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Physician's First Watch

May 13, 2008

Perioperative Beta-Blockers Increase Risks After Noncardiac Surgery

Perioperative beta-blockers increase the risk for stroke and death after noncardiac surgery, according to a study published online in Lancet.

In an international, double-blind, industry-supported study, some 8350 patients with (or at risk for) atherosclerotic disease were randomized preoperatively to a 30-day regimen of extended-release metoprolol or placebo. Patients already receiving beta-blockers were excluded.

By 30 days, patients on metoprolol showed favorable results for the primary endpoint (a composite of cardiovascular death, nonfatal MI, and nonfatal cardiac arrest) — but they had significantly higher rates of death and stroke.

The authors write that current perioperative guidelines ought to be reconsidered. Commentators agree that the regimen used carries more risk than benefit; however, they recommend a lower-dose long-acting regimen that is "titrated to effect" at least 7 days before surgery. That regimen, they say, "is associated with overall benefit compared to risk."

Asked to comment, Journal Watch Cardiology editor-in-chief Harlan Krumholz says that using extended-release metoprolol to reduce risk in patients undergoing noncardiac surgery "has suddenly become a lot more controversial than it was yesterday. If this strategy is contemplated, then it should be done with the patient's knowledge of the potential trade-offs in outcomes."

[Editor's note: Although Lancet has released this study from embargo, it has not posted it on its website. Rather than delay coverage while awaiting those postings, we have provided a link to Lancet's early-release page, where the study will eventually appear.]

LINK(S):

Lancet early online publication page (Free)

Published in Physician's First Watch May 13, 2008

Patients with Urologic Cancers May Face Higher Risk for Colorectal Cancer — and Vice Versa

Patients with urologic cancers may face increased risk for colorectal cancer — and vice versa — reports Archives of Internal Medicine.

Researchers retrospectively analyzed data on nearly 187,000 patients with urologic cancers and 358,000 with colorectal cancer from 1973 to 2000.

Compared with the general population, patients with urologic cancers had higher risks for subsequent colorectal cancer. Risk was increased by 10% with initial bladder cancer, 14% with renal parenchymal cancer, 44% with renal pelvis cancer, and 80% with ureteral cancer. Meanwhile, patients with colorectal cancer had higher risks for subsequent urologic cancers. Bladder cancer risk was increased by 13%; renal parenchymal, 50%; renal pelvis, 59%; and ureteral, 100%.

Risk for a second cancer was even greater when the initial cancer was diagnosed at an early age.

Possible explanations include environmental exposures, genetic predisposition, screening bias, and cancer treatment effects. The authors conclude that patients with some urologic cancers may benefit from earlier and more frequent colorectal cancer screenings.

LINK(S):

Archives of Internal Medicine article (Free abstract; full text requires subscription)

Published in Physician's First Watch May 13, 2008

Transition to CFC-Free Inhalers Mandatory by Next Year

Your patients may be asking about a New York Times story that details the mandatory transition from inhalers with chlorofluorocarbons (CFCs) to ones with ozone-friendly hydrofluoroalkane (HFA) by January 1, 2009.

Patients may notice that the newer inhalers:

• are about three times as expensive;
  
• must be pumped four times before use;
  
• have a weaker spray;
  
• require a slower inhale;
  
• need to be cleaned weekly.
  

The FDA says that it has logged over 400 complaints since January 2007 regarding the cost and functionality of HFA inhalers, the Times reports.

The four currently available HFA inhalers are Ventolin, ProAir, Proventil, and Xopenex.

LINK(S):

New York Times story (One-time registration required)

Published in Physician's First Watch May 13, 2008

May 12, 2008

Generic Version of Restless Legs Syndrome Drug Approved

A dopamine agonist used to treat restless legs syndrome — Requip (ropinirole hydrochloride) — has been approved in generic form, the FDA announced on Friday.

Other indications for Requip (for example, Parkinson disease) are still protected by patent. The generic's manufacturers may also seek approval for that indication once the patent expires later this month.

As with Requip, the generic equivalents will carry a warning about sudden somnolence during activities of daily living.

LINK(S):

FDA announcement (Free)

Requip label (Free PDF)

Published in Physician's First Watch May 12, 2008

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