Clinical Briefs
By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.
Alendronate: How Much of a Good Thing?
The most popularly used pharmacotherapy for prevention and/or treatment of osteoporosis (OSPS) is bisphosphonate (BIS), specifically alendronate and risedronate. Once an appropriate treatment candidate is identified, therapy is usually employed on "indefinite" basis, since an optimum duration of treatment remains to be elucidated. Black, et al compared 5 years vs 10 years of BIS in a large population of patients (n = 1,099) by following all patients on BIS for 5 years, and then discontinuing BIS in half of the population and following the entire group for an additional 5 years.
As might be intuitively obvious, subjects who discontinued BIS during the second 5-year phase of the study did show declines in BMD (bone mineral density) and increases in markers of bone turnover compared with persons continuing BIS. More importanly, there was NOT an increase in fracture occurrence among persons who discontinued BIS after 5 years. All in all, even with 5 years of BIS treatment followed by 5 years with no active agent, BMD remained better than at baseline.
Long term use of BIS is generally considered safe, and the optimum duration of treatment remains unknown. This data suggests that for persons who have convincing rationale to discontinue BIS (eg, expense, inconvenience, intolerance), a hiatus of as long as 5 years may not increase risk of osteoporotic fracture.
Black DM, et al. JAMA. 2006;296:2927-2938.
Early Localized Prostate Cancer: Does Intervention Make a Difference?
PSA screening is utilized by most clinicians for men at age 50 and beyond. As a result, the distribution of prostate cancers discovered in middle-aged men has evolved to include a disproportionate number of early, localized tumors. There have been conflicting data about the impact on survival of intervention (radiation therapy or radical prostatectomy) in persons with localized disease.
The SEER database (Surveillance, Epidemiology, and End Results) provides observational data on US cancer registry patients representing 14% of the US population. From this database, men aged 65-80 (n = 111,640) with a new diagnosis of prostate cancer in the 1991-1999 time period were classified as either receiving active intervention or observation.
At the end of a 12-year study period, the hazard ratio for death was 31% greater in men in the observation group (p = < 0.05) than in men who received active intervention. Active intervention was associated with increased frequency of incontinence and erectile dysfunction compared to observation, although the latter population had more obstructive voiding symptoms.
Observational data cannot provide conclusive answers to questions about outcomes related to particular interventions. Results from randomized interventional trials to more conclusively address the question of whether active treatment improves outcomes in senior men with localized prostate cancer are pending.
Wong YN, et al. JAMA. 2006;296:2683-2693.
CV Biomarkers: The More Is Not Always the Merrier
Initiated in 1948, the Framingham Heart Study is the longest ongoing epidemiologic study in the United States. Thanks to reports stemming from this observational data set, we have come to recognize "conventional" risk factors for cardiovascular disease (CVD): smoking, hypertension, and cholesterol. Although attributable risk for CVD from these risk factors is substantial, emerging biomarkers—eg CRP, brain natriuretic peptide (BNP), plasma rennin, homocysteine, urinary albumin-to-creatinine ratio—might provide greater risk prediction.
Wang, et al followed 3,209 Framingham Heart Study participants who were free of known cardiovascular disease at baseline for 7.4 years (mean) to evaluate the relationship between 10 biomarkers (individually and in aggregate) and CVD.
After adjustment for conventional risk factors, each individual biomarker was associated with an incremental increase in CVD risk, most prominent of which was BNP (hazard ratio = 1.25). However, even though biomarkers did independently predict risk for CVD, the incremental amount added in addition to conventional risk factors was reported to be only "modest." Although biomarkers are associated with CVD risk, conventional risk factors are responsible for the majority of attributable risk.
Wang TJ, et al N Engl J Med. 2006;355:2631-2639.
The most popularly used pharmacotherapy for prevention and/or treatment of osteoporosis (OSPS) is bisphosphonate (BIS), specifically alendronate and risedronate.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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