Commentary by Cara Litvin MD, Executive Editor, Clinical Correlations
The sensation of déjà vu was likely very common this week. First, we experienced a flashback to 1994 when we saw OJ in handcuffs again…and then Hillary unveiled her new plan for universal health care. Her plan would require everyone to buy insurance, but emphasizes choices, including both the currently existing private options in addition to a public plan similar to Medicare. The plan also includes tax credits for families and small businesses to help them cover the costs of insurance and would prohibit insurance companies from denying coverage for any reason. Although many people still feel uneasy about the words “Hillary” and “healthcare” uttered in the same sentence, this new plan is strikingly different from her previous early 1990s plan which was a much more radical plan requiring major bureaucratic restructuring and many regulations.
Off the beaten track this week came a report from the ICAAC (Interscience Conference on Anti-microbial Agents and Chemotherapy) further confirming that statins are a wonder drug. Apparently, statins may have an anti-bacterial and anti-fungal effect, adding to their long list of possible pleiotropic benefits. In laboratory studies, statins, particularly simvastatin, inhibited both sensitive S. aureus and Candida species. Although their antimicrobial effects are not felt to be strong enough to treat infections, they may definitely play a role in preventing infection, although of course more studies are needed to explore this possibility.
In other news, the FDA approved a genetic test that may help to determine which patients have a higher risk of bleeding when taking coumadin. The test detects two genetic polymorphisms that affect warfarin metabolism, which may be present in up to one third of patients. The FDA also recently changed the labeling of coumadin to include a warning that patients with these genetic variations may have an increased risk of bleeding when taking the drug.
Finally, published in Annals this week are two noteworthy articles regarding diabetes. The first, a systematic review comparing oral hypoglycemics, is a very thorough summary of the evidence of both the benefits and harms of the various oral hypoglycemic agents obtained from 216 controlled trials. The review concluded that older agents such as second generation sulfonylureas and metformin have similar or superior effects on intermediate outcomes such as hemoglobin a1c and lipids when compared to newer agents (thiazolidinediones, A-glucosidase inhibitors, and meglitinides). Also, referring to the recent controversy regarding rosiglitazone, the reviewers found no compelling evidence to suggest a statistically significant difference between specific oral agents in terms of cardiovascular outcomes other than congestive heart failure. Interestingly, evidence was inconclusive on oral hypoglycemic agents’ effects on microvascular, macrovascular, and mortality outcomes.
In a separate study in Annals looking at the effects of exercise on glycemic control in diabetic patients, patients were randomized to an exercise program (aerobic training, resistance training, or both) and compared to a sedentary control. Aerobic training and resistance training both improved hemoglobin a1c about half a percentage point, and a1c was further decreased in the group receiving both types of training (nearly 1 percentage point lower than the control group). In a sense, this study may be viewed as a counterpart to the systematic review. When looking at cost, side effects, and possible cardiovascular benefits, exercise may be one of the best weapons in our armaterium to combat diabetes.