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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: September 2012


September 28, 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.

NSAIDS Raise Risk for Second Heart Attack

Most people occasionally use ibuprofen (Motrin, Advil), naproxen (Aleve, Naprosyn), celecoxib (Celebrex) or similar drugs. These are called nonsteroidal anti-inflammatory drugs (NSAIDs).

They are generally safe pain medicines, but they do carry some risks. They can irritate the digestive tract, sometimes resulting in an ulcer with bleeding.

The most commonly used NSAID of all is aspirin. It helps to prevent heart attacks. But aspirin prevents blood clots in a way that other NSAIDs do not. And recently, we have seen that NSAIDs — other than aspirin — are also risky for people with coronary artery disease, high blood pressure or heart failure.

Vioxx was taken off the market for this reason. Last year two studies linked the use of NSAIDs that are still on the market to a higher rate of heart attack, stroke and death. The largest study from last year included 30,000 people. It tracked these people for 3 years.

Now, a larger and longer study has more clearly defined this risk. The study was done in Denmark. In that country, all NSAIDs, except low-dose ibuprofen, require a prescription. Researchers looked at records for almost 100,000 people who had a first heart attack. In the next 5 years, nearly half of them filled a prescription for an NSAID. People who took the painkillers had a 63% higher risk of death from any cause. They had a 41% higher risk of another heart attack. The journal Circulation published the study online September 10.

We can't prove that all of the extra risk seen in this study came from the NSAIDs. But experts are worried about the drugs. Why would NSAIDs have this hazard? For one thing, aspirin does not work as well in the presence of other NSAIDs. Also, NSAIDs block a natural substance called prostaglandin. This can lead to higher blood pressures, tighter arteries and reduced kidney function when using NSAIDs.

People who have had a heart attack, heart failure or coronary artery disease should avoid NSAIDs (other than aspirin). If you do have to take aspirin and a non-aspirin NSAID, take the aspirin at least two hours before the other drug. Use the NSAID for as short a time as possible.

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IUDs and Contraceptive Implants Are First Choice for Teens

The American College of Obstetricians and Gynecologists (ACOG) just issued guidelines for the use of contraception by teens. The first two choices recommended may surprise some people: the IUD and the contraceptive implant. ACOG published their recommendations online September 20.

Eight out of every 10 adolescent pregnancies are unintended. A recent government survey found that 43% of girls ages 15 to 19 have had sex. For these girls, as well as for sexually active women, the IUD and contraceptive implant are both between 99% and 100% effective at preventing pregnancy. (Far fewer than 1% of teen girls will get pregnant in a year if using one of these methods).

By contrast, the pill is 91% effective. The lower effectiveness of the pill is blamed on missed doses or irregular dosing (different dose times on different days). None of these methods — IUD, implant or pill — prevents the spread of sexually transmitted infections. For this reason, condoms are also recommended. But condoms by themselves are too likely to fail to make them anyone's first choice for preventing pregnancy.

An IUD is a small t-shaped plastic or copper rod that is inserted into the uterus. One device can provide birth control for up to 10 years. Modern IUD brands have a very low risk for infection, and they do not affect fertility after they are removed. The implant is a thin rod that a doctor inserts just under the skin of the upper arm through a small incision. The implant is the size of a matchstick. The most common type of IUD and the implant release hormones to prevent pregnancy. The ACOG guidelines recommend that doctors explain these two options to every sexually active teen girl.

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More News in Brief

    • Short Treatment with New Drug May Help Multiple Sclerosis. Multiple sclerosis (MS) causes episodes with numbness, weakness or lost nerve function. Over time, it can become disabling. This month there was good news concerning progress against MS. The U.S. Food and Drug Administration (FDA) approved a new MS drug, Aubagio (teriflunomide). And a drug that is still not approved was shown in two studies to have a substantial benefit for MS patients. This up-and-coming drug is called "BG-12," a version of the chemical fumarate. It works by protecting nerves against injury. It is given as two doses by mouth. This short treatment seems to affect the course of MS for months or years.

      The New England Journal of Medicine published the two studies about BG-12 September 20. The studies included roughly 12,000 and 14,000 people. Both studies randomized patients with MS to take either BG-12 or placebo. One study had a third group that received a commonly used injectable MS drug, glatiramer (Copaxone). Both studies tracked patients for two years.

      The results from the two studies were both good. In the first study, 27% of MS patients who received BG-12 had relapses, compared with 46% in the placebo group. About 18% who received the drug developed disability, compared with 27% in the placebo group. There were fewer people who had new problem areas on MRI brain scans if they had received the drug. In the study that compared BG-12 to Copaxone, those patients who had BG-12 seemed to do best.

      In these studies, side effects of BG-12 were generally mild. They included flushing, diarrhea, nausea and stomach pain. But the FDA will need longer safety studies before it can consider approving this new drug. If we are lucky, it will pass safety studies and become available in the next several years.

    • Only Half of People With High Blood Pressure Have it Under Control. The U.S. Centers for Disease Control and Prevention released numbers on September 4 that show how well we are controlling high blood pressure. As a nation, we aren't looking very good. The journal Morbidity and Mortality Weekly Report published the study. About 30% of adults ages 18 and older either had high blood pressure, or said they were taking medicine to control high blood pressure. This added up to almost 70 million people. And 53% of them did not have their blood pressure numbers in good control.

      Why did so many people have poor control? Among those who had high blood pressure, 39% didn't know about their condition before they had this check. Another 16% knew about their high blood pressure, but hadn't started treatment. It is easy to understand how blood pressure could run high in these groups. A third group — 45% — had received medicines from their doctors. But they were not yet successful at bringing the numbers down. Control of blood pressure dramatically reduces the risk for stroke, angina, heart attack, heart failure and premature death. To see this benefit, we have work to do.

    • Weight-Loss Surgery Leads to Better Health. Weight-loss surgery results in significant lost weight, less diabetes, better blood pressure and improved cholesterol levels, according to a six-year study. It was published in the Journal of the American Medical Association September 18. This study looked at 1,150 severely obese people. Four hundred of them had gastric bypass surgery, a type of weight loss surgery. After 6 years, people in the surgery group had lost about 28% of their weight. The no-surgery group lost very little weight. Among those who had type 2 diabetes before surgery, 62% who had surgery no longer had the disease at the study's end. About 42% of those with high blood pressure returned to normal pressure. Within the group that did not have surgery, 17% who did not have diabetes developed the disease. This happened to only 2% of those in the surgery group who didn't start out with diabetes. There are risks to weight loss surgery, but there are also benefits. The challenge is to "weigh" the risks and benefits.
  • West Nile Virus Cases are Climbing. It's a big year for mosquitoes. And it's the biggest year for West Nile virus that we have seen in the last decade. The disease, carried by mosquitos — has been reported in 48 states. As of September 18, the CDC reported that 3,142 cases of West Nile virus had been diagnosed this year. There have been 134 deaths. Most people who get West Nile virus get a temporary fever, but do not even realize that they have this disease. A specific diagnosis is made in people who are more ill with the disease. Fifty-two percent of these confirmed cases affected the nervous system (causing meningitis or encephalitis); 48% caused symptoms that did not affect the nervous system. According to the CDC, two thirds of the cases have occurred in seven states (Texas, Mississippi, Michigan, South Dakota, Louisiana, Oklahoma and California). Nearly 40% of all cases have been in Texas.

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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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