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Harvard Commentaries
35320
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: July 2012


July 31, 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.

Antiviral Pills Can Prevent HIV

Just as daily birth control pills can help prevent pregnancy, daily antiviral medicines can help prevent infection with HIV, according to two new studies. They were published online by the New England Journal of Medicine July 11. (A third study published in the same issue did not find a benefit.) As a result, the U.S. Food and Drug Administration (FDA) approved the drug Truvada four days later. The drug is actually a combination pill containing tenofovir and emtricitabine.

Using Truvada in this way is called "pre-exposure" prevention. It may be useful for people at high risk for getting HIV infection. This includes people who are married to a partner with HIV, or men who have sex with men (HIV is common in this group).

All of the studies took place in Africa and lasted one to two years. The drugs were not a substitute for condoms — use of condoms to prevent infection was still encouraged for everyone in the studies. Here's what the studies found:

    • The first study included 1,219 heterosexual men and women. They were randomly assigned to receive either Truvada or placebo pills. Treatment was about 60% effective at preventing HIV infection.

    • The second study included more than 4,700 heterosexual couples. One partner in each couple had HIV infection and the other did not. The partner who was not infected was treated with either placebo pills or antiviral drugs. HIV infection rates were 75% lower for those who got Truvada.

    • The third study involved 2,120 women. It found no benefit for those who took the antiviral medicine compared with placebo pills. But many women in this study were found to have frequently skipped the drug.

Not all experts at the FDA agreed about the drug's approval for prevention. People who know they are in a study are more likely to take every dose they're supposed to take. In real life, however, people may not take their pills as regularly. Spotty use of the drug might allow resistant forms of the HIV to develop. The drugs do have side effects, including nausea, kidney and liver irritation and bone thinning.

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Treatment Helps Kids With Egg Allergy

Doctors are delighted with the way some children with severe egg allergy have responded to a treatment known as oral immunotherapy (oral desensitization). This treatment was successful when tried in children with peanut allergy three years ago. Experts hope that this treatment will prevent dangerous allergic reactions in children who are at risk.

More than 2% of young children have severe egg allergies. They have life-threatening reactions if they eat any egg. Most children outgrow this allergy, but 10% to 20% never do.

Oral immunotherapy works like allergy shots. The idea is to teach the immune system to react to triggers without causing symptoms. But allergy shots are too risky to use for food allergies.

For this study, 55 allergic children were exposed to egg proteins when they swallowed very diluted amounts of egg-white powder on a regular basis. They began by swallowing only trace amounts, and they progressed to a daily dose of about one-third of an egg.

Forty were treated with the powdered egg white; the other 15 were given cornstarch (as a placebo). The amounts were increased every two weeks. The treatment lasted two years. After about a year, half of the children in the treated group were able to eat a small portion of egg in their doctor's office with no reaction. At the end of two years, 75% of the children treated were able to do this with no reaction. None of the kids who got the cornstarch treatment were able to pass the egg challenge. Eleven kids were able to stop the powder treatment and start a diet that included daily eggs. And they stayed healthy. This suggests that the process of oral desensitization may have fairly long-lasting results.

Oral immunotherapy probably works for the same reason that allergy shots do. After months or years of having a small but consistent exposure to your allergen, your body shifts to a different way of reacting to your trigger. You produce IgG antibodies. You also activate cells called suppressor T cells. Your immune system is so busy making these harmless antibodies and cells that it makes very little IgE and histamine in reaction to your allergy trigger.

Scientists caution families of children with a peanut or egg allergy not to try this treatment at home. This process requires great care in giving the appropriate dose of the trigger food.

An expanded study using oral desensitization for peanut allergy is taking place. Doctors are hopeful that within several years, we will know enough about oral desensitization to offer this treatment to far more children with severe food allergies.

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Study Sees No Benefit From Prostate Surgery

In May, the U.S. Preventive Services Task Force (USPSTF) recommended that men without symptoms should not be screened for prostate cancer with the PSA (prostate specific antigen) test. This group pointed to evidence that screening did not help men live longer. But if you have prostate cancer, should you have surgery?

A study released July 19 by the New England Journal of Medicine asked this question. It included 731 men with early-stage prostate cancer. They were randomly assigned to have surgery (removal of the prostate gland) or no treatment. When they started the study, the average age of these men was 67. People in each group lived an average of about 13 years after the study began. There was almost no difference between the two groups in rates of death from prostate cancer or other causes. Some men who had surgery suffered long-term complications.

But there was some evidence of benefit for men with a score of 10 or higher on the prostate-specific antigen (PSA) test. Prostate cancer deaths were 33% lower for men with these higher scores who had surgery rather than no treatment.

What lesson can we take from this study? For men who have low PSA scores and early cancer, surgery may provide peace of mind, but it is not likely to change life expectancy in a meaningful way.

This study was much smaller than planned. It was supposed to recruit 2,000 men. This makes it a weaker study, so we should be cautious how we interpret it. It was hard to enroll men who would leave it up to chance whether they were assigned to treatment or no treatment for their newly diagnosed prostate cancer.

More News in Brief

    • FDA Approves Two New Obesity Drugs. The FDA announced online July 17 that it had approved the weight-loss drug Qsymia. This was three short weeks after the FDA approved another obesity drug, Belviq. We can expect to see these drugs in pharmacies within the next year. Neither of these drugs is a magic bullet. They must be taken for life, and they result in only modest weight loss along with diet and exercise.

      Significant side effects occur. For Belviq (lorcaserin), side effects include depression, migraine, memory lapses, low blood sugar reactions and painful erections in men (these erections may require treatment with drugs or needle drainage in an emergency room). Qsymia is a combination pill containing phentermine and topiramate. They are not new and are separate medications. In combination, side effects include memory loss, suicidal feelings, heart rhythm problems and birth defects.

    • Whooping Cough Epidemic Continues. In Washington State there were 2,520 known cases of whooping cough (pertussis) between January 1 and June 16 of this year. This was reported July 20 in the Morbidity & Mortality Weekly Report, a publication by the U.S. Centers for Disease Control. Neighboring states have also been a part of this outbreak. Whooping cough can be fatal in children younger than one year. And it causes months of coughing for adults. The CDC recommends that all adults get a one-time vaccine, which is available in combination with a tetanus and diphtheria booster.

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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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