Update From the Medical Journals: February 2010
March 1, 2010
By Mary Pickett, M.D.
What's the latest news in the medical journals this month? Find out what your doctor is reading.
During the first three months after a stroke, an antidepressant may help a person recover thinking, learning, memory and verbal skills. This news came from a small, simply designed study that was published February 2 in Archives of General Psychiatry.
It included 129 people who had a recent stroke. None of the individuals who enrolled had depression. They were divided into groups that received the medicine escitalopram (Lexapro), a placebo pill or mental exercises to improve problem-solving skills. Escitalopram is a type of antidepressant called a selective serotonin reuptake inhibitor drug (SSRI).
After three months of treatment, people who took escitalopram scored better on tests of logic and memory. Memory seemed to improve for both words and pictures. The people in this group also scored slightly better on one section of a test that aims to measure "functional independence." This includes problem solving, memory, attention and judgment related to safety issues.
It is difficult to know how large the "real life" benefit may be or whether longer treatment might have showed added benefit.
The authors suggest that the antidepressant may allow more chemical and electrical connections to form between cells. This is not proven though. This stroke study did not evaluate recovery of strength or muscle function, only cognitive (thinking) function. Use of escitalopram or another SSRI antidepressant may eventually become part of standard care in the first months after a stroke. First, the findings from this small study need to be confirmed with more research.
Long-time smokers can develop emphysema, bronchitis or a combination of both. These lung problems are also known as chronic obstructive lung disease (COPD).
Doctors rely on inhalers to keep patients with COPD from having flare-ups in their symptoms. But is this confidence in inhalers over-rated? Yes, say the experts. According to a study published in the February issue of Chest, past studies seem to have overestimated the benefit of corticosteroid inhalers by including primarily patients whose COPD is severe.
Corticosteroid inhalers are meant to reduce inflammation in the airways. Inhaled corticosteroids include the medicines beclomethasone (QVAR), budesonide (Pulmicort), flunisolide (AeroBid), fluticasone (Flovent), mometasone (Asmanex) and triamcinolone (Azmacort). Several combination inhalers also include a corticosteroid drug.
Researchers reviewed over 1,000 separate studies of corticosteroid inhalers. Then they hand-picked 11 studies that met the most rigid criteria for quality. This means they were randomized, double-blind, placebo-controlled trials and included strict definitions of flare-ups ("exacerbations") and objective descriptions of lung function.
The researchers combined the data from all 11 studies into one large data pool. This gave them information from about 8,164 people who were treated with corticosteroid inhalers or with a placebo.
According to the results, using the inhalers if you had mild COPD did not seem to change your likelihood of having a flare-up. But if you had severe COPD (defined in this study by having less than 50% of normal airflow as measured by lung function tests) and used corticosteroid inhalers, your risk for being hospitalized due to an exacerbation was cut by 18%. This is a measurable benefit, but it is not dramatic.
Inhaled steroids can lead to yeast infections in the mouth (thrush) and cataracts. They can also increase the risk for bone fractures. For people who have COPD, inhaled steroids also increase the risk for pneumonia.
Quitting smoking and wearing oxygen if you need it can improve survival for people who have COPD. Based on this study, corticosteroid inhalers should probably not be used routinely to prevent COPD flare-ups, unless the condition is severe. When exacerbations do occur, steroids like prednisone may still be the appropriate treatment to help speed recovery of symptoms.
Treating diabetes to bring blood sugar levels to a normal level can safe lives and prevent complications. But sometimes treatment can make blood sugar levels too low and cause hypoglycemia (low blood sugar). This is not healthy.
In fact, a much-discussed study from 2008, called the ACCORD trial, showed that overly aggresive treatment of blood sugar in type 2 diabetes led to a higher premature death rate. In this study, people reduced their blood sugar levels to an average A1C of 6.4%. Doctors use a test called hemoglobin A1C to estimate average blood sugar levels in people with diabetes. Subsequent studies have not been able to duplicate these findings. Since 2008, however, many expert groups have recommended an A1C goal of less than 7%.
Now, a new study published in Lancet on February 6 may increase the A1C level that doctors consider safe.
This study reviewed the health records of 48,000 people in the United Kingdom who have type 2 diabetes. The information was part of the General Practice Research Database and covered 22 years until 2008. All of these individuals were over age 50 and had recently increased their diabetes treatment in an effort to gain tighter control of their blood sugar.
The researchers ranked all 48,000 people by their A1C levels, and then divided them into ten equally-sized groups from "low" to "high" A1Cs. They reviewed the health outcomes of each patient. The group with the fewest deaths had A1C levels near to 7.5%. The group with the lowest A1C levels (less than 6.7%) had 1.5 more deaths per year than the group with the most "survivable" A1C levels about 7.5%. (There were roughly three deaths in the 6.7% A1C group for every two deaths in the 7.5% group.) People with A1C below 6.7% also had more dangerous "large artery events," which included a heart attack, stroke, chest pain that was blamed on heart disease, heart surgery or angioplasty to open a heart artery or a carotid (neck) artery. For people who had an A1C above 9.8%, the 1-year death rate was 1.79 times greater than that of the "best" surviving group. This translates to about nine deaths in the highest A1C group for every fove deaths in the group with an A1C near to 7.5%.
This study also found that people who were treated with a combination of oral medicines (pills) for diabetes seemed to live longer than people who were treated with insulin. It was not clear from this study whether this difference could be blamed on insulin, because the people who used insulin were older and had diabetes for for a longer period of time than the average person in the oral treatment group.
We can probably safely conclude that the ideal A1C for a person with type 2 diabetes is 7.5%, and that levels below 6.7% are unhealthy.
Long-acting beta agonist (LABA) drugs are commonly used inhaled medications that open the airways. They wear off very gradually. Although it is rare, they may increase the chance of one or more severe asthma episodes, which can lead to death. Experts are not sure why this happens to some people. It may be that the medicines cause the lungs to adapt and adjust over time, limiting the power of rescue medicines to treat severe symptoms.
Now, the U.S. Food and Drug Administration (FDA) has announced new restrictions on the use of these inhalers. This follows a series of previous warnings. If you have asthma, do not use one of these inhalers, says the FDA, unless it is packaged with or combined with an asthma "controller" medicine. (For most people, this is an inhaled corticosteroid.) A LABA medication, says the FDA, should only be used short-term and stopped as soon as symptoms are under control. The FDA's Drug Safety Communication was posted online on February 18.
LABA medications include salmeterol (Serevent), formoterol (Foradil, Perforomist), arformoterol (Brovana), and two inhalers that combine a LABA medication with a corticosteroid (Advair diskus, Symbicort). The restrictions are not meant to apply to bronchitis and emphysema, which are also called chronic obstructive pulmonary disease (COPD).
More than half of older adults complain of muscle cramps. Researchers supported by the American Association of Neurology looked at various drug treatments for muscle cramps to identify the best ones. They reported their findings and treatment guidelines in the February 23 issue of Neurology.
Cramps, confirm these experts, are more frequent when a person has a neurologic or muscle disease. They are also common in the third trimester of pregnancy. They frequently occur after heavy exercise or when a person is dehydrated. Cramps can also be caused by low magnesium or calcium, or when the liver, thyroid or kidneys are not working properly.
To treat muscle cramps, doctors usually recommend that you keep hydrated and stretch. These treatments may help some people. For other people, there are drug treatments. But how effective are they? The researchers reviewed more than 500 articles. They chose only high-quality studies to analyze.
They found that taking gabapentin (Neurontin), vitamin E, magnesium citrate or magnesium sulfate had no benefit. However, vitamin B6, diltiazem (Cardizem, Dilacor, Cartia XT, Tiazac and other brands) and nafthidrofuryl (nafronyl or Praxilène), which is not available currently in the United States, reduced the frequency or severity of cramps.
Quinine drugs, which used to be an old-fashioned favorite among people with cramps, had a modest effect on the frequency of cramps. They reduced them by about 25%, according to the most carefully designed trial. However, the FDA ordered most quinine drugs off the market in 2006 because they were too risky to use for this purpose. Between 1969 and 2006 there were a total of 665 known serious adverse events, including 93 deaths, which were blamed on side effects from quinine drugs.
Mary Pickett, M.D. is an Associate professor at Oregon Health & Science University where she is a primary care doctor for adults. She supervises and educates residents in the field of Internal Medicine, for outpatient and hospital care. She is a Lecturer for Harvard Medical School and a Senior Medical Editor for Harvard Health Publications.