Physician's First Watch: Archives

Atypical Antipsychotics Associated with Weight Gain and Other Adverse Metabolic Effects in Kids

Children and adolescents taking atypical antipsychotics show significant weight gain and other adverse metabolic effects, JAMA reports.

In an observational study, researchers followed nearly 300 children (between ages 4 and 19) who were beginning one of the following antipsychotic drugs: aripiprazole, olanzapine, quetiapine, or risperidone. Patients with eating disorders were excluded.

After a median of 11 weeks' treatment:

• weight (the primary endpoint) increased an average of 8.5 kg with olanzapine, 6.1 kg with quetiapine, 5.3 kg with risperidone, 4.4 kg with aripiprazole, and 0.2 kg in controls not taking drugs;
  
• total cholesterol increased significantly for olanzapine and quetiapine, as did triglycerides, non-HDL cholesterol, and the triglyceride/HDL ratio;
  
• triglycerides also increased with risperidone;
  
• significant metabolic changes did not occur in controls or with aripiprazole.
  

Editorialists say that although the drugs can be lifesaving, "the widespread and increasing use of atypical antipsychotic medications in children and adolescents should be reconsidered."

LINK(S):

JAMA article (Free abstract; full text requires subscription)

JAMA editorial (Subscription required)

Published in Physician's First Watch October 28, 2009

Incremental Cardiovascular Benefits of Increased HDL

Raising HDL levels, by whichever treatment, is associated with decreased risk for coronary events, according to an Archives of Internal Medicine study.

Researchers examined public-domain data on some 450 patients — participants of the Framingham Offspring Study — who started lipid-lowering therapy between 1975 and 2003. (The analysis was supported and partially conducted by a drug manufacturer.)

After an average follow-up of 8 years, the hazard ratio for suffering a coronary event was lowest among those experiencing the greatest increase in HDL relative to baseline. A 1% increase in HDL was associated with a 2% decrease in risk. The effect remained significant after adjustment for pretreatment HDL levels, age, and sex.

LINK(S):

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

Published in Physician's First Watch October 27, 2009

H1N1 Update: President Obama Declares 'National Emergency'

Patients may be asking about President Obama's declaration over the weekend that the 2009 H1N1 pandemic constitutes a national emergency.

The Washington Post reports concern that the declaration, which is meant to allow greater flexibility in treating patients, may cause unnecessary alarm and greater demands from patients for flu shots. The declaration allows, for example, hospitals to set up off-site emergency rooms to accommodate possible overflow.

On Friday, the CDC detailed problems with producing enough vaccine, which will not be available in quantity until later in November, according to Dr. Thomas Frieden, the CDC's director.

Meanwhile, the FDA has lifted restrictions to allow emergency use of an investigational antiviral drug, peramivir, in specific circumstances, such as when the patient is not responding to oral or inhaled antiviral therapy. The drug, a neuraminidase inhibitor, is currently in phase III trials.

LINK(S):

Information on the declaration from flu.gov (Free)

Washington Post story (Free)

Transcript of Friday's CDC flu briefing (Free)

FDA announcement on peramivir (Free)

NEJM/Journal Watch H1N1 Influenza Center (Free)

Published in Physician's First Watch October 26, 2009

Reduction in Rotavirus Infection Since Vaccine Introduction

Rotavirus seasons have been shorter, have started later, and have seen fewer positive test results since the introduction of the rotavirus vaccine in the U.S. in 2006, according to an MMWR study.

CDC researchers compared surveillance data from the 2007–08 and 2008–09 rotavirus seasons with the prevaccine period, 2000–06.

They found that after vaccine approval:

• rotavirus season started 6 to 11 weeks later than 2000–06;
  
• the season was 9 to 12 weeks shorter;
  
• the peak percentage of stool samples testing positive for rotavirus was roughly 20%, compared with 45% before vaccine approval.
  

The greatest effects were seen the first year after vaccine introduction.

LINK(S):

MMWR article (Free)

Published in Physician's First Watch October 23, 2009

Complex Insulin Regimens & Type 2 Diabetes

In patients with refractory type 2 diabetes, the addition of certain insulin regimens seems to offer better control and fewer complications, reports the New England Journal of Medicine.

In a trial supported and partly managed by an insulin manufacturer, researchers followed some 700 patients who did not achieve glycemic control on metformin and a sulfonylurea. Patients were randomized to one of three regimens of added insulin:

• twice-daily biphasic insulin aspart;
  
• thrice-daily prandial aspart; or
  
• once-daily (twice if necessary) basal insulin detemir.
  

If glycated hemoglobin was still above targets after the first year, the sulfonylurea was replaced with a second insulin:

• midday prandial was added to the biphasic regimen;
  
• bedtime basal was added to prandial; and
  
• prandial was added to basal.
  

After 3 years, median glycated hemoglobin values (the primary endpoint) were essentially identical among groups. However, the biphasic group was least likely to have achieved a 6.5% hemoglobin level; the biphasic and prandial groups gained more weight than the basal group; and overall rates of hypoglycemia were highest in the prandial group.

LINK(S):

NEJM article (Free)

NEJM editorial (Free)

Published in Physician's First Watch October 23, 2009

Intensified BP Control Benefits Kids with Chronic Kidney Disease

Intensive blood pressure control in children with chronic kidney disease delays progression, reports a New England Journal of Medicine study.

Researchers in the international ESCAPE trial followed nearly 400 children, about two thirds of whom suffered from renal hypoplasia-dysplasia. All received high doses of the ACE inhibitor ramipril. They were then randomized to either intensified blood pressure control (to under the 50th percentile of the normal range, using drugs that do not target the renin-angiotensin system) or to usual control (to the upper ranges of normal, with no added drugs).

After 5 years' follow-up, those receiving intensified BP control showed delayed progression of their kidney disease. About 30% of the intensified group (versus 42% of controls) showed a 50% decline in glomerular filtration rate or progression to end-stage renal disease.

The authors conclude that "the renoprotective effect of intensified blood-pressure control is additive to the potential benefit conferred by high-dose ACE inhibition."

LINK(S):

NEJM article (Free abstract; full text requires subscription)

NEJM editorial (Subscription required)

Journal Watch Pediatrics and Adolescent Medicine summary (Your Journal Watch subscription required)

Published in Physician's First Watch October 22, 2009

Ketorolac for Injection Recalled

American Regent is recalling all lots of its 30 mg/mL ketorolac tromethamine for injection because the product may contain particulate matter due to crystallization, according to a company press release.

Potential adverse effects include blood vessel obstruction leading to venous thromboembolism, as well as anaphylactic reactions.

The recall affects 1- and 2-mL single-dose vials.

LINK(S):

Manufacturer press release (Free)

Published in Physician's First Watch October 22, 2009

Aldosterone Antagonists Underused in Heart Failure

Aldosterone antagonists are prescribed to only one third of eligible heart failure patients at discharge, according to a JAMA study.

Using data from a national quality improvement program comprising nearly 250 hospitals, researchers recorded discharge prescriptions of aldosterone antagonists among some 12,500 eligible patients over a 3-year span. They found that 32% of eligible patients received the drugs, which are recommended in ACC/AHA guidelines. Patients most likely to receive treatment tended to be younger, have lower systolic blood pressure, and have an ICD or pacemaker implant. Usage was also higher among those receiving other evidence-based therapies for heart failure.

The authors note that inappropriate usage — e.g., among those with medical contraindications — was low.

LINK(S):

JAMA article (Free abstract; full text requires subscription)

Journal Watch Cardiology coverage of 2009 ACC/AHA heart failure guidelines (Your Journal Watch registration required)

Published in Physician's First Watch October 21, 2009

Supervised Exercise Improves Knee Pain, Function in the Short-Term

Patients with patellofemoral pain syndrome achieve improvements in pain and function after a program of supervised exercise, although they often don't consider themselves to be recovered, according to a small BMJ study.

Some 130 patients presenting to Dutch general medicine or sports medicine practices with patellofemoral pain syndrome were randomized to supervised exercise or usual care. Exercise patients performed strength, balance, and flexibility exercises with a physical therapist for 6 weeks, and practiced the exercises at home for 3 months. Usual-care patients adopted a wait-and-see approach whereby they avoided pain-inducing activities and rested when in pain.

The exercise group showed significant improvements in pain and function at 3 months and in pain at 12 months, compared with usual care. The two groups did not differ, however, in self-reported recovery at either time point.

LINK(S):

BMJ article (Free)

Published in Physician's First Watch October 21, 2009

Baby Food Recalled

Plum Organics has recalled a batch of Apple & Carrot Portable Pouch baby food because of a potential risk for Clostridium botulinum contamination.

Tests showed that the product did not meet FDA standards for acidity level, according to a company spokesperson. The manufacturer has not received any reports of botulism.

The pouches (4.22 oz.; best-by date: May 21, 2010) are sold at Toys"R"Us and Babies"R"Us.

LINK(S):

Manufacturer's recall notice (Free)

Published in Physician's First Watch October 21, 2009