ShortCuts- This Week in the Journals

October 27, 2008

800px-centralpark.pngCommentary by Josh Remick MD, NYU Senior Chief Resident 

As this endless political campaign is entering its final days, I’d like to start this week’s ShortCuts with a plug to vote.  It doesn’t matter who you vote for, just so long as you make your voice heard.  While we’re on the topic of the campaign, an issue that’s important to many of us in the medical field is the two presidential candidates’ health care plans.  If you’re still unsure where they stand on the issue of health care reform, here’s a nice summary from The New England Journal of Medicine

So while it’s hard not to talk politics these days (and while we’re on the subject, one last article about the unwillingness of each campaign to release medical information about their candidates) it’s certainly not hard for doctors to prescribe medicine.  We’re great at it.  In fact we’re so good at it that half the time we don’t even prescribe medicine!  That’s right, a new study in the British Medical Journal reports that about half of all doctors surveyed reported prescribing placebos to patients.  Many doctors would tell their patients that they were prescribing a medicine that is “not typically used for your condition but might benefit you.”  However, while placebos have been shown in clinical trials to have significant benefit, what was troubling in this study was that many doctors appear to be using sedatives and antibiotics as placebos, rather than the classic “sugar pill.”  In a commentary in the New York Times this troubling issue was mentioned but largely left unexplored compared to the ethical issues raised about treating patients with placebos for diseases that many believe are more psychosomatic than anything else.  In theory, the trust and bond of the doctor-patient relationship may be broken by this apparent deception.   In summary, we practice medicine in a world where patients are educated and often want “something.”  How we satisfy that desire in patients is up to the individual, but clearly many doctors are opting for prescribing something rather than nothing.

Speaking of prescribing pills, researchers this week published two separate articles that may one day spell the end of that whole “diet and exercise” thing.  Cause who wants to really get off the couch anyways right?  In the Lancet researchers published results of a safety and efficacy phase II trial of a novel weight loss medication called Tesofensine, which showed that 0.5 mg resulted in an almost 10% mean weight loss over a 24 week period compared to placebo and diet.  While side effects included an increase in heart rate of an average of 7.4 beats per minute without any changes in systolic or diastolic blood pressure, they also included dry mouth, constipation, nausea and insomnia.  Whether or not the weight loss seen can be maintained and whether these results truly are better than diet and exercise remain to be explored with a phase III clinical trial.  And just in case you thought diet-pills would replace healthy eating, now there’s evidence that an exercise pill may not be that far away!  In an article in the New England Journal of Medicine this week, researchers appear closer to harnessing the positive benefits of exercise in a pill form.  The findings that both PPAR-δ and AMP-activated protein kinase play critical roles in metabolic and contractile function of myofibers, especially during exercise, has led to investigation of whether activation of these nuclear proteins can result in the beneficial effects of exercise.  Interestingly, mice treated with AICAR (an activator of AMP-activated protein kinase) showed a 44% increase in endurance and metabolic changes consistent with exercise (like upregulation of skeletal GLUT-4 receptor); effects that mimic those of training.  Will this be the new doping drug of choice?  Will it be the new Lipitor prescribed for anyone with a hint of cardiovascular disease?  Or will its transition from mice to humans ultimately lead nowhere?  The answers appear to be coming soon.

So with all that said, I’m feeling the need to go eat some fruit and get to the gym, so I’ll wrap up this week’s shortcuts with a few rapid fire highlights.  The ADA updated their algorithm for the management of hyperglycemia in Type II Diabetics this week in Diabetes Care.  Some of the highlights include recommending exenatide or pioglitazone for patients in whom hypoglycemia may be particularly harmful (such as those with hazardous jobs) and they also no longer recommend using rosiglitazone because of the association with increased cardiovascular risk.  Still recommended are hemoglobin A1C goal <7%, initiation of lifestyle modification and metformin upon diagnosis and addition of other meds (including basal insulin) after 2-3 months if A1C is not at goal.  Not to be outdone, the AGA updated their guidelines for the management of GERD in Gastroenterology.  There is a stronger emphasis on the use of Proton-Pump Inhibitors (PPIs) in the update as they are deemed more effective than H-2 Receptor Antagonists.  Twice daily PPI should be used if once daily cannot control symptoms, but long term use of PPIs should be titrated down to the lowest possible dose as a result of side effects (see prior posts on  Lastly, antireflux surgery should only be used as a last resort if the patient is intolerant to PPIs. 

The USPSTF came out this week recommending primary care interventions during pregnancy and after childbirth to encourage breast feeding.  Citing the proven benefits of breast feeding, which include decreased risk of breast and ovarian cancer, decreased risk of ear, respiratory and gastrointestinal infections in infancy and decreased risk of asthma, type II diabetes and obesity in childhood, the USPSTF feels that it is no longer acceptable to be passive on this issue.  Lastly (and like you needed a research study to prove this one), adults who eat rapidly or until they are full are more likely to be overweight.  Maybe we should just prescribe those fast eaters a diet pill…