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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: May 2014

June 02, 2014

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.

Review Looks at Drugs that Help Reduce Alcohol Abuse

One out of every 20 deaths in the United States is related to alcohol use. If you are dependent on alcohol and you don't stop drinking, your life expectancy may be shortened by 15 years or more. But quitting alcohol is not easy.  A long-term support program, such as Alcoholics Anonymous, is likely to be helpful. Some drinkers take prescription medicines to help them quit. A report published May 14 in the journal JAMA summarizes the research on how effective these drugs are. Researchers analysed the results of 123 studies of various medicines that treat alcoholism.

Two drugs have the most proven benefit:

  • Acamprosate (Campral) reduces heavy drinking and risk of relapse. It can also minimize symptoms of alcohol withdrawal when a person stops drinking. With acamprosate, about 12 people need to be treated to prevent 1 person from relapsing.
  • Naltrexone (ReVia, Depade) pills blunts the amount of pleasure that alcohol triggers in the brain. The drug reduces cravings and gives people more control over urges to drink. In at least 2 studies, people taking naltrexone pills were twice as likely to remain off alcohol for 6 months or longer as people who were given a placebo pill. Like acamprosate, it takes treating 12 people with naltrexone to prevent 1 person from having a relapse.

Both acamprosate and naltrexone can also help alcoholics to avoid heavy binge drinking, even people who relapse to some drinking. These 2 drugs seem to have a roughly equal benefit.

Other medicines that are useful for drinkers have either less obvious benefit or fewer studies showing benefit. But they may still be options for some patients.

  • Injectable naltrexone (Vivitrol) is given monthly in a doctor's office. It helps reduce the number of heavy drinking days. It does not seem to be as effective as the pill form of naltrexone. However, it does not require a drinker to remember a daily pill.
  • Nalmefene (Selincro) is a drug that became available in some European countries one year ago. It is not currently sold in the United States in pill form.  Nalmefene is intended to reduce the amount of alcohol a person drinks. It does not help a person quit completely. This has made it an attractive option to drinkers who only want to cut down how much they drink. This pill is taken once daily on days that a person feels they are likely to drink.  It blocks opioid receptors on brain cells. This blunts the emotional feeling of "reward" that can come with drinking. Nalmefene seems to successfully reduce the number of heavy drinking days per month and number of drinks on drinking days. One out of 12 people taking this medicine had to stop due to side effects such as nausea, dizziness, headache, insomnia or confusion.  Side effects were more common with this drug than with naltrexone.
  • Topiramate (Topomax) leads to a pattern of fewer drinking days or fewer heavy drinking days for some patients. It was less beneficial compared with acamprosate and oral naltrexone.
  • Valproic acid is an anti-seizure medicine and a mood stabilizing medicine (it is commonly used to treat bipolar depression). It was associated with less drinking in alcoholics.
  • Other medicines, including various anti-depressants and the pain drug gabapentin, showed much smaller benefits. For some patients, it is possible that treatment of depression or pain may help reduce alcohol abuse, if alcohol is used as a coping strategy.
  • Disulfuram (Antabuse) did not score well in this analysis. This drug creates unpleasant symptoms after a person drinks alcohol. Although it's been used in the past to treat alcohol dependence, there isn't enough evidence for benefit to make it a good choice today.

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Study Provides Hope for Muscular Dystrophy

Duchenne muscular dystrophy is a genetic disease that can affect boys and young men. The disease causes progressive loss of muscle function, as well as heart failure and impaired breathing. The disease is fatal.

Steroid medicines can slow the disease, but there is no other treatment. Now, a new idea for treatment is exciting researchers and stirring hope.

Duchenne muscular dystrophy is caused by a missing protein in muscles. Without this protein, muscles can't get an adequate blood supply during exercise. Researchers wondered if drugs that dilate blood vessels could be a treatment for muscular dystrophy. The two drugs they had in mind both treat erectile dysfunction in men: tadalafil (Cialis or Adcerca) and sildenafil (Viagra). They gave 10 boys with Duchenne muscular dystrophy one of these medicines, and compared them to 10 boys without the disease. All the boys were between 8 and 13 years of age. The researchers tested blood flow in hand muscles during gripping exercises.

Before taking the medicine, blood flow was lower in the boys with muscular dystrophy. But after treatment with either tadalafil or sildenafil, blood flow measurements were normal. The study was published online May 7 by the journal Neurology. This small study did not last long enough to detect a change in muscle function. To know whether these drugs might have a lasting benefit, much longer studies will be needed.

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More News In Brief

  • FDA Warns Lunesta Users to Cut Dose. The U.S. Food and Drug Administration (FDA) issued a safety alert on May 15 regarding the sleeping pill Lunesta (eszopiclone). The usual dose prescribed has ranged between 2 and 3 milligrams. But now the FDA  warns that 3 milligram doses can cause impaired driving, poor coordination and faulty memory more than 11 hours after an evening dose. The recommended starting dose is now 1 milligram for both women and men. A year ago, the FDA issued similar warnings about the drug zolpidem (Ambien, Ambien CR). If you use any medicine to treat insomnia, you should not drive for at least 8 hours after use. (For long acting forms of sleeping pill, the FDA has recommended an even longer delay before driving. In the case of Ambien CR, the FDA recommends no driving for a full day following a nighttime dose).
  • Snacking Contributes to Fatty Liver. A small study is getting the attention of nutrition experts. It links snacking between meals to fatty changes in the liver, even when calorie count is kept the same. The study included 36 thin men. They were divided into 3 groups. One group ate 3 meals per day consisting of a moderate amount of calories. A second group ate 3 high-calorie meals a day that were supersized to include extra calories from high-fat foods and sugary drinks. The third group ate 3 meals a day; they received the same number of extra calories (from foods high in fat and sugar) as did group 2. But their extra calories — the high-fat snacks and sugary drinks — were eaten between meals. Although this study was small, it was notable. Study subjects were monitored with magnetic resonance imaging (MRI) scans of the liver and tests to determine insulin sensitivity. Both of the groups who received excess calories gained weight. But insulin resistance (a condition that can lead to diabetes) and fatty liver changes were only seen in the group that snacked between meals. Fatty liver changes were not apparent in the men who ate 3 large meals. The study was published by Hepatology on May 6.
  • Antibiotics Don't Help Bronchitis, But Doctors Still Prescribe Them. A new report in the journal JAMA has found that doctors are writing lots of prescriptions for antibiotics to treat acute bronchitis. This is embarrassing news for doctors. Acute bronchitis should not be treated with antibiotics. For 15 years, the Centers for Disease Control and Prevention and many treatment guidelines have advised doctors that antibiotics do not help acute bronchitis. That's because the condition is caused by a virus. To avoid overuse of antibiotics, the prescribing rate for acute bronchitis should be zero. But between 1996 and 2010, the prescribing rate was nearly 70%. This was based on data researchers collected from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey. Overuse of antibiotics leads to unnecessary side effects and contributes to antibiotic resistance.
  • Treatments May Soon be Available for Pulmonary Fibrosis. Idiopathic pulmonary fibrosis (IPF) is a lung disease that causes progressive stiffening and scarring of the lungs. Doctors have not had effective treatments for IPF. But on May 18, the New England Journal of Medicine published results of several drug trials that have shown benefit. The medicine nintedanib (also known by its study name BIBF-1120) limits scar formation in the lungs. The drug is an antibody. It slowed progression of IPF. Patients had larger breath volumes (a measurement called "forced vital capacity" or FVC) 1 year after start of treatment. The medicine pirfenidone (Esbriet) has an effect on growth factor hormones in the lung that are involved in healing. This drug demonstrated an improved FVC, like mintendanib. Additionally, pirfenidone was associated with an ability to walk longer distances in a 6-minute walking test. Neither of these drugs has received full approval from the FDA yet, but experts anticipate that this will happen soon.

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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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