November 3rd, 2014

Selections from Richard Lehman’s Literature Review: November 3rd

CardioExchange is pleased to reprint this selection from Dr. Richard Lehman’s weekly journal review blog at Selected summaries are relevant to our audience, but we encourage members to engage with the entire blog.

JAMA Intern Med October 2014

Initial Choice of Oral Glucose-Lowering Medication for Diabetes Mellitus (OL): Metformin is the politically correct first treatment for “type 2 diabetes,” although there is only indirect evidence that it is any better than the others. To the existing collection of observational data, we can now add: “LESS IS MORE: Initial Choice of Oral Glucose-Lowering Medication for Diabetes Mellitus: A Patient-Centered Comparative Effectiveness Study.” That sounds like a great study to set up: offer people with newly discovered hyperglycaemia a choice between various drug treatments or none, and then observe the outcomes. Unfortunately, this would have to take a decade or more for collection of long term vascular endpoints. Instead, here we have a retrospective cohort study of a large US health insurance database, and the endpoints are time to addition of a second oral agent or insulin, each component separately, hyperglycaemia, other diabetes related emergency department visits, and cardiovascular events over a prescribing period of four years. The 57.8% of patients who started off with metformin showed reduced subsequent treatment intensification, without differences in rates of hyperglycaemia or other adverse clinical events. That’s a little useful knowledge, but we need much more.

Lancet 1 November 2014 Vol 384

Dual-Antiplatelet Treatment Beyond 1 Year After Drug-Eluting Stent Implantation (pg. 1577): Less is more is becoming quite a theme this week. Can you remember what thienopyridine is? Basically, it’s a grel. A platelet inhibitor that is not aspirin. In the ARTIC-Interruption trial it meant clopidogrel or prasugrel, given after coronary stenting. Now we know that when the magic 12 months have elapsed after the placement of drug eluting stents, patients are advised that they can stop their grel and carry on taking aspirin. This French trial randomised some patients to do this, and some to carry on with their clopidogrel or prasugrel for a further six to 18 months. But they have shown that this does not prevent cardiovascular events while it does increase major bleeding. So current practice seems right. A year is the holy grel.

The BMJ 1 November 2014 Vol 349

Reappraisal of Thienopyridine Pretreatment in Patients with Non-ST Elevation Acute Coronary Syndrome: Can you remember what a thienopyridine is? All together now: “A thienopyridine is a GREL!” Very good, children. Now in the land of grels, boys and girls, you can make a lot of money by inventing a new grel and selling it to lots of people. This is known as economic activity, and that is why we protect our pharmaceutical companies like dear little lambs. Now you remember that grels stop platelets sticking to each other, so they stop blood clots forming. That’s why they have been sold for people to use when they are having a kind of clot in the heart called non-ST elevation myocardial infarction. The trouble is that when you look at all the trials, you find that these grels don’t do any good but cause more of these people to bleed. So you can see, girls and boys, that it’s very important to have all the results of all the trials, because most of them are conducted by people wanting to sell grels. We don’t think they might want to tell fibs, but we need to be sure.

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