Clinical Briefs in Primary Care
Clinical Briefs in Primary Care
Prognostic Value of ABPMs in patients with Treated Hypertension
Source: Clement DL, et al. N Engl J Med. 2003;348(24):2407-2415.
Ambulatory blood pressure monitoring (ABPM) has been available for more than a decade, yet it has not attracted routine application in clinical practice. Several factors have recently stimulated increased interest in ABPM, not the least of which is the acknowledged association between increased ABPM and adverse clinical outcomes. Indeed, ABPM measurements have been shown to correlate better with presence of target organ damage than office blood pressure measurement. Recently, Medicare has expanded coverage to include payment for ABPM when performed for suspected white coat hypertension.
Clement, et al prospectively studied hypertensive subjects (n = 157) who were followed using both ABPM and office BP measurement for a mean of 5 years. They measured relative risk of subsequent cardiovascular events by increments in ABPM 24-hour mean BP, systolic BP, diastolic BP, and nocturnal BP, adjusted for gender, smoking, diabetes, cholesterol, BMI, and office BP.
For each one standard deviation increase in ABPM, the relative risk of cardiovascular events increased 34% for 24-hour mean BP, 30% for mean ABPM systolic BP, and 27% for mean ABPM diastolic BP. Although the prognostic information obtained from ABPM was consistent, and provided information beyond that obtained with simple office BP, it did not predict all cause death. AS ABPM becomes more accessible, less costly, and more often covered by third-party payers, it may find an increasing role in standard care.
Tazarotene Cream in the Treatment of Psoriasis
Source: Weinstein GD, et al. J Am Acad Dermatol. 2003;48:760-767.
Tazarotene (TZT) is a receptor-selective retinoid used topically. Tazarotenic acid, the primary metabolite of TZT, binds to the retinoic acid receptor-gamma sites in the keratinocyte nucleus. Effects of TZT upon gene transcription include normalization of abnormal keratinocyte differentiation, reduction of inflammation, and reduction of epidermal hyperproliferation, each of which plays an important role in cutaneous psoriasis (PSR). Although TZT gel formulations have already been demonstrated to be effective in PSR, local adverse effects have been problematic. The cream formulation of TZT was developed in an attempt to reduce these adversities. The study included 1,303 patients with PSR who applied TZT cream (or vehicle) once daily for 12 weeks.
Clinical success was achieved with TZT cream, and persisted through a posttreatment observation period (12 weeks). The authors mention that local adverse effects were seen with the cream such as pruritus, burning, erythema, and stinging, but no statistical comparison between adverse effects seen with the cream formulation versus earlier studies employing the gel formulation were provided. Nonetheless, the authors comment that availability of both gel and cream formulation will offer clinicians a greater diversity of therapeutic choices for psoriasis.
Antihyperglycemic Effect of Oolong Tea in Type 2 Diabetes
Source: Hosoda K, et al Diabetes Care. 2003;26(6):1714-1718.
Animal studies have shown that tea consumption can reduce plasma glucose. Teas fall into three primary categories: green, oolong, and black, which, though they all come from the same plant species, are differentiated by the fermentation technique with which they are processed. Green tea is not fermented, oolong is partially fermented, and black tea is fully fermented.
Study subjects were 20 Taiwanese diabetic men and women randomly assigned (cross-over design) to 4-week sessions of drinking either water or oolong tea. Daily consumption of oolong tea was 50 ounces, with specific instructions for ensuring consistency of brewing methodology. The patients in this study were already receiving oral hypoglycemic agents.
Oolong tea reduced plasma glucose to a statistically significant and clinically relevant degree: 220 mg/dL (pretreatment) to 162 mg/dL (posttreatment). Water had no significant effect upon glucose levels. There were no adverse effects attributable to Oolong tea, although the strength of the tea brewed was acknowledged to be greater than that consumed in the typical Taiwanese diet. This study supports the role of oolong tea to enhance glucose control in type 2 diabetes.
Metformin and Thiazolidinedione Use in Medicare Patients with Heart Failure
Source: Masoudi FA, et al. JAMA. 2003;290:81-85.
With expert guidance encouraging increasingly austere levels of A1C control for diabetics, clinicians have been required to become more sophisticated and diversified in diabetes (DM) pharmacotherapy. Although insulin sensitizers such as metformin (MET) and the thiazolidinediones (TZD) have played a progressively more prominent role in DM control, heart failure (CHF) is a listed precaution for TZDs and contraindication to MET use.
Masoudi and colleagues analyzed data obtained from the National Heart Care Project, an initiative to improve quality of care for hospitalized CHF patients. In a sample population (n = 12,505) from 1998-1999, approximately 7% of patients discharged with a diagnosis of CHF received prescription for TZD or MET, despite the precautionary labeling for both. A comparative sample from the same population obtained 2 years later (n = 13,158) indicated that not only had TZD/ MET prescribing not shown greater conformity to existing prescribing recommendations, but rather the number of persons receiving either drug had actually increased to 11% (MET) and 16 % (TZD).
Prescription of MET or TZD to patients with CHF presents a recognized risk. Even if some of the provision of these medications is based upon the belief that the benefits of the medication for DM outweigh the risks for worsening CHF, there likely remain a number of patients who receive inappropriate treatment because of lack of clinician awareness. Masoudi et al endorse enhanced adherence to recommended precautionary guidance for patients with CHF and DM, until studies prove whether such treatment can be safely used.
Alcohol Consumption Patterns and Biologic Markers of Glycemic Control
Source: Kroenke CH, et al. Diabetes Care. 2003;26:1971-1978.
Several decades of observational data have indicated that moderate alcohol consumption (ALC) is associated with reduced incidence of cardiovascular end points, particularly stroke and myocardial infarction. The relationship between ALC and glycemic control has been less clearly established. Using the population enrolled in the Nurses Health Study II (n = 116,671), a prospective cohort study, Kroenke and colleagues studied the relationship between ALC and glycemic control in healthy women, specifically excluding individuals who had preexisting cardiovascular or other serious disease. In addition to stratification of drinking behaviors, women were categorized by BMI.
The most common alcoholic beverage chosen in this population was white wine. ALC was found to relate inversely with A1C levels, when adjusted for multiple covariates. There was no difference in the relationship when analyzed for a particular type of alcoholic beverage, nor did it make a difference whether ALC occurred with meals or in other venues. Potential mechanisms for the association of ALC with improved A1C include alcohol-induced increases in insulin binding factors, reduced hepatic gluconeogenesis, and increases in plasma leptin levels, which may decrease appetite for sweets. Kroenke et al conclude that 1-2 drinks on several days per week are associated with favorable effects on glucose homeostasis.
Azelaic Acid Gel as a New Treatment for Papulopustular Rosacea
Source: Thiboutot D, et al. J Am Acad Dermatol. 2003;48:836-845.
Rosacea (ROS), although sometimes called "acne rosacea," is unrelated pathophysiologically to acne. The pathology of ROS is characterized by vascular, inflammatory, and tissue proliferative components which results in one or more of flushing, erythema, telangiectasia, inflammatory lesions, edema, localized cutaneous swellings, and ocular symptoms. Currently available treatments for ROS include systemic antibiotics, topical antibiotics, and oral isotretinoin, each of which has its own limitations and adverse effects profile. Initial observations have indicated some potential efficacy of azaleic acid, which is recently available in a gel formulation, for ROS.
This report compared azaleic acid gel (AZA) with vehicle in ROS in 2 separate randomized, controlled trials.
AZA was applied twice daily for 12 weeks, after a suitable washout period from prior treatments. Subjects (n = 664) had moderate ROS (mild and severe patients were excluded). Severity of ROS was stratified a 5-point scale, with 1 including compete remission, and indicating severe disease (and hence a deterioration from baseline). AZA gel provided a statistically significant improvement over vehicle, with approximately half of treated individuals showing disease resolution or marked improvement. In the AZA-treated patients, 38% experienced transient, mild-moderate cutaneous burning, stinging, or itching. Such symptoms were considered severe in < 1%.
AZA gel has been demonstrated to be a safe and effective treatment for ROS.
Prognostic Value of ABPMs in patients with Treated Hypertension; Tazarotene Cream in the Treatment of Psoriasis; Antihyperglycemic Effect of Oolong Tea in Type 2 Diabetes; Metformin and Thiazolidinedione Use in Medicare Patients with Heart Failure; Alcohol Consumption Patterns and Biologic Markers of Glycemic Control; Azelaic Acid Gel as a New Treatment for Papulopustular RosaceaSubscribe Now for Access
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