September 28, 2007
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.
Osteoporosis Medicine May Lengthen Your Life
On September 19, the New England Journal of Medicine released a study online showing that a bone-building drug called zolendronic acid (Reclast) may save lives in addition to treating osteoporosis. All of the 2,127 people in the study had recently suffered a broken hip. They were assigned to get either zolendronic acid or a placebo once a year by intravenous (IV) infusion. (The placebo was IV fluid with no drug in it).
Researchers then followed the two groups of participants for several years. Those who received the real drug had 35% fewer repeat fractures in the first two years of treatment.
More than 13% of those who received the placebo died in the first two-year period. Only 9.6% of those treated with zoledronic acid died. That means that the death rate in the treatment group was 28% lower than the death rate in the placebo group.
It isn't clear why the non-drug group had such a high death rate during those two years. It's possible that the extra fractures were to blame. If that is so, other medicines commonly used to treat osteoporosis may also offer life-saving benefits. More study will be needed for us to know that.
A fracture or surgery to repair a fracture puts people at risk for a blood clot in the leg or lungs and increase the risk of death. A major fracture, such as a hip fracture also limits a person's mobility. A person who is bedridden has a higher risk for pneumonia and other health problems.
This study will make screening for osteoporosis a bigger priority and doctors may be more earnest to start treatment when osteoporosis is identified.
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Vitamin D Supplements May Lengthen Your Life, Too
A variety of studies have suggested that vitamin D might help prevent certain cancers, heart disease and diabetes. Does it also help people to live longer on average?
A study in the September 10 issue of Archives of Internal Medicine, suggests that people who take vitamin D supplements are less likely to die during the first five or six years after starting the supplements than are people who don't take them.
The researchers combined data from 18 separate trials, a technique called "meta-analysis," and studied 57,311 adults. Most participants who took vitamin D supplements took a dose close to that of commercially available supplements (between 400 and 600 international units).
Over an average follow-up time of 5.7 years, 4,777 of the participants died. During the time they were studied, those people who took vitamin D had a 7% lower rate of death as a group, compared with people who did not take vitamin D. In the nine trials that collected blood samples, those who took the supplements definitely had a higher average blood level of vitamin D.
This study is exciting, since vitamin D supplements are safe and inexpensive. Ordinary doses of vitamin D supplements seem to be associated with a decrease in mortality rate. Doctors will almost certainly be more motivated to identify people who have vitamin D deficiency. For people who are not deficient in vitamin D, supplemental vitamin D might still be helpful. More analysis of data would be needed for us to know. Although this study was not a randomized trial, it's possible that vitamin D supplements may soon be recommended for all adults as part of standard medical care.
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Which Insulin Schedule For Diabetes Is Best?
About one out of three people with type 2 diabetes will eventually require insulin in order to keep blood sugar under good control. On September 21, the New England Journal of Medicine released results of a study online to identify which insulin plan improved blood glucose levels the most in patients already taking oral diabetes medicines.
This study included the results from just the first year of the three-year trial, called Treating to Target in Type 2 Diabetes (the 4-T study), which is still ongoing.
All of the 708 people with diabetes who took part in the study had hemoglobin A1C blood test levels — a measure of glucose control — that were higher than ideal. (For people with diabetes, it's best to have an A1C level lower than 7.0%.) A1C levels at the beginning of the study ranged from 7.0% to 10.0%. The participants were already taking metformin and a sulfonylurea medicine (such as glipizide, glimepiride, or glyburide) to manage their diabetes.
They were randomly assigned to also take one of the following:
- long-acting insulin taken once a day
- a mixture of long and short acting insulin taken twice a day
- fast-acting insulin taken three times a day before meals.
The results were a bit discouraging. By the end of a year, the average hemoglobin A1C levels were still above goal levels in all three of the insulin groups. —7.6 in the long-acting insulin group, 7.3 in the combination long and short acting group, and 7.2 in the fast-acting insulin group. More people in the pre-meal, three-injection-per-day group were able to lower their A1C to their goal level, but these patients also had an average of one known hypoglycemic episode (low blood sugar) every month. They also experienced the most weight gain. Hypoglycemia and weight gain were also common in the combination group.
Due to the hypoglycemic episodes, many diabetes specialists think this study favors the use of long-acting insulin as the first "add-on" to oral medicines, because it's the safest treatment. For most people, injections of short-acting insulin will need to be added to their treatment later in order to bring glucose levels down to the desired range.
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More News in Brief
- Childhood Diagnoses of ADHD and Bipolar Disorder Are Common. Mental health problems, such as attention deficit hyperactivity disorder (ADHD) and bipolar disorder (also known as manic depression) are much more frequently diagnosed in children today than in previous decades. A report released September 3 by the Archives of Pediatrics & Adolescent Medicine suggests that 8.7% of U.S. children between ages 8 and 15 meet the criteria for diagnosis of ADHD, although a majority of these children are not receiving drug treatment. Also on September 3, the Archives of General Psychiatry published a study showing a huge increase in the diagnoses of bipolar disorder over the last decade for kids under age 19. This study recorded how often doctor-office visits listed bipolar disorder among problems that were managed in the visit. A diagnosis of bipolar disorder was discussed in clinic visits about forty times more frequently between 2002 and 2003 than between 1994 and 1995. This either means the diagnosis is made much more frequently, or that doctors have more reasons to talk about it with patients. (For example, doctors now might more intensively manage medicines for this condition.) These studies show that childhood psychiatric problems are getting much more attention today than in previous years. Mental health problems were probably missed in the past. It's also possible that children with challenging behavior are being mistakenly diagnosed with mental health problems. It will be a challenge for pediatricians and children's mental health specialists to consider the accuracy of psychiatric diagnoses based on the criteria that are used today, so that children are not inappropriately labeled as having a mental illness. We need to ensure that the right children are offered effective treatment.
- Aerobic Exercise and Strength Training Can Each Improve Blood Sugar in Diabetes. Researchers in Canada enrolled 251 people with diabetes in a study to see if aerobic exercise or strength training exercises were better at lowering blood sugar levels. The study appeared in the September 18 issue of the Annals of Internal Medicine. All of the participants were sedentary at baseline. They were assigned to exercise for 45 minutes, three times per week. People who did just aerobic exercise lowered their A1C levels by an average of 0.5%. People who exclusively did strength training lowered their A1C levels by an average of 0.38%. People who were assigned to do both types of exercise had nearly a 1% drop in A1C. This study emphasizes the value of regular exercise for blood sugar control. Any active effort appears to help, and the more varied your exercise, the better.
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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, Ore.
