Clinical Briefs by Louis Kuritzky, MD
Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for Abbott, AstraZeneca, Boehringer Ingelheim, Daiichi, Sankyo, Forest Pharmaceuticals, Lilly, Novo Nordisk, Takeda.
Combination therapy to prevent DM2
Source: Zinman B, et al. Low-dose combination therapy with rosiglitazone and metformin to prevent type 2 diabetes mellitus (CANOE trial). Lancet 2010;376:103-111.
Clinicians are increasingly presented with the tasks of addressing not only a burgeoning population of type 2 diabetics, but an equally voluminous group of prediabetics. It has been clearly established that numerous interventions can prevent the development of DM2 in prediabetes, including metformin, diet, exercise, thiazolidinediones, alpha-glucosidase inhibitors, and pharmacologically induced weight loss. Typically, 7%-10% of prediabetes will progress to overt DM2 per year if untreated. Pharmacotherapy, diet, and exercise have each been shown to reduce the incidence of DM2 by more than 50% among prediabetics, but each of the pharmacotherapy trials has been based on monotherapy.
Zinman et al report on the CANOE trial (Canadian Normoglycemia Outcomes Evaluation), which randomized 207 prediabetics to either low-dose metformin (500 mg bid) plus low-dose rosiglitazone (2 mg qd) or placebo. Subjects were followed for 3.9 years.
Relative risk reduction for development of DM2 was impressive: 66%. As has been seen in earlier diabetes prevention trials, in the placebo group almost 40% of prediabetics had developed DM2 over the 4-year interval of study. Tolerability of the low-dose regimen was excellent, with only four patients discontinuing medication for adverse effects possibly linked to medication. Low-dose combination treatment offers another reasonable choice to offer patients with prediabetes.
Home-based diagnosis of sleep apnea
Source: Skomro RP, et al. Outcomes of home-based diagnosis and treatment of obstructive sleep apnea. Chest 2010;138: 257-263.
Clinicians are increasingly aware of the adverse outcomes associated with obstructive sleep apnea (OSA), including hypertension, cardiac arrhythmia, stroke, MI, and overall CV mortality. Overnight polysomnography (OPSG) in a sleep laboratory has been recognized as the gold standard for diagnosis, but because this process is expensive, time-consuming, and not readily available in all settings, other methodologies, if sufficiently accurate, would be welcome.
Skomro et al compared home-based OSA diagnosis and treatment with OPSG in 102 Canadians referred for evaluation of potential OSA due to associated symptoms (e.g., daytime sleepiness) and/or signs (e.g., snoring). Outcomes included the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, SF-36, and adherence to CPAP after 1 month.
Home diagnosis was performed with Embletta, a portable battery-operated device that records position, activity, leg movement, oxygen saturation, pulse, oral flow, and respiratory events. Confirmation of OSA was followed by auto-CPAP for 1 week, followed by further fixed CPAP derived from auto-CPAP measurements.
After 1 month, outcomes in the subjects diagnosed and treated with home methodology were essentially the same as those diagnosed by means of OPSG. Technical factors led to the need to repeat Embletta in a small subset (16.6%). These data support a role of home methodologies for diagnosis and management of OSA.
What is the risk of bariatric surgery?
Source: Birkmeyer NJ, et al. Hospital complication rates with bariatric surgery in Michigan. JAMA 2010; 304:435-442.
Bariatric surgery has become the second most common abdominal surgical procedure in the United States. Both the likelihood of a favorable outcome and the frequency of adverse surgically related events may be linked to the frequency with which a particular surgery is performed. To that end, the American College of Surgeons and the American Society for Metabolic and Bariatric Surgery have established criteria for accreditation as a Center of Excellence in bariatric surgery.
Birkmeyer et al report upon surgical outcomes in 25 hospitals throughout the state of Michigan, including more than 15,275 bariatric surgeries reported from 2006 to 2009. Two of the 25 hospitals had Center of Excellence status.
Mortality (within 30 days of surgery) was very low (< 0.2%), and serious adverse events were similarly infrequent (1.6%-3.5%). Adverse outcomes were inversely related to hospital case volume, but did not differ significantly between Centers of Excellence and hospitals without such designation. Hospitals with at least 300 cases/year and individual surgeons with experience of least 100 procedures/year had the fewest adverse outcomes.
Bariatric surgery is a generally safe and effective tool. Although adverse outcomes are infrequent, they are related to the volume with which the procedure is performed.
Clinicians are increasingly presented with the tasks of addressing not only a burgeoning population of type 2 diabetics, but an equally voluminous group of prediabetics.Subscribe Now for Access
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