ultimately may be what is fatal. These medicines are useful, and they will continue to be used to treat elderly patients. Still, the association between drugs and deaths is concerning, so doctors will be cautious about using them in elderly patients. Doctors, patients, and families will need to make a conscious decision about whether the improved quality of life that can be gained from an antipsychotic drug justifies its use, despite its possible risk. Back to top Anti-Acid Drugs May Increase Diarrhea Infections Many adults use anti-acid drugs to improve symptoms of heartburn or stomach irritation. Certainly, these drugs bring relief. But an acid-free stomach might not be better biology in every way. Researchers have begun to worry there may be consequences of increased infections once we eliminate stomach acid. After all, we all swallow germs. Stomach acid is one of the body's most basic defenses against infection, killing many bacteria, viruses and spores. People who take anti-acid medicines regularly may have a slightly higher risk of certain intestinal infections. A specific infection suspected to occur more frequently is diarrhea caused by the bacterium Clostridium difficile. This infection has been occurring more frequently in recent years, when the use of anti-acid medicine also has increased. Researchers from Great Britain monitored the pattern of C. difficile infections from 1994 to 2004, and they confirmed that this diarrhea illness was more common among people who took acid-blocking drugs. They published their review December 21 in the Journal of the American Medical Association (JAMA). These researchers watched for a pattern by doing a "case-control" study. They obtained a list of all known cases of the illness (all the people in the United Kingdom who had C. difficile diarrhea), and they noted major features of each person with the illness, such as age, gender, home town and other illnesses. Then they scouted in a database to identify other people with similar age, gender and other major features. These people were labeled "controls." By comparing "case" patients and "control" patients, researchers can look for exposures or treatments that may be uniquely different between the two groups. In this way, they can show that an exposure or treatment is "associated" with an illness. In this study, researchers reviewed medical records of more than 18,000 people and matched the 1,672 cases with 10 control patients apiece. The two groups were combined into one large database, and then they were sorted based on anti-acid use. People who had received a prescription for an acid-blocking drug were compared with people who had not received a prescription. Among the people who had received an anti-acid prescription, there were many more "cases" (people who at some point developed C. difficile). The researchers calculated that people who had received a prescription for the most potent type of acid-blocker (a "proton-pump inhibitor") were almost three times as likely to get C. difficile colitis as untreated people. People who had received a prescription for a milder acid-blocker (an "H2 blocker" drug) were about twice as likely to get C. difficile colitis. Proton pump inhibitors include omeprazole (Prilosec, Prilosec OTC), esomeprazole (Nexium), lansoprazole (Prevacid), pantoprazole (Protonix, Pantoloc) and rabeprazole (Aciphex). Drugs in the H2 blocker family include ranitidine (Zantac), cimetidine (Tagamet), nizatidine (Axid) and famotidine (Pepcid). This study can't prove that anti-acid drugs cause C. difficile infections, but it definitely raises this suspicion. The drugs probably result in more good than harm for most people who take them, but after this study doctors may hesitate to recommend long-term use for people who have mild symptoms. Back to top More News in Brief - New Guidelines for CPR -- Adjusted recommendations about how to perform cardiopulmonary resuscitation (CPR) most effectively were published in a supplement to the November 29 issue of Circulation, a journal of the American Heart Association. The new recommendations emphasize that chest compressions are most effective if the pushing is forceful and fast, if the chest wall is allowed to come back to a normal, unpressured position between compressions, and if compressions are not interrupted very frequently for rescue breaths. In almost all cases, 30 chest compressions in a row are now recommended, with two rescue breaths between each batch of compressions. CPR rescuers are now also trained to use a defibrillator, if one is available. Learning the modern CPR recommendations will be important for everyone, doctors and non-doctors alike.
- Yoga Helps Back Pain -- On December 20, the Annals of Internal Medicine published the results of a study that reviewed the benefit of yoga sessions as a possible treatment for back pain. Just over 100 patients participated. Patients who were randomly assigned to do yoga attended an average of 9 out of 12 scheduled 75-minute sessions. They were advised to do yoga postures daily at home, as well. By the end of the 12-week treatment, these patients had a better improvement in function and were less bothered by their pain than participants who instead were given a back care book, and they appeared to have at least as good a response in their pain as people treated with exercise (physical therapy). Six months after beginning yoga treatment, the yoga participants still reported improved symptoms compared with their baseline.
- Important New Drug Warnings -- On November 18, the U.S. Food and Drug Administration (FDA) issued a public health advisory warning that some commonly used inhalers for asthma treatment may put people at risk of more severe or even fatal asthma flares, even though they appear to reduce the frequency of flares for many people. The inhalers of concern are long-acting beta agonist inhalers, and they include salmeterol (Serevent), formoterol (Foradil) and Advair (a combination inhaler, which contains salmeterol).
On December 8, the FDA issued a public health advisory about newly identified dangers from the drug paroxetine (Paxil) when it is used in the first trimester of pregnancy. This drug, which is used to treat depression and some anxiety problems, was associated with a doubled risk of heart birth defects, including atrial septal defect (ASD) and ventricular septal defect (VSD). These defects are abnormal holes between chambers of the heart. People who are currently taking one of these medicines are advised to discuss the FDA advisories with their doctor. Back to top Mary Pickett, M.D. is a lecturer for Harvard Medical School and an assistant professor of medicine at Oregon Health & Science University. At OHSU, she is a director of student programs and she oversees teaching of students and medical residents. She practices general internal medicine in Portland, Oregon.
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