PrimeCuts: This Week in the Journals

February 8, 2010

Shortcut 3Rachana Jani, MD

Faculty peer reviewed

Women’s health stepped into the spotlight this week as the public and the media painted New York City red for cardiovascular awareness.  And appropriately so, as new information about heart disease in women continues to emerge. In the Annals of Rheumatic Diseases, a population-based study found that elderly women with gout were at increased risk of acute myocardial infarction compared to men with this ailment.  De Vera et al found that women were at an increased overall risk of 39% for MI, independent of age, comorbidities, and medications [1].  The exact mechanism eludes researchers at this time, but they speculate that women respond to hyperuricemia differently than men, leading to a more atherogenic and thrombogenic response.  

Diabetes and its complications were also alluded to this week. In JAMA, researchers found that three-year risk of death and myocardial infarction was increased in those with proteinuria despite differences in estimated glomerular filtration rate (eGFR).  The study showed an increase in relative rates of death, MI, and end-stage renal disease (1.22,1.18,1.92 respectively) independent of the level of eGFR[2].

The Journal of the American College of Cardiology touches on the need for enhanced communication between physician and patient this week by acknowledging what a large role homeopathic medicine plays in patient lifestyle [3].  Tachjian et al reviewed over 90 herbal medications and their cardiovascular effects, noting 15 in particular that increase the serum levels of common cardiac medications through cytochrome P450 enzymes.  Much of the time, physicians are unaware of all the supplements that patients are taking, partly because patients do not view herbal supplements as part of full disclosure and some fear judgment by their physicians.  These barriers in communication not only limit insight into patients’ medical history, but also serve as a barrier to teamwork and goal-forming that ideally exists between physician and patient.

The Journal of General Internal Medicine found that there is a discrepancy between the goals diabetics have for their health and quality of life and those that physicians hold for their patients, even though the ultimate goal is often the same.  This prospective cohort study found that while physicians rank hypertension as one of their most important concerns for patient welfare, only 18% of diabetics share this view [4]. This difference was partly attributable to patients being unaware of the importance of managing blood pressure and the priority that patients place on pain and depression.

Some good news is that during the American Academy of Pain Medicine’s meeting this week, there were some promising results for the treatment of pain.  Iyengar et al looked at four placebo-controlled trials of duloxetine in those who suffer from fibromyalgia and major depression.  They found a 50% improvement in pain in both low and high depression scores as compared to placebo, both of which were statistically significant [5].  

Biologics also continue to play new roles in pain management in those who suffer from autoimmune disease.  This week’s British Medical Journal looked at etanercept, a tumor necrosis factor-alpha inhibitor, and found a significant improvement in psoriatic skin manifestations when patients received etanercept twice weekly as opposed to weekly. This blinded, multicenter study found that 46% of patients on a twice-weekly regimen of etanercept completely cleared lesions as compared to 32% in the once-a-week group.  Unfortunately, there was not a significant effect on psoriatic arthritis, a manifestation that occurs in approximately one third of psoriasis sufferers [6].  It is unclear why the skin manifestations responded so well to treatment and not the arthritic symptoms.

This week’s New England Journal of Medicine also focused on immunomodulating agents for a different autoimmune process: multiple sclerosis [7].  MS is often treated with injectable medications, an obstacle for some patients.  In this double-blind randomized study, oral fingolimod, a sphingosine-1-phosphate-receptor modulator that inhibits lymphocytic exit from lymph nodes, showed a significant reduction in relapse rates as compared to placebo or intramuscular interferon beta-1a.  Another oral drug, cladribine, which targets specific lymphocyte subclasses, also showed a significant decrease in the relapse rate as compared to placebo [8].  Though exciting news, as with all immunomodulators, side effects were concerning. Fingolimod was associated with conduction defects and cladribine with leukocytopenia.  This week the FDA warned of a risk of progressive multifocal leukoencephalopathy with natalizumab, another immunomodulator used in multiple sclerosis.

Lastly, despite all the new therapies available, the CDC reminds us not to forget preventable illnesses. Adults are not receiving all of the recommended age-appropriate vaccinations. This is in part due to a lack of institutional access and to a lack of coverage by insurance companies, problems that may improve in the near future.  That being said, even rates for hot items such as the H1N1 influenza vaccine have declined as the majority of Americans assume the H1N1 pandemic is over, as noted in the New York Times [9]. Anne Schuchat, MD, director of the CDC’s National Center for Immunization and Respiratory Diseases, warns that even with a decrease in activity over the last three weeks, the H1N1 strain is still circulating and poses a threat to those not vaccinated, so it may be time to visit your friendly neighborhood doctor.

Dr. Jani is 3rd year resident in internal medicine at NYU Medical Center.

Peer reviewed by Michael Tanner MD, Associate Editor, Clinical Correlations

References:

1. De Vera MA, Rahman MM, Bhole V, Kopec JA, Choi HK. Independent impact of gout on the risk of acute myocardial infarction among elderly women: a population-based study. Ann Rheum Dis. 2010; DOI: 10.1136/ard.2009.122770.

2. Hemmelgarn BR, Manns BJ, Lloyd A, et al. Relation between kidney function, proteinuria, and adverse outcomes” JAMA. 2010;303(5):423-429.

3. Tachjian A, Viqar M, Jahangir A. Use of herbal products and potential interactions in patients with cardiovascular diseases. J Am Coll Cardiol. 2010;55:515-525. doi:10.1016/j.jacc.2009.07.074

4. Zulman DM, Kerr EA, Hofer TP, Heisler M, Zikmund-Fisher BJ. Patient-provider concordance in the prioritization of health conditions among hypertensive diabetes patients. J Gen Intern Med 2010; DOI: 10/1007/s11606-009-1232-1.

5. Iyengar S, et al. Fibromyalgia and comorbid major depressive disorder: assessment of mood and pain response to duloxetine hydrochloride compared to placebo. AAPM 2010; Abstract 121.

6. Sterry W, Ortonne J-P, Kirkham B, et al. Comparison of two etanercept regimens for treatment of psoriasis and psoriatic arthritis: PRESTA randomized double blind multicenter trial. BMJ.  2010; 340: c147. DOI:10.1136/bmj.c147.

7. Cohen JA, Barkhof F, Comi G, et al. Oral fingolimod or intramuscular interferon for relapsing multiple sclerosis. N Engl J Med. 2010;362(5):402-425.

8. Giovannoni G, Comi G, Cook S, et al. A placebo-controlled trial of oral cladribine for relapsing multiple sclerosis. N Engl J Med. 2010;362(5):416-426.

9. http://www.nytimes.com/2010/02/06/health/06flu.html?ref=health

 

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