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Harvard Commentaries
Harvard Commentaries
Reviewed by the Faculty of Harvard Medical School

What Your Doctor Is Reading What Your Doctor Is Reading

Update From the Medical Journals: April 2012

April 30, 2012

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.

"One Size Fits All" Is No Longer Recommended for Blood Sugar Goals in Diabetes

Good control of blood sugar levels can reduce complications from type 2 diabetes. Doctors use a test called hemoglobin A1C to measure a person's average blood sugar during the prior two to three months. For the last four years, guidelines have recommended the same A1C goal for all people with diabetes — 7%. For some people this has resulted in unexpectedly low blood sugars, which makes this goal unrealistic.

But now, the American Diabetes Association and the European Association for the Study of Diabetes are jointly revising this recommendation. They are making the goal more flexible so it can be tailored to each person. The new recommendation was published online April 19 in the journals Diabetes Care and Diabetologia.

The guideline authors emphasize that good glucose control lowers the risk for complications, such as heart disease, blindness, kidney failure and neuropathy. In fact, they say especially young and healthy patients can aim for a goal that is a bit lower than 7%.

But the authors also recognize dangers from pushing to get near-perfect blood sugar levels. Overtreatment can result in low blood sugars. They cited a large study from four years ago called the "ACCORD" trial. In this study people with "tight" glucose control were compared with people who were treated with "loose" glucose control. This study showed that the more ambitiously treated group had more episodes of abnormally low blood sugar (hypoglycemia), and more people in this "tight control" group died during the study.

Tight control is particularly dangerous for older people, who are at risk for falls and accidents. Low blood sugar is dangerous for people who have heart disease, because it stresses the heart. Tight control, in general, requires more medications. And it may be too complicated or too expensive for some patients.

The new recommendations say a goal between 7.5% to 8% may be appropriate for people with short life expectancy, with frequent low blood sugars, or even with difficulty reaching a lower goal.

Good exercise and diet — for all people with diabetes — is still in the treatment plan. But when it comes to medication decisions, doctors will need to personalize A1C goals for each patient. And they may change as a person grows older.

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New Drugs For Psoriasis Show Great Potential

Psoriasis is a common and long-term skin condition. It causes unsightly crust-like patches of skin along with itching and flaking.

Two new drugs were the subject of separate studies in the March 29 issue of the New England Journal of Medicine. Both drugs are molecules that block a chemical messenger called IL-17. IL-17 is a protein that stimulates skin inflammation. It is found at high levels in the blood of people with psoriasis.

The first study tested the drug brodalumab. This drug is an antibody that blocks IL-17. The study involved 198 people with psoriasis. They were randomly assigned to get treated with injections of brodalumab or placebo injections. After 10 weeks, the drug dramatically reduced symptoms. In 85% of the patients who received the drug, signs of psoriasis were gone.

The second study included 142 people with psoriasis. They were also randomly assigned to their treatment groups. Some received six injections of a drug called ixekizumab; others received placebo injections. About 40% of people who received the drug responded completely, and had no signs of psoriasis after 12 weeks.

There were some side effects, but they were minor. These two drugs are not yet available by prescription. They will need more testing to show they are safe to use before the U.S. Food and Drug Administration approves them.

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Can Aspirin Prevent Cancer?

On March 20, The Lancet and The Lancet Oncology published three related papers that suggested taking an aspirin a day might help prevent cancer. Soon afterwards, the American Cancer Society (ACS) put out a press release and outlined what we know about aspirin and cancer.

The information we have about aspirin and cancer comes mostly from studies that looked at aspirin and heart health. But many of these studies recorded cancer rates as well.

Some studies indicate that aspirin might be linked to a slightly lower overall cancer risk. One study even says the risk may be 20% lower. But a very large study known as the Women's Health Study didn't show aspirin to have a measurable effect on cancer. Why would that be? The ACS says it may be because the Women's Health Study only kept track of people for 10 years.

If we can't find a benefit from aspirin in a very large study that lasted 10 years, then the benefit is definitely small. But if you are already considering taking a daily aspirin for other reasons, a "small" protection against cancer may increase your interest.

More News in Brief

    • The United States Is Seeing A Lot of Measles. Measles had a big year in the United States in 2011. And it is still causing trouble. According to the Centers for Disease Control and Prevention (CDC), 222 measles cases were reported in 2011. This included 17 small measles outbreaks (clusters of cases). In most other recent years we have seen about one-fourth as many cases and an average of only four outbreaks. Most cases could be traced to travel — either the affected American had been traveling abroad or a traveler who came to the United States was infected.

      The CDC report was released in the April 20 Morbidity and Mortality Weekly Report (MMWR). Most of the people who got measles had not been vaccinated against it. In the case of school-aged children who got measles, 76% of the time, parents had signed a school form indicating that they had a philosophic, religious or personal objection to vaccinations.

      Measles vaccination is strongly recommended to anyone who has not been vaccinated, who does not have a weak immune system (which could make the vaccine unsafe), and who was born after 1957 (before that year, the infection was so common that most people became immune by being exposed as children).

    • New Coxsackievirus Spreads Rash and Fever. On March 30, the MMWR also reported about a number of people who became ill from a new strain of Coxsackievirus. Milder and more familiar strains of this virus cause a childhood rash and illness that is known as "hand, foot and mouth disease." The new strain causes more severe sickness. Between November 2011 and February 2012, 63 people in Alabama, Connecticut, California and Nevada got sick from the new virus strain. Most were children under two years, but adults were affected as well. More cases have been identified since the time of that report.

      The virus caused blisters and a skin rash that formed scabs. The rash appeared on the hands, feet, mouth and other areas. People also had fevers. A surprisingly large number of patients needed to be hospitalized for dehydration or for pain from the blistering. In at least 1 out of 25 patients, fingernails or toenails fell off. Because this virus is contagious, good hygiene habits, such as hand washing, can reduce the spread. The health department would like to hear about possible new cases.

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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.

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