Update From the Medical Journals: February 2012
February 29, 2012
By Mary Pickett, M.D.
What's the latest news in the medical journals this month? Find out what your doctor is reading.
The drug dutasteride (Avodart) is sometimes used to shrink an enlarged prostate. It is similar to finasteride (Proscar), another drug for enlarged prostate. New research suggests that Avodart may also suppress the growth of early prostate cancers. If this is true, men who choose to monitor their cancer (called "surveillance") instead of having radiation or surgery right away may have a way to minimize the growth of their cancer. The new study was published online by The Lancet on January 24.
In the past, researchers wondered if Avodart might be able to prevent prostate cancer. Overall, research was not convincing: Fewer slow-growing cancers were found in men who had been on the drug, but Avodart did not appear to suppress more aggressive cancers. Cancer experts suspected that the drug might not have prevented the start of cancer in that study. It may have only slowed down tumor growth and delayed diagnosis. The follow-up time of the study was not long enough to know for sure. But even if this was the case, isn't slowing tumor growth useful?
A new study enrolled 302 men who had been diagnosed with "low risk" prostate cancer. ("Low risk" means their cancer was small and the biopsy had a low Gleason score of 5 or 6.) These men were randomly assigned to either take Avodart or a placebo pill for three years.
The men had repeat biopsies to see if the cancer had become more aggressive or had spread. This change is called "pathological progression." They also rechecked their PSAs. Patients who decided it was too stressful not to have their cancer treated could have radiation or surgery. The researchers called this change "therapeutic progression."
The study showed that patients who were taking the drug had lower PSA scores and felt more comfortable going with surveillance. In terms of pathologic progression, the findings were not as clear. Gleeson scores seemed slightly worse in the Avodart group, even though fewer biopsy samples showed traces of cancer (each patient had multiple samples taken). When pathologic progression and therapeutic progression were combined, 38% of people in the group receiving Avodart had progression compared with 48% in the group that had placebo treatment.
The results of this study would be more convincing to me if the researchers had limited their report to cancers with pathologic progression, instead of lumping biopsy changes together with men who moved on to have surgery or radiation.
Why am I skeptical? Because therapeutic progression doesn't prove that Avodart slows cancer growth. Avodart causes side effects, such as a loss of interest in sex or failure to have erections. So it is likely that many of the men in this study had a clear idea whether they were on the active drug or on placebo. It is possible that men who suspected they were getting placebo pills were more impatient to change to a more active treatment strategy. Also, I am wary of studies like this one whose authors have received compensation from drug makers.
Based on this study, men might decide to take Avodart while they watch and wait with prostate cancer. But more study should be done before we decide the drug is beneficial.
Most grand mal seizures stop by themselves within 5 minutes. After having a seizure, a person can be confused for a few hours. Most seizures that end quickly are not dangerous. There may be some bruising, but they do not cause brain damage.
A seizure that lasts for more than 5 to 10 minutes is a medical emergency. It's called status epilepticus. Drugs are necessary to stop this type of seizure. This kind of prolonged seizure can cause permanent damage and disability. There is also a 15% to 22% risk of death. The fastest way to get medicine to the brain is by injecting it through a vein into the bloodstream. However, it takes time to set up an IV, find a "good" vein and make a successful stick. This is especially challenging when someone is having a seizure. Researchers have been looking for other ways to deliver anti-seizure drugs.
On February 16, the New England Journal of Medicine published results of a study that was sponsored by the National Institutes of Health. Researchers trained more than 4,000 paramedics in the use of a pre-loaded syringe (needle) to inject seizure medicine into the thigh muscle. Paramedics gave every patient with a seizure both an IV infusion and a syringe injection as fast as they could. But in half of the patients, the syringe had a real anti-seizure drug (midazolam) and the IV had a placebo. In the other half, the syringe had a placebo and the IV had real medicine (lorazepam), which is usually the first choice for seizure treatment. Midazolam and lorazepam are chemically almost the same, but midazolam can be given by an injection into the thigh muscle.
Researchers treated 893 patients. The researchers were hoping that the muscle injection would work as well as the IV injection. It actually worked faster and better. The muscle injection stopped the seizure in 73.4% of the patients. The IV route stopped the seizure in 63.4%. People who got the auto-injector drug were less likely than the others to be admitted to the hospital after their seizure. Among those admitted, both groups had similarly low rates of recurrent seizures.
These auto-injectors will become part of standard equipment in ambulances. In the future, people with a history of status epilepticus may be able to have an auto-injector for use at home, much like the single-dose pre-filled automatic injection "pens" that allergy patients have.